Aortic Aneurysm

Aortic Aneurysm

Topic Overview

What is an aortic aneurysm?

An aortic aneurysm
(say "a-OR-tik AN-yuh-rih-zum") is a bulge in a section of the
aorta, the body's main artery. The aorta carries
oxygen-rich blood from the heart to the rest of the body. Because the section
with the aneurysm is overstretched and weak, it can burst. If the aorta bursts,
it can cause serious bleeding that can quickly lead to death.

Aneurysms can form in any section of the aorta, but they are most common in the
belly area (abdominal aortic aneurysm). They can also happen in
the upper body (thoracic aortic aneurysm). Thoracic aortic aneurysms
are also known as ascending or descending aortic aneurysms.

What causes an aortic aneurysm?

The wall of the
aorta is normally very elastic. It can stretch and then shrink back as needed
to adapt to blood flow. But some medical problems, such as
high blood pressure and
atherosclerosis (hardening of the arteries), weaken
the artery walls. These problems, along with the wear and tear that naturally
occurs with aging, can result in a weak aortic wall that bulges outward.

What are the symptoms?

Most aortic aneurysms
don't cause symptoms. Sometimes a doctor finds them during exams or tests done
for other reasons. People who do have symptoms complain of belly, chest, or
back pain and discomfort. The symptoms may come and go or stay constant.

In the worst case, an aneurysm can burst, or rupture. This causes
severe pain and bleeding. It often leads to death within minutes to hours.

How is an aortic aneurysm diagnosed?

Aneurysms
are often diagnosed by chance during exams or tests done for other reasons. In
some cases, they are found during a screening test for aneurysms. Screening
tests help your doctor look for a certain disease or condition before any
symptoms appear.

Experts recommend screening tests for abdominal aneurysms for men who
are:

  • Ages 65 to 75 and have ever smoked.footnote 1
  • At least 60 years old and have a first-degree relative (for
    example, father or brother) who has had an aneurysm.footnote 2

These men are more likely to have an aneurysm than are
women or nonsmoking men.

Experts recommend screening tests for a thoracic aneurysm for anyone who has a close relative who has had a thoracic aortic aneurysm.footnote 3

If your doctor thinks you have an
aneurysm, you may have tests such as an
ultrasound, a
CT scan, or an
MRI to find out where it is and how big it is.

How is it treated?

Treatment of an aortic aneurysm
is based on how big it is and how fast it is growing. If you have a large or
fast-growing aneurysm, you need surgery to fix it. A doctor will
repair the damaged part of the blood vessel during open surgery or a minimally invasive procedure.

Small aneurysms rarely rupture and
are usually treated with high blood pressure medicine. This medicine helps to lower blood
pressure and stress on the aortic wall. If you don't have a repair surgery or procedure, you will
have routine
ultrasound tests to check the size of the aneurysm and see how fast it is growing.

Even if your aneurysm does not grow fast or rupture, you may
be at risk for heart problems. Your doctor may suggest that you exercise more,
eat a heart-healthy diet, and stop smoking. He or she may also prescribe
medicines to help lower high cholesterol.

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Cause

Abdominal and
thoracic aortic aneurysms have a number of causes,
including:

  • Hardening of the arteries (atherosclerosis). Exactly how
    atherosclerosis leads to abdominal aortic aneurysms is
    unclear. It is thought that
    atherosclerosis causes changes in the lining of the
    artery wall that may affect oxygen and nutrient flow to the aortic wall
    tissues. The resulting tissue damage and breakdown may lead to the development
    of an
    aneurysm.
  • Genetics. In some people who have
    Marfan's syndrome,
    Ehlers-Danlos syndrome, or other inherited conditions,
    the walls of the major arteries, including the
    aorta, are weakened. Aortic aneurysms can run in
    families.
  • Aging. The aorta naturally becomes less elastic and stiffer with age,
    increasing the risk for an abdominal aortic aneurysm.
  • Infections. Infections such as
    syphilis and
    endocarditis, an infection of the lining of the heart,
    can cause aneurysms.
  • Injury. A sudden, intense blow to the chest or
    abdomen, such as hitting the steering wheel in a car accident, can damage the
    aorta.
  • Inflammation. Inflammation of the aorta can weaken
    the aortic wall. What causes the aorta to become inflamed is not clear.

