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By Sean V. Ryan, M.D., Vascular and Endovascular Surgeon
The Chester County Hospital
Published: January 15, 2007
The Aorta is the main blood vessel in the body. Beginning from the heart and traveling down the center of the body, it supplies blood to the vital organs of the body. The normal size of the aorta is about 2 cm or roughly the diameter of your thumb. An aneurysm, or dilation of the vessel, occurs due to a structural weakness in the wall of the vessel. Although any vessel in the body can become aneurysmal, the most common location is the aorta in the abdomen. In most cases, atherosclerosis or "plaque" build-up in the wall is present. Abdominal aneurysms typically occur after the age of 60. Approximately a quarter of patients have a relative or sibling with an aneurysm suggesting a genetic predisposition. Men are at higher risk.
Abdominal aortic aneurysms (AAA) are a silent killer because most patients do not experience symptoms until catastrophe occurs. With any aneurysm, one of two consequences can occur. First, the vessel could rupture due to extreme weakening of the wall resulting in life threatening internal bleeding. The risk of rupture rises rapidly after the vessel has dilated to over 5 cm. This is a surgical emergency that without treatment will lead to death. Second, blood clots which form in the lumen could break off damaging distal organs leading to limb loss or organ dysfunction. Unfortunately, abdominal aortic aneurysms tend to rupture. Symptoms that herald a rupture include severe abdominal or back pain associated with dizziness, or loss of consciousness.
The diagnosis of an AAA is typically made when a CT scan, MRI or ultrasound of the abdomen are done for some other reason. Occasionally, a "pulsatile mass" is noted on physical exam but this is an extremely unreliable method of detection.
Once an AAA is found, the only treatment is surgical repair. In general, aneurysms less than 5 cm have a low risk of rupture and routine surveillance to monitor growth is appropriate. Unfortunately, it will not regress, but sometimes it can remain stable for long periods of time. Once the aneurysm reaches 5 cm, repair should be considered because the risk of rupture exceeds the risks associated with surgery. Most patients can undergo elective aneurysm repair with less than a two percent risk of death or major morbidity. This is in contrast to the emergent rupture that carries a 50-to-80 percent risk of death.
Traditional open surgery entails opening the abdomen, exposing the aorta and replacing the aneurysmal portion with a prosthetic tube graft. Typically, patients spend seven-to-10 days in the hospital and need four-to-six weeks to fully recover. In the past 15 years, the treatment of AAA has undergone a minimally invasive revolution. Currently, 60-to-70 percent of patients are candidates for minimally invasive endograft repair. This procedure is performed by exposing the arteries in the groin with small incisions. A graft housed inside a catheter is advanced from the groin arteries to abdominal aorta under x-ray guidance. The graft is opened inside the aorta allowing attachment to the normal aorta above and below the aneurysm. In effect, flow is directed through the graft thereby excluding the aneurysm. In most cases, patients go home the next day. The decision to perform traditional surgery or endograft repair will depend on several factors, most importantly the anatomy of the aneurysm. Since this is relatively new, make sure your vascular surgeon performs this procedure before undergoing traditional repair.
The key to AAA survival is early detection and elective treatment. If you are a past or present smoker and over age 60, or have a relative with an aneurysm, get tested!
This article was published as part of the Daily Local News Medical Column series which appears every Monday. It has been reprinted by permission of the Daily Local News.
Last Updated: 7/27/2009