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What Are Aortic Diseases?

The Aorta, the largest vessel in the body, is the “main blood highway” carrying clean blood directly from the heart to all organs. Depending on a person’s height and weight, it carries 3 to 6-7 liters of blood per minute. While doing so, there is a certain pressure inside, depending on the strength of the heart’s beats and the body’s structure (80 – 140 mmHg), commonly known as blood pressure. The Aorta can silently enlarge for various reasons. Detecting this early is crucial.

aortic-aneursym

What is an Aneurysm?

An aneurysm is an abnormal bulging of the wall of an artery. Arteries carry oxygenated blood from the heart to other parts of the body. A sufficiently enlarged aneurysm can rupture, potentially causing fatal bleeding.

What is an Aortic Aneurysm?

The diameter of the aorta is approximately 2.5 cm where it originates from the heart. There is no other vessel in the body with such a wide diameter. The diameter of the aorta increases and expands for various reasons. We call this “Aneurysm” in medicine. If the aneurysm expands even more after a certain period of time, there is a possibility of rupture. If the blood passing through it flows outward and reaches a level that affects neighboring organs, we call this “rupture” (burst) in medicine. Another known complication of the growing aorta is called “Dissection” (tearing inward). Both of these are very dangerous pathologies and are life-threatening situations that require immediate or very rapid treatment.

The aorta comes from the left ventricle of the heart and progresses through the chest and abdominal cavities. Aneurysms that form in the section of the aorta in the chest cavity are called “thoracic aneurysms”. Those that form in the section of the aorta in the abdominal cavity are called “abdominal aneurysms”.

Aneurysms can also occur in the vessels of the brain, heart, neck, spleen, behind the knee and other parts of the body. If an aneurysm in the brain ruptures, it can cause a stroke.

An aortic aneurysm is defined as an abnormal expansion in the wall of the main artery called the aorta. Especially abdominal aortic aneurysms, that is, aneurysms that occur in the abdominal region, are quite common. This condition can cause serious health problems and potentially life-threatening risks. Therefore, the importance of determining the stage and surgery in the treatment of aortic aneurysms is of great importance.

Symptoms of aortic aneurysms usually include complaints such as abdominal pain, back pain and chest pain. However, sometimes patients may have this condition without showing any symptoms. For this reason, various methods are used to detect aortic aneurysms.

The most commonly used methods for diagnosing aortic aneurysms include ultrasonography, computed tomography (CT) scanning and magnetic resonance imaging (MRI). Thanks to these examinations, factors such as the size of the aneurysm, its location and the condition of the vessel wall are evaluated.

What are the Types of Aortic Aneurysms?

abdominal-aortic-aneurysm

The aorta in the chest consists of three parts. Ascending Aorta, Aortic Arch, Descending Aorta. These aneurysms can grow silently without any symptoms. Sometimes, they are diagnosed incidentally during examinations performed with back pain symptoms. The ascending aorta that has reached a diameter of 5.5 cm and above poses a vital risk for the patient. Because as a result of the thinning and tearing of its wall, blood spreads into the heart chamber in a few seconds and compresses and stops the heart. Therefore, treatment is mandatory. Surgery is inevitable for the part we call the ascending aorta (Ascending Aorta) and endovascular (closed) treatments are not suitable. However, this vessel can also be replaced with a small incision of 3-4 cm (See Aortic Valve Replacement Closed Method). The aorta in the back (Descending Aorta) is suitable for endovascular treatment. In other words, it can be replaced with the TEVAR method without opening the rib cage.

Why is Aneurysm Screening Important?

Every year, about 15,000 people die due to ruptured aneurysms. Ruptured aneurysms are the 10th leading cause of death in men over 50. Most ruptured aneurysms can be prevented with early diagnosis and medical treatment. Aneurysms can develop and grow for years without causing any symptoms. Hence, screening for aneurysms in high-risk individuals is crucial. Once diagnosed, aneurysms can often be successfully treated with medication or surgery. When an abdominal aortic aneurysm is diagnosed, doctors may prescribe medications to lower heart rate and blood pressure, reducing the risk of rupture. For larger aneurysms, surgical intervention, typically replacing the diseased part of the aorta, may be recommended.

What are the Causes of Aortic Aneurysms?