Thoracic aortic aneurysms are much less common than
abdominal aortic aneurysms. They are often caused by
an abnormal breakdown of the elastic fibers in the aortic wall.

A pseudoaneurysm happens when a bulge occurs in the wall of the aorta. But the bulge doesn't affect all three layers of tissue in the wall of the aorta. This type of aneurysm might be caused by an injury.

Symptoms

Most people with
aortic aneurysms, especially ones in the chest area
(thoracic aortic aneurysms), do not have symptoms. But symptoms may begin to occur
if the aneurysm gets bigger and puts pressure on surrounding organs.

If an aortic aneurysm bursts, or ruptures, there is sudden,
severe pain, an extreme drop in blood pressure, and signs of
shock. Without immediate medical treatment, death
occurs.

Abdominal aortic aneurysm

The most
common symptoms of
abdominal aortic aneurysm include general abdominal
(belly) pain or discomfort, which may come and go or be constant. Other
symptoms include:

  • Pain in the chest, abdomen, lower back, or
    flank (over the kidneys), possibly spreading to the groin, buttocks, or legs.
    The pain may be deep, aching, gnawing, and/or throbbing, and may last for hours
    or days. It is generally not affected by movement, although certain positions
    may be more comfortable than others.
  • A pulsating sensation in the
    abdomen.
  • A "cold foot" or a black or blue painful toe, which can happen
    if an abdominal aortic aneurysm produces a blood clot that breaks off and
    blocks blood flow to the legs or feet.
  • Fever or weight loss, if it
    is an
    inflammatory aortic aneurysm.

Thoracic aortic aneurysm

Symptoms of a thoracic aortic aneurysm are most
evident when the aneurysm occurs where the aorta curves down (aortic arch). They may include:

  • Chest pain, generally described as deep and
    aching or throbbing. This is the most frequent symptom.
  • Back
    pain.
  • A cough or shortness of breath if the aneurysm is in the area
    of the lungs.
  • Hoarseness.
  • Difficulty or pain while
    swallowing.

The symptoms of aortic aneurysm are similar to the
symptoms of other problems that cause chest or belly pain such as
coronary artery disease, gastroesophageal reflux (GERD), and
peptic ulcer disease.

What Increases Your Risk

The leading risk factors
for an
aortic aneurysm are:

  • Being over 65 years old.
  • Being
    male.
  • Smoking.
  • High blood pressure.
  • Family
    history of aortic aneurysms in first-degree relatives (parent,
    brother, or sister).

Abdominal aortic aneurysms are about 5 times more common in men than in women. An aneurysm happens in about 3 to 9 men out of 100 who are older than 50.footnote 4

When to Call a Doctor

Call 911 or other emergency services immediately if you have signs of a ruptured
aortic aneurysm such as:

  • Sudden, severe pain.
  • An extreme
    drop in blood pressure.
  • Signs of
    shock, such as passing out or feeling very dizzy, weak, or less alert.

If you witness a person become unconscious, call
911 or other emergency services and start
cardiopulmonary resuscitation (CPR). The emergency operator can coach you on
how to do CPR. For more information about CPR, see the Rescue Breathing
and Cardiopulmonary Resuscitation section of the topic
Dealing With Emergencies.

Call a doctor immediately if you have:

  • A pulsating mass in your
    abdomen.
  • Sudden weakness in the lower extremities on one side of
    the body.
  • Chest pain you have not experienced before.
  • A "cold foot" or a black or blue painful toe for no apparent reason.

Call for a doctor appointment if you have:

  • Fever or weight loss for no apparent
    reason.

Who to see

Health professionals who can evaluate
symptoms that may be related to an aortic aneurysm and order the tests needed
for further evaluation of symptoms include:

If you have a fast-growing aortic aneurysm, you may be
referred to a vascular surgeon, who can evaluate your need for surgery.

