Men are significantly more likely to develop an aortic aneurysm than women. Genetic factors are discussed as a further cause in cases of familial clustering of the disease.
One of the main causes of aortic aneurysm formation is arteriosclerosis, the "calcification" of the blood vessels. High blood pressure can also weaken the arterial wall in the long term. 90 - 95 % of all aortic aneurysms are caused by these circulatory diseases.
Patients have so-called plaques (= calcium deposits) in the vessel wall. These damage the wall structure and cause the vessel to harden (= sclerosis). This reduces the elasticity of the aorta and causes it to widen.
If increased blood pressure is added to the wall damage, the blood vessel can eventually burst. If only the vessel wall tears without breaking through, the doctor speaks of an aortic dissection. In this case, blood flows between the tissue layers of the aorta.
Rupture of the aneurysm is a serious complication. Large amounts of blood immediately flow into the chest or abdominal cavity. The subsequent lack of volume in the circulatory system quickly leads to shock.
Shock is a life-threatening condition. Less than 10% of patients with aortic rupture survive this emergency. Another 10 - 15 percent reach the hospital alive, but only about half of them are saved in an emergency operation. The risk of rupture increases with the increasing diameter of the aortic aneurysm. The risk is particularly high from a diameter of more than 5 cm.
There are also cases of patients who suffer from a congenital weakness of the connective tissue. Such possible connective tissue diseases can be
- Marfan syndrome
- Ehlers-Danlos syndrome
- Erdheim-Gsell cystic medianecrosis
What they all have in common is the defective structure of the connective tissue in the blood vessel wall. This leads to the vessel wall becoming more unstable and giving way.
Inflammatory diseases can also weaken the vessels and lead to an aortic aneurysm.
There is an increased risk with:
- Syphilis in the late stages
- Takayasu arteritis
Rarer causes of an aortic aneurysm are
- congenital malformations
- Hormonal changes, e.g. during pregnancy
- Injuries in the chest area
- contact with harmful substances (e.g. cocaine)
The aortic aneurysm is often asymptomatic. However, the following symptoms may also occur:
- hoarseness
- shortness of breath
- shoulder pain
- back problems
- Coughing up blood
However, the doctor most frequently discovers the aortic aneurysm as an incidental finding during an X-ray examination.
Thoracic aortic aneurysm
The aortic aneurysm in the chest area is usually caused by existing arteriosclerosis, high blood pressure and inflammatory processes in the vessel wall. Injuries to the chest can also lead to an aortic aneurysm of the thoracic aorta either suddenly (= acute) or after several years (= chronic).
Chest pain can be a sign of a thoracic aortic aneurysm
A special form is aortic dissection. This involves a tear in the wall of the aorta. This causes blood to flow between the different layers of the aortic wall. At an early stage, there are often no symptoms. However, if the aortic aneurysm continues to grow, the following symptoms may occur:
- Chest pain
- difficulty swallowing
- hoarseness
- Paralysis of the legs
- Kidney problems
Aneurysm of the abdominal aorta (abdominal aortic aneurysm)
The abdominal aortic aneurysm usually manifests itself in abdominal pain. Diffuse back pain that resembles "lumbago" or renal colic is just as likely. Very large aneurysms may appear as a pulsating lump on the abdomen.
Abdominal pain can be a sign of an abdominal aortic aneurysm
If the abdominal aneurysm ruptures, a life-threatening state of shock quickly sets in. Patients often describe severe "annihilation pain" and abdominal pain that radiates to the back. Nausea and nausea also occur.
Due to the high blood loss after a rupture, the person bleeds to death internally within a very short time. Life can only be saved by immediate surgery.
The diagnosis is made by clinical examination by palpation of the abdomen and by ultrasound. During such routine ultrasound examinations of the abdomen, the aortic aneurysm is usually found by chance. Larger aneurysms must be examined using computer tomography(CT) and contrast medium.
Vascular surgeons must view and assess the CT images so that treatment can be better planned. A report by theradiologist alone is not sufficient.
