Aortic Aneurysms

What is an aortic aneurysm?

The blood inside the aorta is pumped under pressure of the heart, just like water supply in pipes. The aortic wall is designed to bear this pressure over the lifespan of the person.

In some cases, the wall of the aorta becomes weak. Under the pressure of the blood within, this weak part bulges like a balloon, and is called an aneurysm. As the wall continues to weaken, this bulge increases. Eventually the wall can break down (rupture) and then the patient can bleed into the chest or the abdomen. Due to the large amount of blood in the aorta, this bleeding can rapidly cause death if untreated.

What are the symptoms of an aortic aneurysm?

Unfortunately, most unruptured aneurysms cause no symptoms. Few patients can have pain, or feel a swelling. Sometimes clots form in the aneurysm and flow into and block branches supplying other parts of the body. This is called embolism ad the symptoms depend upon what organ gets affected. Embolism can cause stroke in the brain, or damage to the kidneys, or cause leg pain or gangrene.

Most aneurysms though are silent, and until they rupture, are unsuspected.

What are the symptoms of an aortic aneurysm?

Most aortic aneurysms are found by ulttrasound of abdomen, or a CT scan of the chest, or are suspected on an X Ray. Smokers are at high risk of developing aneurysms of the aorta and should undergo a screening ultrasound of the abdomen.

What happens if an aortic aneurysm is found?

All aortic aneurysms do not need treatment.

The aneurysms with increased risk of rupture and bleeding need treatment.

This risk is estimated based on size of the aneurysm, its shape, and the patient's age, as well as the presence of other diseases like high blood pressure. It is also important to see the rate of growth and change. Aneurysms which grow rapidly or change shape rapidly over months are considered high risk and need treatment.

Aneurysms not considered at high risk for bleeding are kept under observation, using CT/MRI and ultrasound. During observation, lifestyle changes and blood pressure control are important.

What are the treatment options if treatment is required?

Treatment options are :

1. Open Surgery: Before endovascular treatment became viable, open surgery was the only option. This surgery essentially replaces the weak part of the aorta with a synthetic tube . This is a relatively high risk procedure especially in aged patients, or those who have many other diseases which increase the risk of surgery.

2. Endovascular treatment: Endovascular treatment of aortic aneurysms is done by placing a tube which has a metal framework covered by a fabric inside the aorta. This tube is kept folded inside a device and then released inside the desired part of the aorta, covering the weak part of the aorta from the inside and supporting it so that the aneurysm cannot rupture. This procedure can be done for the part of the aorta in the chest and in the abdomen. No opening of the chest or abdomen is necessary. The procedure for Thoracic Aneurysms (in the chest) is called Thoracic Endovascular Repair (TEVAR) and the procedure for the Abdominal Aortic Aneurysm is called Endovascular Aneurysm Repair (EVAR).

What are the risks of treatment?

The risks of the procedure varies with the location of the aneurysm and health of the patient.

Some risks are common to all cases. Complications are uncommon, less than 2% overall.

There can be damage to blood vessels through which the stent graft is placed, this may need additional procedures or surgery.

Other risks are related to the area which is being treated, and can range from stroke or paralysis to kidney failure.

What happens after the procedure?

Usually the patient is observed in the ICU for 24 hours after.

Patients can usually start walking in 24 - 48 hours.

Depending on the condition and the technique of the procedure, discharge within 4 days or so is usual.

The procedure is relatively pain free if done using Percutaneous Technique without surgical cuts to expose the artery.

Surgical cutdown may have some pain for a few days.

What is the follow up after the procedure?

Patients need to undergo scanning at 3 months, 6 months, 1 year and every year thereafter for 5 years.

In TEVAR cases, this is done by CT scan.

EVAR cases may be followed up with Ultrasonography in selected cases, other cases CT scan may be done.

This is to ensure that the repair is durable and the aneurysm is not filling any more. If such leakage is seen, which is uncommon, additional procedures may be necessary.