Can You Live With an Aortic Aneurysm?

“Aneurysm” is a scary word for most people. Abnormal, balloon-like bulges that form in the walls of arteries, aneurysms have the reputation of being silent killers that can strike without warning. And while many people think of an aneurysm as something that happens in the brain, it can occur almost anywhere in the body.

The most common type of aneurysm is an aortic aneurysm, which forms in the aorta: the major blood vessel that carries oxygenated blood away from the heart to the rest of the body. Fortunately, not all aortic aneurysms rupture and lead to death. Aortic aneurysms can usually be managed successfully through monitoring and, when needed, repaired with minimally invasive surgery.

William Yoon, MD, a vascular surgeon and endovascular specialist with University Hospitals Harrington Heart & Vascular Institute, answers some common questions about aortic aneurysms.

What causes aortic aneurysms?

The bulging of an aortic aneurysm occurs as a result of a weakening in a part of the aortic wall. The exact cause of the weakening is not known.

Aortic aneurysms occur most often in the portion of the aorta that runs through the abdomen. These aneurysms are known as abdominal aortic aneurysms, or AAAs. Aneurysms that form in the section of the aorta that runs through the chest are called thoracic aortic aneurysms. AAAs are more common than thoracic aortic aneurysms.

Who gets aortic aneurysms?

The biggest risk factors for developing an aortic aneurysm are age and being male. Men are six times more likely than women to develop an AAA. Other significant risk factors include smoking, high blood pressure and high cholesterol. You can reduce your aneurysm risk by modifying these risk factors. Also, having a family history of aortic aneurysm puts people at higher risk for developing one themselves.

Is an aortic aneurysm considered a medical emergency?

Most aortic aneurysms do not pose a serious threat. However, larger aneurysms can possibly rupture. A ruptured aneurysm can cause massive internal bleeding, shock and death. As such, a ruptured aneurysm is always considered a medical emergency. In fact, only about one in five patients survive a ruptured AAA.

How long can someone typically survive without medical treatment following rupture of an aortic aneurysm?

When left untreated, ruptured aortic aneurysms are almost always fatal within several hours to a week, depending on the size of rupture.

How quickly do aortic aneurysms develop?

Aortic aneurysms grow slowly, typically 1 to 2 millimeters a year. An aortic aneurysm is usually classified as “large” once it reaches a diameter of 5.5 centimeters.

How would you know if you had an aortic aneurysm?

Unless they are large, AAAs usually do not cause symptoms. Therefore, they tend to be diagnosed either as a result of screening or incidentally during the course of an unrelated procedure – for example, during a routine medical examination.

But some people may develop abdominal pain if the aneurysm becomes large and puts pressure on adjacent organs. Other people with a larger aneurysm may feel a pulsating sensation in their abdomen or experience persistent back pain.

If you have symptoms that could possibly be caused by an aortic aneurysm, when should you call a doctor?

Whatever your symptoms, if you feel you are unable to manage them, you should call your doctor. Some signs that you need to seek emergency care include:

• Fast heartbeat or heart palpitations
• Dizziness
• Fainting
• Nausea and vomiting
• Shortness of breath
• Clammy, sweaty skin
• Sudden, severe pain in your belly, chest, lower back or legs

What activities could make an aortic aneurysm worse?

Activities that increase your blood pressure, such as vigorous physical activity or heavy lifting, can put additional pressure/stress on your aneurysm. In addition, emotional stress can raise blood pressure.

What is the most effective treatment for aortic aneurysms?

We repair aortic aneurysms using either open surgery or endovascular surgery. In endovascular aneurysm repair (EVAR), we use X-ray guidance and special instruments to access an aneurysm through a small incision or incisions made in the groin. We then insert a stent graft inside the aorta at the site of the aneurysm. Also called an endograft, a stent graft is a tube made of fabric supported by a metal mesh. The endograft relines the weakened part of the aorta to help prevent the artery from future rupture.

When endovascular repair is done on a thoracic aortic aneurysm, the procedure is called thoracic endovascular aortic repair (TEVAR). Because EVAR and TEVAR are both minimally invasive treatments, they are the preferred surgery options for many people and an alternative for patients who are unsuitable for open surgery.

However, to be a suitable candidate for EVAR or TEVAR, certain general anatomic criteria must be fulfilled. Consequently, EVAR and TEVAR are not appropriate for all patients. EVAR and TEVAR presently account for nearly 50 percent of all aortic aneurysm repairs performed in the U.S.

What are outcomes like for people with aortic aneurysms?

Outcomes depend on the size of the aortic aneurysm and its location. Because aortic aneurysm is a progressively degenerative disease that, if left undiagnosed and untreated, may lead to a life-threatening rupture, outcomes are closely tied to diagnosis and screening.

The United States Preventive Services Task Force recommends that men ages 65 to 75 years who have smoked in their lifetime get a one-time ultrasound screening for AAA, even if they do not have symptoms. If an aneurysm is detected, the person will be monitored regularly. Repair is done if the aneurysm grows greater than 5.5 centimeters or is seen to grow more than 0.6 to 0.8 centimeter per year.

Once an aortic aneurysm has been repaired, patients tend to remain stable for the rest of their lives. However, because AAA is a progressive disease that can cause continuous expansion of the aorta even after surgical repair, complications occur that require a secondary surgical intervention in approximately 19 percent of EVAR cases and 24 percent of TEVAR cases. Fortunately, most secondary interventions can be performed with minimally invasive techniques.

Medicare covers one AAA screening ultrasound for people who are at risk. Why isn’t thoracic aortic aneurysm screening covered, too?

Thoracic aneurysms are less common than AAAs, hence the difference in Medicare coverage for screening. AAAs are the most common type of aneurysm overall, accounting for 75 percent of all aortic aneurysms. That said, if your doctor suspects you have a thoracic aortic aneurysm, imaging tests such as echocardiogram, CT and MRI can be done to screen for it.

Are there any new treatments for aortic aneurysm in development?

A present, our ability to repair complex aortic aneurysms with endovascular surgery is limited by the need to maintain blood flow to vital organs. Conventional endografts cannot be used in certain types of complex aortic aneurysms because they would block blood flow to organs such as the kidneys, intestines and liver. Instead, we must use special endografts (called fenestrated or branched endografts) for these patients.

Most of the fenestrated or branched endografts we now use must be custom manufactured or modified by the physician to fit the patient’s specific anatomy. As such, an important area of research at the moment is the development of off-the-shelf fenestrated and branched endografts—ones that are immediately ready for use and do not require modification. Clinical trials in the U.S. are currently underway for such endografts.