The doctor can diagnose the aortic aneurysm via ultrasound
An aortic aneurysm normally enlarges over the years. The risk of a rupture must therefore always be considered. For this reason, even small aneurysms are regularly examined by ultrasound. A small aortic aneurysm does not often rupture, but it can cause pain.
Before an aortic aneurysm is operated on, the blood values are checked. Thyroid hormones and kidney values are of particular interest here. These values are checked again shortly before CT or treatment.
The patient must be physically fit to survive the operation. This can be determined with the help of an ECG and lung function test . If the patient also suffers from heart problems, a cardiologist will assess the patient's suitability for the procedure.
An aortic aneurysm can be a life-threatening condition, depending on its severity and location. It is not always operable and the risk of aneurysm rupture increases with further growth .
Patients are usually afraid of bleeding. This considerably reduces their quality of life. They often avoid sport and jerky movements, which promotes risk factors such as obesity and arteriosclerosis.
In many cases, those affected are treated with medication. This reduces the risk of the aortic aneurysm progressing and slows down the course of the disease.
Severe cases of aortic aneurysms are usually treated surgically. Complications can also occur. This cannot always be predicted in advance, so a special risk-benefit assessment is always carried out.
In any case, the doctor should inform the patient that an aortic aneurysm can reduce life expectancy with increasing age.
The disease progresses slowly over the years and is not reversible.
If the aortic aneurysm is smaller than 4 cm, a wait-and-see approach is usually taken. The patient must then be examined annually using ultrasound. Above this size, a six-monthly check-up follows.
There are a number of risk factors that promote the further growth of an aortic aneurysm:
- Diabetes mellitus
- High blood pressure (hypertension)
- High cholesterol and blood lipid levels
- obesity
- Nicotine and alcohol
Those affected should eat a healthy and varied diet to avoid putting additional strain on the metabolism and blood vessels. This is because the combination of malnutrition and arteriosclerosis is an important cause of the formation and further growth of the aortic aneurysm.
The larger the aortic aneurysm becomes over time, the greater the risk of a rupture of the aorta. Surgery should be performed if the diameter is more than 5.5 cm in the thoracic aorta and 5 cm or more in the abdominal aorta.
In the case of smaller diameters, the attending physician decides depending on the symptoms and shape of the aortic aneurysm. Any thrombi that may have formed are also important for the assessment of the aortic aneurysm. Blood congestion can not only lead to reduced blood flow to tissues and organs, but can also cause the aneurysm to swell further.
The technique of minimally invasive treatment has been developing steadily for many years. Under certain circumstances, the patient is spared an incision in the chest or abdomen to expose the aorta. Instead, the doctor punctures the femoral arteries and advances a catheter into the aortic aneurysm.
The doctor then implants the aortic stent there. The stent replaces and relieves the blood vessel. This minimally invasive operation is gentle on the patient. However, stents do not last indefinitely. Several follow-up operations may therefore be necessary. Minimally invasive care is particularly useful for older patients who often suffer from secondary diseases. These factors increase the risk of open surgery.
The minimally invasive method cannot be used for certain types of aortic aneurysm. This is the case if there are problems with the stent prosthesis or in an acute emergency if the aortic aneurysm has burst. In these cases, open surgery may often be necessary.
The surgeon exposes the abdominal aorta with an abdominal or flank incision. He then replaces the part with the aortic aneurysm with a plastic tube, the aortic prosthesis.
Open surgery is always possible and offers long-term durability. The decision for one of the two treatment methods is made together with the patient. The doctor takes this into account:
- Concomitant diseases,
- life circumstances and
- the personal wishes
of the patient.
How does the operation to insert a stent for an aortic aneurysm work? The following sections explain the operation in detail:
Before the operation
A number of examinations are carried out before the operation in order to better plan the procedure. The doctor then decides which stent is most suitable. He then discusses his plans with the patient.
Operation on a thoracic aortic aneurysm
Before the operation begins, the patient's groin area is cleaned and disinfected. The area is then anesthetized locally or the patient is given a general anesthetic. The doctor then makes a small incision in the groin area. He inserts the catheter and stent into the artery in the groin area.