Exams and Tests

Aortic aneurysms are often discovered during an
X-ray,
ultrasound, or
echocardiogram done for other reasons. Sometimes an
abdominal aneurysm is felt during a routine physical exam. If your doctor thinks you might have an aortic aneurysm, you will likely have a medical history and physical exam. You might have further tests to locate the aneurysm.

When an aneurysm is suspected or diagnosed, it is important to:

  • Pinpoint the location of the
    aneurysm.
  • Estimate its size.
  • Find out how fast it is
    growing.
  • Find out whether
    other blood vessels are involved.
  • See if there are blood
    clots or inflammation.

Medical history and physical exam

Your doctor may ask:

  • Do you have symptoms and when did they start?
  • Do you smoke?
  • Do you have other diseases, such as high
    blood pressure?
  • Do you have a family member who has had an aortic aneurysm?
  • Have you had a chest injury recently?

As part of a physical exam, your doctor might:

  • Listen to your heart to check for blood flow problems.
  • Check your legs
    and feet.

If your doctor finds a mass in your abdomen, he or she will
suggest further testing. If you are overweight and your doctor feels strongly
that you may have an abdominal aortic aneurysm, he or she may also suggest
further testing. This is because an abdominal aortic aneurysm is typically more
difficult to find in those who are overweight.

Imaging tests

Tests to help find out the location, size, and rate of
growth of an aneurysm include:

  • Abdominal ultrasound. Ultrasounds help
    your doctor check the size of the aneurysm.
  • Computed tomography (CT) and
    magnetic resonance angiogram (MRA), which are used if
    a view more detailed than an ultrasound is needed. This is important when
    information is needed about the aneurysm's relation to the blood vessels of the
    kidney or other organs. Your doctor needs this information especially before
    surgery. CT is used to watch the growth of a thoracic aortic
    aneurysm.
  • Echocardiogram, an ultrasound exam used
    to study the heart. A transthoracic echocardiogram (TTE) or a transesophageal
    echocardiogram (TEE) may be done to diagnose thoracic aortic
    aneurysm.
  • Angiogram. An angiogram can help
    your doctor know what the size of the aneurysm is and if there are
    aortic dissections, blood clots, or other blood vessel
    involvement.

Ongoing testing

One of the most important goals of testing is to estimate
the risk that an aneurysm may burst, or rupture, and to compare the risk of
rupture to the risks of surgery. If an aortic aneurysm is detected, tests such
as abdominal ultrasound can be used to closely follow any change in the size or
other aspect of the aneurysm and help measure the risk for
rupture.

If your aneurysm is large, you
may need an ultrasound every 6 to 12 months. If your aneurysm is small, you may
need one every 2 to 3 years.

If you had an endovascular repair of an aneurysm, and you have a stent graft, you will need tests every year, such as a CT scan, to check for problems with the graft.footnote 5

Screening tests

For abdominal aortic aneurysm

Your doctor may recommend an
abdominal ultrasound screening test if you are a man
who is:

  • Age 65 to 75 and has ever smoked.footnote 1
  • At least 60 years old and who has a first-degree relative (for
    example, father or brother) who has had an aneurysm.footnote 2

Some doctors think that other groups should be screened too. Talk to your doctor about whether the benefits of screening would outweigh the risks in your case.

For thoracic aortic aneurysm

Your doctor may recommend screening tests for a thoracic aortic aneurysm if you have a close relative (parent, brother, or sister) who has had a thoracic aortic aneurysm.footnote 3

Treatment Overview

After you are diagnosed with an
aortic aneurysm, your doctor will evaluate:

  • Whether you need the aneurysm repaired.
  • Whether
    you will be able to withstand a surgery or procedure.
  • Whether you should wait to repair the aneurysm and get regular tests to check its size and growth.

When repair is recommended

Aortic aneurysms that
are causing symptoms or enlarging rapidly are considered at risk of rupturing.
Repair is usually recommended if either of these factors is present.

In men, repair is also typically recommended for
abdominal aortic aneurysms that are 5.5 cm or larger
in diameter, causing symptoms, or are rapidly growing. In women, repair may be recommended for smaller aneurysms.

Repair of thoracic aortic aneurysms is usually recommended when they reach 5.5 to 6.0 cm in
diameter. In general, the risks of surgery to repair smaller
aneurysms outweigh the possible benefits, because smaller aneurysms rarely
rupture.