  • Atherosclerosis (hardening or deterioration of the vessel quality): Aneurysms can form as a result of atherosclerosis. As atherosclerosis progresses, artery walls thicken, become damaged, and lose their normal inner surfaces. The damaged part of the artery can bulge or balloon, resulting in an aneurysm.
  • Aneurysms can also occur due to continuous high blood pressure inside the arteries.
  • Trauma, such as chest impact during a car accident, can lead to the formation of an aneurysm.
  • Certain medical conditions like Marfan syndrome, characterized by tall stature and long fingers, can lead to aneurysms. Individuals with Marfan syndrome may experience thinning of the blood vessel walls.
  • In rare cases, untreated infections like syphilis can lead to aortic aneurysms.

What are the symptoms of Aortic Aneurysms?

Aortic aneurysm symptoms and signs depend on its type, location, whether it has ruptured, or its relationship with other structures in the body. Aneurysms can develop and grow over years without causing any complaints.

They slowly enlarge over the years and do not cause any symptoms until they rupture. Sometimes, during an examination, a pulsating mass can be noticed in the patient’s abdomen. If they cause symptoms, these may include deep, stabbing pain in the back or along the edges of the abdomen, a constant burning pain lasting for hours or days in the abdomen, and cooling or numbness in the feet.

Aneurysms in the abdominal region are referred to as Abdominal Aortic Aneurysms (AAA). If AAA ruptures, symptoms include sudden and severe pain in the lower abdomen or back, nausea and vomiting, sweating, dizziness, and an increased heart rate when standing up. Internal bleeding caused by a ruptured AAA can lead to shock in the patient.

Thoracic (chest) aortic aneurysms may not cause symptoms until they grow or rupture. The emerging complaints may include pain or coughing in the jaw, neck, back, or chest, hoarseness, or difficulty breathing.

Symptoms associated with peripheral aneurysms include a pulsating mass felt in the neck, arm, or leg, pain in the arm or leg, and exercise cramps.

How is Aortic Aneurysm Diagnosed?

Aort Anevrizması Tanısı

Aneurysms can be found incidentally during routine physical examinations. They are often discovered by chance during procedures such as ultrasound, X-rays, or computerized tomography conducted for other reasons, such as chest or abdominal pain. To diagnose an aneurysm, methods like X-ray, ultrasound, computerized tomography, magnetic resonance imaging, and angiography are employed.

What are the Treatment Methods for Aortic Aneurysm?

The treatment time and method for aortic aneurysm vary depending on its location in the body. If we divide the aorta within the chest into ascending and descending aorta, the situations requiring treatment can be summarized as follows:

For the Ascending Aorta, treatment is needed if:

  • The diameter has reached 5.5 cm, or
  • The diameter has increased by 5 mm in the last 6 months, or
  • The diameter is 5 cm, and there is labile (fluctuating) hypertension.

For the Descending Aorta, treatment is needed if:

  • The diameter is 6 cm, or
  • The diameter has increased by 5 mm in the last 6 months, or
  • There is pressure on any other organ.

For the Abdominal Aorta, treatment is needed if:

  • The diameter is 5.5 cm, or
  • The diameter has increased by 5 mm in the last 6 months, or
  • There is suspicion of bleeding in any aneurysm.

In the above situations, aortic aneurysms should be treated either by surgical methods or endovascular (interventional) methods (EVAR, TEVAR). The latter method is commonly referred to as the “closed method” in public.

Why is Aneurysm Dissection an Emergency?

Acute aortic dissection is the most common aortic condition requiring emergency surgery. Aortic dissection occurs when there is a tear between the layers of the aortic wall, allowing blood to enter a false lumen within the layers. It is most often observed in elderly individuals. Since the survival chances decrease significantly if the aorta ruptures, newly developed aortic dissection is an urgent and life-threatening condition.

 

This condition is typically classified into Type A (involving a tear in the ascending thoracic aorta) and Type B (involving a tear in the descending thoracic aorta). Type A dissections carry a high mortality risk of around 1% for every hour without surgery. In cases of Type B dissection, surgery is not required unless there is rupture or impaired circulation in the organs. Standard tube graft placement is employed in dissection surgery.

How is surgical decision made?

The decision regarding the need for surgery for an aneurysm is made by cardiovascular surgeons. If surgery is deemed necessary, the choice of surgical procedure is based on the location, size, and functionality of the aortic valve.

