Aortic Aneurysm

Types of aortic aneurysm

Aneurysms that span both chest and abdomen are called thoracoabdominal aneurysms. For details on the belly type, see abdominal aortic aneurysm, and for the chest type, thoracic aortic aneurysm.

Causes and risk factors

• Smoking: the strongest modifiable risk factor for AAA. It also speeds growth.
• Age and sex: risk rises after 65 and is several times higher in men, although aneurysms in women rupture at smaller sizes.
• High blood pressure and atherosclerosis.
• Family history: a first-degree relative with an aneurysm significantly raises your risk.
• Genetic connective tissue disorders: Marfan syndrome, Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome and Turner syndrome, which cause thoracic aneurysms at young ages.
• Bicuspid aortic valve, a common inherited heart valve variant.
• Inflammation and infection: giant cell arteritis, Takayasu arteritis and, rarely, infected (mycotic) aneurysms or syphilis.
• Fluoroquinolone antibiotics have been linked to a small increased risk in people already at risk.

Symptoms

Most aortic aneurysms are silent. When symptoms occur:

• AAA: a pulsing feeling near the navel, deep belly or back pain, or a tender pulsating mass.
• TAA: chest or upper back pain, hoarseness (pressure on a voice box nerve), cough, difficulty swallowing or breathlessness.

New pain in someone with a known aneurysm may mean it is expanding or about to rupture.

Rupture and dissection

• Rupture: sudden, severe belly, back or flank pain, collapse, low blood pressure and rapid pulse. Most people with a ruptured AAA die before or during treatment, which is why prevention matters.
• Aortic dissection: a tear in the inner wall lets blood split the layers. It causes sudden tearing chest or back pain and can cause stroke, limb ischemia or kidney failure. It is an emergency.

Screening

The US Preventive Services Task Force recommends a one-time abdominal ultrasound for men aged 65 to 75 who have ever smoked. Men in that age group who never smoked can be screened selectively. Many experts also recommend screening first-degree relatives of people with aneurysms. People with Marfan syndrome, bicuspid valves or a family history of thoracic aneurysms need regular imaging of the chest aorta.

Diagnosis

• Ultrasound for abdominal aneurysms: quick, safe, and used for monitoring.
• CT angiography: precise size and shape, essential for planning repair.
• Echocardiogram and MRI for the aortic root and ascending aorta.

Treatment

Small aneurysms: watch and reduce risk

• regular imaging, every 6 months to 3 years depending on size
• stop smoking, the single most important step
• control blood pressure and cholesterol, often with a statin
• avoid fluoroquinolone antibiotics when alternatives exist
• moderate exercise is encouraged. Very heavy lifting or straining may be discouraged with large thoracic aneurysms.

When repair is recommended

Repair is usually advised when the risk of rupture outweighs the risk of surgery:

• AAA: about 5.5 cm in men, 5.0 cm in women, growth over 1 cm a year, or any symptoms
• Ascending TAA: about 5.5 cm in most people, smaller (often 4.5 to 5.0 cm) with Marfan syndrome, other genetic conditions or a bicuspid valve
• Descending TAA: about 5.5 to 6.0 cm

Types of repair

• Endovascular repair (EVAR or TEVAR): a stent graft is guided through the groin arteries and expanded inside the aneurysm. Recovery is faster, but lifelong scan surveillance is needed.
• Open surgery: the weakened section is replaced with a fabric graft. It is a bigger operation but very durable, and preferred for some anatomy and for younger patients with genetic disease.

Outlook

Small aneurysms grow slowly, often 1 to 3 mm a year for AAA, and many never need repair. After successful repair, life expectancy is close to that of people of the same age with similar heart risk factors. The outlook after rupture is poor, which makes screening and follow-up so valuable.

Frequently asked questions

What are the warning signs of an aortic aneurysm?

Most aneurysms have no warning signs. Some cause a pulsating feeling in the belly, deep back or belly pain, or chest pain, hoarseness or difficulty swallowing in the chest type. Sudden severe pain with fainting suggests rupture or dissection and is an emergency.

What size of aortic aneurysm needs surgery?

For abdominal aneurysms, repair is generally recommended at about 5.5 cm in men and 5.0 cm in women, or if growing more than 1 cm a year or causing symptoms. Thoracic aneurysms are usually repaired at about 5.5 cm, or earlier with genetic conditions.

What causes an aortic aneurysm?

The aortic wall weakens from a combination of smoking, aging, high blood pressure, atherosclerosis and genetics. Inherited connective tissue disorders such as Marfan syndrome and a bicuspid aortic valve are important causes of thoracic aneurysms in younger people.

Can an aortic aneurysm shrink?

Aneurysms do not usually shrink on their own. Stopping smoking and controlling blood pressure slow growth. After endovascular repair, the aneurysm sac often shrinks over time because it is no longer pressurized.

Can you live a normal life with an aortic aneurysm?

Most people with small aneurysms live normally with regular monitoring, not smoking, blood pressure control and moderate exercise. Your doctor may advise against very heavy lifting or straining if the aneurysm is large. Know the warning signs and attend follow-up scans.