Monitoring and medical treatment for aortic aneurysm

If surgery is not done to repair your aneurysm, you will
have regular tests to check its size.

You may need to
take medicine to treat
high cholesterol and
high blood pressure.

For more
information, see:

Despite some claims, taking antioxidant vitamins has not been proved to
reduce the risk of aneurysm or the risk of rupture.

Lifestyle changes for aortic aneurysm

If you smoke, try to quit. Medicines and counseling can help you quit for good.

Your doctor will probably recommend that you make other lifestyle
changes, such as following a
heart-healthy diet, limiting alcohol, and exercising.
Try to do activities that raise your heart rate. Exercise for at least 30
minutes on most, preferably all, days of the week.

Ongoing Concerns

If you have an aortic aneurysm, you will see your doctor regularly to check on the size of the aneurysm. The size of the aneurysm and how fast it is growing both help determine how and when to treat it.

Rupture is a dangerous complication. As an aneurysm expands, the tension on the blood vessel wall increases. This causes the aneurysm to expand further, which puts even more tension on the wall. The larger the aneurysm gets, the greater the chances that it will grow larger and eventually burst.

Your doctor will want to repair an aneurysm before it has a risk of rupture.

Inflammatory aneurysms are not common, but they can cause complications like
fever and weight loss. A massive inflammatory
reaction can affect body parts close to the aorta, including part of the small intestine,
the
ureter, or the veins to the kidney. Any of these
body parts can become blocked by the inflammation.

Living With an Aortic Aneurysm

If you have an
aortic aneurysm, you need close medical monitoring and
possibly treatment.

Go to your regular checkups. You will have regular tests to check the size and growth of the aneurysm. Talk with your doctor about how often you should get tested.

Home treatment is appropriate to help prevent or
control conditions that may be causing you to have an aortic aneurysm, such as
atherosclerosis or
high blood pressure.

  • Quit smoking. Medicines and counseling can help you quit for good.
  • Control high blood pressure. To control
    high blood pressure, eat a low-sodium diet, and get
    regular exercise. For more information, see the topic
    High Blood Pressure.
  • Control high cholesterol. To control
    high cholesterol, eat a low-fat diet
    and get regular exercise. For more information, see the topic
    High Cholesterol.
  • Manage your weight. Losing weight will not likely
    change the course of an aortic aneurysm, but it may lower the risk of
    complications if you eventually need surgery. For more information, see the
    topic
    Weight Management.
  • Be active. Ask your doctor what type and amount of exercise is safe for you. If aerobic activity is safe, try to do activities that raise your
    heart rate. Exercise for at least 30 minutes on most, preferably all, days of
    the week.
  • Eat a heart-healthy diet. A heart-healthy diet includes fruits, vegetables, high-fiber foods,
    and foods low in saturated fat and trans fat.
    For more information, see the topic Heart-Healthy Eating.

Medications

You may take a medicine to lower your blood pressure. This lowers stress on your aorta.

If you have
high cholesterol, your doctor might recommend that you
take medicines, such as
statins, to lower it. Having high cholesterol
increases your risk of
atherosclerosis, which can cause aortic aneurysms and
other conditions, such as
coronary artery disease and
stroke.

Surgery

Thoracic or abdominal
aortic aneurysms that are large, causing symptoms, or
rapidly getting bigger are considered at risk of rupturing. A repair surgery or procedure is usually
recommended if any one of these factors is present. A doctor uses a man-made graft to repair an aortic aneurysm.

Your doctor will
consider:

  • Whether you need the aneurysm repaired right away.
  • Whether you will be able to withstand a
    surgery or procedure.
  • The shape and location of your aneurysm to see which repair option is possible.

It is not an option to wait until an aneurysm has ruptured
before having it repaired. Most people who have a ruptured aortic aneurysm die.
A ruptured aneurysm is dangerous because of the large amount of
blood loss.

Abdominal aortic aneurysm

In men, repair is typically recommended for
abdominal aortic aneurysms that are causing symptoms, are growing rapidly,
or that are 5.5 cm or larger in diameter. In women, repair may be recommended
for smaller aneurysms.

