Aortic Aneurysm: Symptoms, Diagnosis and Modern Treatment Methods

What is an Aortic Aneurysm?

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The aorta is the main artery that emerges from the heart and distributes oxygenated blood throughout the body. The aortic wall consists of three layers: intima (inner layer), media (middle layer), and adventitia (outer layer). An aortic aneurysm is the enlargement of the aorta by at least 50% of its normal diameter due to weakening of these wall layers.

Anatomical Sections of the Aorta

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Ascending Aorta: First segment emerging from the heart, origin of coronary arteries.

Aortic Arch: Curved section giving branches to the brain and arms.

Descending Thoracic Aorta: Downward course within the thoracic cavity.

Abdominal Aorta: Section below the diaphragm within the abdominal cavity.

Aneurysm Types

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By Shape:

• Fusiform (Spindle-shaped): Symmetric enlargement around the entire circumference
• Saccular (Sac-like): Asymmetric protrusion from one area of the wall

By Location:

• Thoracic Aortic Aneurysm (TAA): Affects the aorta in the chest region
• Abdominal Aortic Aneurysm (AAA): Affects the aorta in the abdominal region (75-80%)
• Thoracoabdominal Aortic Aneurysm: Involves both regions

Causes and Risk Factors

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Structural and Genetic Causes

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Connective Tissue Disorders:

• Marfan syndrome
• Ehlers-Danlos syndrome (vascular type)
• Loeys-Dietz syndrome

Familial Predisposition:

• First-degree relatives with aneurysm history
• Genetic polymorphisms (FBN1, TGFBR1/2 genes)

Acquired Causes

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Atherosclerosis (Artery Hardening):

• Most common cause (80-90%)
• Lipid accumulation, inflammation, smooth muscle cell loss
• Particularly strong association with abdominal aortic aneurysm

Hypertension:

• Chronic pressure overload
• Degeneration of the medial layer
• Accelerates aneurysm growth

Infections (Mycotic Aneurysm):

• Complication of bacterial endocarditis
• Salmonella, Staphylococcus aureus
• Rapid progression and rupture risk

Trauma:

• Blunt or penetrating injuries
• Motor vehicle accidents, falls from height
• Pseudoaneurysm development

Vasculitides:

• Giant cell arteritis
• Takayasu arteritis
• Behçet’s disease

Risk Factors

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Non-modifiable Risk Factors:

• Age: Risk increases over 65 years
• Gender: 4-5 times more common in men
• Genetics: Family history (risk increases 2-4 fold)
• Race/Ethnicity: More common in Caucasians

Modifiable Risk Factors:

• Smoking: Strongest risk factor (risk increases 5-6 fold)
• Hypertension: Uncontrolled high blood pressure
• Hypercholesterolemia: High LDL, low HDL
• Obesity: Body mass index >30
• Sedentary Lifestyle: Lack of physical activity

Aortic Aneurysm Symptoms

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Asymptomatic Period

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The great majority of aneurysms (70-80%) are asymptomatic. They are discovered incidentally during imaging studies or routine examinations.

Thoracic Aortic Aneurysm Symptoms

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Compression Findings:

• Trachea and bronchial compression: Cough, shortness of breath, stridor
• Esophageal compression: Swallowing difficulty (dysphagia)
• Recurrent laryngeal nerve compression: Hoarseness
• Superior vena cava compression: Facial and neck swelling

Pain:

• Chest pain (often radiating to the back)
• Sharp, tearing sensation pain (suspicion of dissection)
• Constant, dull pain (growing aneurysm)

Other Symptoms:

• Aortic insufficiency (murmur, shortness of breath)
• Stroke or ischemia due to clot embolization

Abdominal Aortic Aneurysm Symptoms

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Early Stage:

• Mostly asymptomatic
• Pulsating sensation in abdomen
• Mild abdominal or back pain

Advanced Stage:

• Significant abdominal pain (may radiate to back)
• Palpable mass (especially in thin patients)
• Loss of appetite, nausea (gastrointestinal compression)

Emergency Symptoms (Pre-rupture or Rupture):

• Sudden, severe abdominal/back pain (“tearing sensation”)
• Hypotension, tachycardia
• Syncope (fainting)
• Shock findings (cold sweat, pallor, altered consciousness)

Diagnostic Methods

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Physical Examination

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Abdominal Aortic Aneurysm:

• Palpable enlarged, pulsatile mass
• Bruit (on auscultation)
• Evaluation of distal pulses

Thoracic Aortic Aneurysm:

• Chest wall asymmetry
• Murmur (aortic insufficiency)
• Focal neurological deficit (embolism)

Imaging Methods

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Ultrasonography (USG):

• Gold standard for abdominal aortic aneurysm screening and follow-up
• Non-invasive, radiation-free, inexpensive
• Diameter measurement, thrombus presence
• Limited thoracic imaging

Computed Tomography Angiography (CT Angio):

• Most valuable method for diagnosis and treatment planning
• 3D reconstruction capability
• Aneurysm diameter, length, neck, related vessels
• Measurements for endovascular treatment planning
• Contrast agent and radiation exposure disadvantages

Magnetic Resonance Angiography (MR Angio):

• Radiation-free alternative
• Non-contrast (TOF) or contrast-enhanced techniques
• Can show wall characteristics in connective tissue diseases
• Metal implant, claustrophobia limitations

Transesophageal Echocardiography (TEE):

• Detailed imaging for thoracic aorta evaluation
• Ideal for aortic valve and ascending aorta segment
• Invasive procedure requiring sedation

Conventional Angiography:

• Now used more during treatment than diagnosis
• Hemodynamic evaluation capability
• Invasive, contrast agent risk

Screening Recommendations

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Abdominal Aortic Aneurysm:

• USPSTF Recommendation: One-time ultrasonography screening in men aged 65-75 who have ever smoked at least 100 cigarettes
• ACC/AHA Recommendation: Men aged 65-75 who smoke or have family history; women aged 65-75 who smoke or have family history
• Family History: Screening at age 65 for those with first-degree relative with AAA

Thoracic Aortic Aneurysm:

• Regular echocardiography/TEE in Marfan syndrome, Ehlers-Danlos, or other connective tissue disorders
• Patients with bicuspid aortic valve
• Those with family history

Treatment Approaches

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Treatment decisions are individualized based on aneurysm characteristics, patient clinical status, and risk factors.

Medical Therapy and Monitoring

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Small Aneurysms (AAA <5.5 cm, TAA <5.5-6.0 cm):

• Regular imaging follow-up
• Diameter measurement every 6-12 months with CT or USG
• More frequent monitoring if growth rate >0.5 cm/year

Risk Factor Modification:

• Smoking Cessation: Most critical intervention
• Blood Pressure Control: Target <130/80 mmHg
• Statin Therapy: LDL <70 mg/dL (plaque stabilization)
• Beta Blockers: Slows progression in Marfan syndrome
• ACE Inhibitors/ARBs: TGF-β inhibition in connective tissue diseases

Surgical Treatment Indications

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Absolute Indications:

• Symptomatic aneurysm (pain, compression findings)
• Suspected rupture or dissection
• Rapid growth (>0.5 cm/6 months)
• Abdominal aortic aneurysm ≥5.5 cm (men), ≥5.0 cm (women)
• Thoracic aortic aneurysm ≥5.5-6.0 cm (without connective tissue disease)

Relative Indications:

• Family history of rupture
• Female patients (higher rupture risk)
• Aneurysm morphology (saccular, asymmetric)
• Young patient (long life expectancy)

Open Surgical Repair

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Abdominal Aortic Aneurysm:

• Transperitoneal or retroperitoneal approach
• Aneurysm opened and replaced with graft
• 95-98% success rate
• Hospital stay: 5-10 days
• Full recovery: 6-12 weeks

Thoracic Aortic Aneurysm:

• Sternotomy or thoracotomy
• Often requires cardiopulmonary bypass
• Hypothermic circulatory arrest (brain protection)
• Spinal protection techniques (CSF drainage)

Endovascular Therapies

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EVAR (Endovascular Aneurysm Repair):

• Minimally invasive alternative for abdominal aortic aneurysm
• Stent-graft placement via catheters through groin arteries
• Anesthesia: Usually spinal/epidural
• Hospital stay: 2-3 days
• Recovery: 2-4 weeks
• Requires long-term follow-up (endoleak monitoring)

TEVAR (Thoracic Endovascular Aortic Repair):

• Endovascular approach for thoracic aortic aneurysms
• More complex anatomical requirements
• Higher spinal ischemia risk
• Carotid-subclavian bypass may be needed if left subclavian artery coverage is required