The success of this procedure is checked using an X-ray(angiography). The surgeon can see the exact location of the aortic aneurysm in the X-ray image and can advance the catheter to this point. The stent is then placed inside the aneurysm and adjusted to the width of the blood vessel.
The catheter is then pulled out of the artery; the inserted stent remains in place. If the aortic aneurysm is very large, the doctor can place several stents.
Mini-invasive stent surgery for an aortic aneurysm © bilderzwerg | AdobeStock
Surgery for an abdominal aortic aneurysm
As with the thoracic aorta, there are various procedures available for treating an abdominal aortic aneurysm. Open surgery is performed on the exposed abdominal aorta after the abdominal cavity has been opened.
The artery is stapled above and below the aortic aneurysm in order to temporarily stop the blood flow. The aneurysm sac is then opened and a vascular substitute is inserted as a prosthesis . Depending on the size of the aortic aneurysm, either a tubular or a bifurcation prosthesis is implanted.
Open surgery is possible for all patients without restrictions.
The stent procedure, on the other hand, is not possible for everyone due to different anatomical conditions. However, older patients and high-risk patients benefit from the stent procedure due to the lower risk.
The time after the operation
After the procedure, you will need to stay in hospital for a few days for monitoring. Patients must initially lie quietly for four to six hours to support healing in the groin area. After-effects of the operation may include
- Swelling of the thigh
- Numbness in the legs
- Discomfort, nausea and vomiting
- pulsating pain in the legs
- Loss of appetite with/without fever
On average, patients leave hospital after a minimally invasive aortic aneurysm operation after 5 days. After a further 1-2 weeks, patients can return to their daily work routine.
Patients should not lift heavy weights for up to 3 months after open surgery to avoid the risk of an incisional hernia. To prevent thrombus formation, you will be given so-called platelet aggregation inhibitors. These reduce blood clotting.
Anyone who has been operated on using the endovascular method must have an annual CT check-up. In the open procedure, ultrasound procedures replace the CT scan.
The rupture of an abdominal aortic aneurysm is a life-threatening emergency. In comparison, aortic aneurysm surgery using a stent or open surgery is a much lower risk. Nevertheless, aortic surgery is not without risks. However, these are often calculable and are mostly based on complications due to inflammation:
- Infections
- pneumonia
- Cardiovascular problems
Blood leakage can also occur when a stent is inserted. This means that blood leaks into the aneurysm sac (= "endoleak"). If the leak does not close by itself, it must be closed again using catheter treatment. Surgery on an aortic aneurysm may lead to temporary circulatory problems in the kidneys, intestines and legs.
Open surgery always carries the risk of damaging other abdominal organs. The operating doctors may discover other diseases in the open abdominal cavity that they have to operate on immediately.
Successful treatment includes regular blood circulation checks and ultrasound examinations.
An aneurysm can be congenital or develop over the course of a lifetime. An acquired aneurysm often takes years to form and can increase significantly in size during this time.
Aneurysms frequently occur in the abdomen, brain, heart and chest. Due to the long development time until a visible aneurysm appears, the disease is predominantly noticeable above the age of 50.
Meta-analyses of brain aneurysms have shown that around 9% of aneurysms enlarge within a period of around 3 years. The long-term risk of enlargement within the next 19 years was also around 45%. Using the ELAPPS score, experts estimate the risk of growth within the next 3-5 years based on 6 risk factors:
- Previous aneurysm rupture
- Place of origin of the aneurysm
- Age - especially from 65 years onwards
- Geographical origin of the patient
- Aneurysm size
- Shape of the aneurysm
The risk of an aortic aneurysm can be significantly reduced in some cases by adopting an appropriate lifestyle. This includes plenty of exercise and a healthy, low-fat and low-sugar diet. This allows you to minimize the main risk factors of aneurysm - arteriosclerosis and high blood pressure.
A healthy diet and exercise minimize the risk of an aortic aneurysm
People with a congenital weakness of the connective tissue often develop an aortic aneurysm. They should therefore pay particular attention to the symptoms and seek medical advice and an ultrasound scan if necessary.