The decision to have your aneurysm repaired or not depends on other things too. These
may include older age or medical problems that make the repair more
dangerous.

Repair options are:

Talk to your doctor about the benefits and risks of each
repair option to see which is better for you.

Thoracic aortic aneurysm

Your doctor
will recommend that you have surgery for a
thoracic aortic aneurysm based on many things. These include:footnote 3

  • The location of the aneurysm, such as the ascending or descending part of the aorta.
  • The size of the aneurysm. Repair might be recommended if an aneurysm is 5.5 to 6.0 cm in
    diameter.
  • Whether the aneurysm is part of a genetic problem, such as Marfan's syndrome.
  • Whether you need another heart surgery such as a heart valve replacement surgery.

Open surgery and the less invasive procedure, called endovascular repair, are the two options for repairing a thoracic aortic aneurysm. The choice of repair can depend on the size and location of the aneurysm.footnote 4

Many of the risks of surgical or endovascular repair are similar for abdominal and thoracic aortic aneurysms.

Other Places To Get Help

Organizations

National Heart, Lung, and Blood Institute (U.S.)
www.nhlbi.nih.gov

American Heart Association
www.heart.org

References

Citations

  1. U.S. Preventive Services Task Force (2014). Screening for abdominal aortic aneurysm. http://www.uspreventiveservicestaskforce.org/uspstf14/abdoman/abdomanfinalrs.htm. Accessed August 27, 2014.
  2. Hirsch AT, et al. (2006). ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): A collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation, 113(11): e463–e654.
  3. Hiratzka LF, et al. (2010). 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. Circulation, 121(13): e266–e369.
  4. Braverman AC, et al. (2012). Diseases of the aorta. In RO Bonow et al., eds., Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 9th ed., vol. 2, pp. 1309–1337. Philadelphia: Saunders.
  5. Rooke TW, et al. (2011). 2011 ACCF/AHA Focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 58(19): 2020–2045.

Other Works Consulted

  • De Bruin JL, et al. (2010). Long-term outcomes of open or endovascular repair or abdominal aortic aneurysm. New England Journal of Medicine, 362(20): 1881–1889.
  • Elefteriades JA, et al. (2011). Diseases of the aorta. In V Fuster et al., eds., Hurst's The Heart, 13th ed., pp. 2261–2289. New York: McGraw-Hill.
  • Eliason JL, Upchurch GR Jr (2008). Endovascular abdominal aortic aneurysm repair. Circulation, 117(13): 1738–1744.
  • Gornik HL, Creager MA (2007). Diseases of the aorta. In EJ Topol, ed., Textbook of Cardiovascular Medicine, 3rd ed., pp. 1473–1495. Philadelphia: Lippincott Williams and Wilkins.
  • Hirsch AT, et al. (2006). ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): A collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation, 113(11): e463–e654.
  • Lederle FA, et al. (2009). Outcomes following endovascular vs open repair of abdominal aortic aneurysm: A randomized trial. JAMA, 302(14): 1535–1542.
  • Rooke TW, et al. (2011). 2011 ACCF/AHA Focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 58(19): 2020–2045.
  • Smith SC, et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: A guideline from the American Heart Association and American College of Cardiology Foundation. Circulation, 124(22): 2458–2473. Also available online: http://circ.ahajournals.org/content/124/22/2458.full.
  • United Kingdom EVAR Trial Investigators (2010). Endovascular versus open repair of abdominal aortic aneurysm. New England Journal of Medicine, 362(20): 1863–1871.
  • Whelton PK, et al. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
    Journal of the American College of Cardiology, published online November 13, 2017. DOI: 10.1016/j.jacc.2017.11.006.
    Accessed November 20, 2017.

Credits

ByHealthwise StaffPrimary Medical Reviewer E. Gregory Thompson, MD - Internal Medicine Kathleen Romito, MD - Family Medicine Adam Husney, MD - Family Medicine Specialist Medical Reviewer Jeffrey J. Gilbertson, MD - Vascular Surgery

Current as ofDecember 19, 2017

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