Mixed/Hybrid Procedures:

• Open surgery + endovascular combinations
• Debranching + TEVAR for arch aneurysms
• Visceral debranching + EVAR for thoracoabdominal aneurysms

New Technologies and Developments

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Branched and Fenestrated Stent-Grafts:

• Increase EVAR/TEVAR applicability in complex anatomy
• Preservation of renal, mesenteric, arch branches
• Custom-made production

Flow Diverter Stents:

• For saccular aneurysms
• Diverts blood flow from aneurysm neck to promote thrombosis

Biological Grafts and Tissue Engineering:

• Infected (mycotic) aneurysms
• Homograft or bovine/pericardial grafts

Complications and Management

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Open Surgical Complications

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Early Period:

• Bleeding, infection
• Heart attack, arrhythmia
• Acute kidney failure
• Spinal ischemia (paraplegia risk 5-8% in thoracoabdominal)
• Colon ischemia (inferior mesenteric artery coverage)

Late Period:

• Graft infection
• Aortoenteric fistula
• Anastomotic aneurysm
• Graft occlusion

Endovascular Treatment Complications

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Endoleak (Blood Leak Around Stent-Graft):

• Type I: Proximal/distal attachment site leak (urgent intervention)
• Type II: Retrograde flow from lumbar/inferior mesenteric arteries (monitoring)
• Type III: Stent-graft component separation (intervention)
• Type IV: Graft porosity (resolves spontaneously)
• Type V: Endotension (diameter increase, no leak)

Other Complications:

• Stent migration, fracture
• Access artery injury (dissection, rupture)
• Renal artery coverage (kidney failure)
• Spinal ischemia (3-10% in TEVAR)
• Microembolism (blue toe syndrome)

Rupture and Dissection

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Aortic Dissection:

• Separation of aortic wall layers
• Stanford classification (Type A: ascending aorta involvement - emergency surgery; Type B: descending aorta only - medical/endovascular)
• Sudden tearing sensation pain
• Organ malperfusion (kidney, bowel, extremity)

Rupture Management:

• Emergency hemodynamic stabilization
• Blood transfusion protocols
• Emergency EVAR or open surgery
• Mortality: 80-90% (pre-hospital after rupture), 40-50% (with surgical intervention)

Follow-up and Lifestyle Recommendations

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Post-treatment Follow-up

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After EVAR/TEVAR:

• 30 days: Clinical evaluation, CT angio
• 6 months, 12 months: CT angio
• Annually thereafter: CT angio or USG/Duplex
• Monitoring for endoleak, migration, aneurysm size

After Open Surgery:

• 30 days: Clinical evaluation
• 6 months, 12 months: USG/CT (graft function, anastomosis)
• Every 2-3 years thereafter: Imaging

Lifestyle Modifications

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Exercise Recommendations:

• Regular moderate-intensity aerobic exercise (walking, swimming)
• Avoid heavy lifting (especially Valsalva maneuver)
• Avoid activities that suddenly raise blood pressure

Nutrition:

• Mediterranean diet (olive oil, vegetables, fruit, fish)
• Salt restriction (<5 g/day)
• Saturated fat and cholesterol limitation

Medication Adherence:

• Regular use of antihypertensive medications
• Statin therapy (plaque stabilization)
• Antiplatelet therapy (if stent present)

Regular Check-ups:

• Blood pressure monitoring (home measurement)
• Lipid profile, kidney function tests
• Cardiology/vascular surgery follow-up

Frequently Asked Questions (FAQ)

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When to See a Doctor?

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Seek medical help without delay if you experience:

1. New or changing pain: Chest, back, or abdominal pain
2. Shortness of breath, cough, hoarseness
3. Swallowing difficulty
4. Pulsating sensation or mass in abdomen
5. Sudden severe pain (suspicion of rupture/dissection)
6. Dizziness, fainting, shock symptoms
7. Family history of aortic aneurysm or rupture for screening
8. Smoking history + over 65 years in men for screening

Especially if you are in a high-risk group (smoking, hypertension, family history), regular cardiovascular evaluation is critical for early diagnosis and complication prevention.

Schedule an Appointment

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You can schedule an appointment for aortic aneurysm evaluation, screening, or information about treatment options.