Anevrizma tedavisi

Surgical Treatment Modalities for Aneurysms

Surgical methods that can be chosen for the treatment of thoracic aortic aneurysms:

Repair of ascending aneurysm with tube graft placement

If the aortic valve is normal, the aortic root is not enlarged, and the aneurysm is in the ascending aorta, the repair is done by placing a tube graft. The enlarged part of the ascending aorta is cut, and artificial tubes, known as Dacron or Gore-Tex, are placed in its position. These artificial tubes are durable for a lifetime.

Aneurysm repair preserving the aortic valve

If possible, surgery is performed by preserving the aortic valve rather than replacing it. This procedure can be applied to patients with an aneurysmatic aortic root and aortic valve insufficiency but with normal-shaped aortic leaflets. The aortic valve and coronary arteries are reattached to the artificial vessel. Patients undergoing this type of operation are relieved from long-term use of blood thinners.

Composite aortic root replacement

If patients require replacement of both the aortic root and the aortic valve, a composite aortic root replacement operation is performed. In this surgery, an artificial vessel with a pre-implanted artificial aortic valve is used to replace the aorta. Both mechanical and biological valves can be used in these operations.

Aortic arch surgery

Aortic arch surgery is technically challenging. During this surgery, a branched graft is used to protect the brain, the body is cooled (hypothermic circulatory arrest), and a procedure called “antegrade cerebral perfusion” is used to send oxygen-rich blood to the brain. The use of these techniques reduces the risk of death and stroke.

Thoracoabdominal aneurysm repair

Repairing aneurysms involving the thoracoabdominal aorta requires a complex and extensive surgical procedure. A potential complication of surgery is the disruption of blood supply to the spinal cord due to the exit of arteries supplying the spinal cord from this area. An anesthesia procedure is performed by an anesthetist to reduce this complication.

Stent graft placement (endovascular repair)

In some cases, and for aneurysms that do not involve the ascending aorta, there is a new repair method known as “stent graft repair.” It is a minimally invasive treatment for abdominal aneurysm repair. This type of stent graft placement can be performed in centers with sufficient equipment. This procedure can be performed if the patient’s aortic anatomy is suitable. If it is not suitable, standard open aortic surgery should be performed.

Repair of abdominal aortic aneurysm

In the surgical treatment of abdominal aortic aneurysms, tube graft placement is performed. In some cases, if the iliac arteries are also aneurysmal, a pant leg graft is used.

Post-Operative Care and Recovery Process

It is important for the patient to have a full recovery after aortic aneurysm surgery. The aim is for the patient to regain their health with careful follow-up and care after the surgery. During the first days in the intensive care unit, the patient is kept under close surveillance and their vital parameters are closely monitored.

The patient may need to rest in bed and limit their activities for a few days after the surgery. It is very important to take medications regularly according to the doctor’s instructions. Check-ups and follow-ups continue in the post-operative period. The post-operative recovery process may vary depending on the patient’s general health status and the complexity of the surgery.

The success rate of aortic aneurysm surgery is generally high, but close communication between the patient and the doctor should be continuous during this process. It is important for the patient to follow the doctor’s instructions correctly and to attend regular check-ups during the recovery process. Successful completion of the post-operative care and recovery process allows the patient to return to their daily lives in a healthy way.

Who is at risk for Aortic Aneurysm?

Individuals over the age of 50, smokers, patients with high blood pressure, those with a family history of aneurysms, and those with genetic disorders (e.g. Marfan syndrome) are at higher risk of developing aortic aneurysms.

Can Aortic Aneurysm Be Prevented Naturally?

Although it cannot be completely prevented, the risk can be reduced by adopting a healthy lifestyle. Steps such as quitting smoking, exercising regularly, eating a balanced diet and keeping blood pressure under control are important for aorta health.

Can a Normal Life Be Sustained with Aortic Aneurysm?

As long as the size and location of the aortic aneurysm are under control, a normal life can be lived with regular medical follow-up. However, if the aneurysm is large or growing rapidly, surgical intervention may be necessary.

Is There a Genetic Link to Aortic Aneurysm?

Yes, certain genetic conditions (such as Marfan syndrome and Ehlers-Danlos syndrome) may increase the risk of aortic aneurysms. People with a family history of aneurysms are also at higher risk.

What is the Difference Between Aortic Aneurysm and Aortic Dissection?

Aortic aneurysm is the widening of the wall of the aorta. Aortic dissection occurs when the layers of the wall tear and blood accumulates between these layers. Dissection is a more acute and life-threatening condition.