Aneurysm - Causes, Symptoms, and Treatment Options | Expert Guide

Wednesday, 24 January 2024

The aorta, the largest artery in the body, receives the blood ejected from the left ventricle and carries it throughout the body except to the lungs. Like a big tree, it branches into smaller branches from the left ventricle to the lower part of the abdomen in the pelvic area.



ANEURISM: General | Aneurysms | Abdominal Aortic Aneurysms | Symptoms | Diagnosis | Treatment | Thoracic Aortic Aneurysms | Symptoms | Diagnosis  |Treatment | Aortic dissection | Understanding Aortic Dissection | Symptoms | Diagnosis | Treatment | Forecast | Diseases of veins and lymphatic vessels | Questions and Answers | Sources/references



Among the changes that affect the aorta are weak spots in its wall that allow the formation of expansions (aneurysms), external tears and bleeding, and separation of the layers of the aortic wall (dissection).

Image: Showing the aorta and its large branches.



Aneurysms

An aneurysm is an enlargement of an arterial wall, usually the wall of the aorta. Expansion usually occurs in a weak area of the wall. Although aneurysms can develop anywhere along the aorta, three-quarters occur in the abdominal segment. Aneurysms can be bag-shaped (saccular) or spindle-shaped (fusiform). Most are spindly. Aortic aneurysms are mainly caused by arteriosclerosis, which weakens the aortic wall so that the pressure in the vessel bulges outward.

A blood clot (thrombus) often forms in an aneurysm, which can spread along its entire wall. High blood pressure and smoking increase the risk of aneurysms. The tendency to aneurysms is increased by injuries, inflammatory diseases of the aorta, and hereditary connective tissue diseases, e.g., Marfan syndrome and syphilis. In patients with Marfan syndrome, the aneurysm is most common in the ascending part (the part that originates from the heart and goes up).

Image: Aortic aneurysms are mainly caused by arteriosclerosis.

aneurysms.jpg

Aneurysms can also develop in other arteries, not only in the aorta. Many arise from congenital weakness or arteriosclerosis; others are the result of stab or gunshot injuries or bacterial or fungal infections in the arterial wall. The infection usually starts elsewhere in the body, most often in the heart valve. Infected aneurysms in the arteries leading to the brain are particularly dangerous, so early treatment is essential. Treatment often involves surgical repair, which is very risky.



Aneurysms of the abdominal aorta

Aneurysms in the area of the aorta that passes through the abdomen often run in families. They often develop in people with high blood pressure. Such aneurysms are often giant, 8 cm wide, and can rupture (the average diameter of the aorta is 2 to 2.5 cm).



Symptoms

People with an abdominal aortic aneurysm often experience a throbbing sensation in their abdomen. Aneurysm can cause pain, which is usually deep and piercing and occurs mainly in the back! It can be severe and is usually constant, although changing body position relieves the pain in some patients. The first sign of rupture is usually severe pain in the lower abdomen and back and tenderness in the area above the aneurysm. With severe internal bleeding, the patient quickly goes into shock. The rupture of an abdominal aneurysm is often fatal.



Diagnosis

Pain is an early but late sign. Many people with an aneurysm, however, have no symptoms, and the change is discovered by chance during a routine medical exam or an X-ray needed for something else. The doctor usually feels a pulsating mass in the middle of the abdomen. Aneurysms that are increasing and could soon rupture are often painful or tender to pressure during an abdominal examination. In obese people, sometimes even giant aneurysms cannot be detected.



Video content: Understanding Abdominal Aortic Aneurysm.

Several tests can help diagnose an aneurysm. X-ray imaging of the abdomen reveals an aneurysm with calcium deposits in the wall. An ultrasound scan usually clearly shows the size of the aneurysm. A CT scan of the abdomen shows the size and shape of the aneurysm even more accurately, especially if it is done after an intravenous injection of a contrast agent, but this test is more expensive. Magnetic resonance imaging is also accurate but is more expensive than an ultrasound examination and rarely needed.



Treatment

If the aneurysm is not about to rupture, treatment depends on its size. Aneurysms less than 5 cm in diameter rarely rupture, but the risk is much greater if the size exceeds 6 cm. Therefore, doctors usually recommend surgery for aneurysms that measure more than 5 cm unless the intervention is too risky due to another medical condition. During surgery, a synthetic graft is placed on the vessel to repair the aneurysm. Mortality in such interventions is approximately 2%.

Image: Rupture of an abdominal aneurysm is often fatal.

abdominal aneurysm.jpg

Rupture or threatened rupture of an abdominal aneurysm requires emergency surgery. The risk that a patient will die during surgery due to a ruptured aneurysm is approximately 50%. If the aneurysm ruptures, the kidneys are at risk due to impaired blood flow or shock associated with blood loss. If kidney failure develops after surgery, the chances of survival are abysmal. Untreated aneurysm rupture is always fatal.



Aneurysms of the thoracic aorta

A quarter of all aortic aneurysms occur in the area of the aorta that passes through the chest. A prevalent form of thoracic aortic aneurysm is an expansion at the point where the aorta leaves the heart. The enlargement can cause the valve between the heart and the aorta (aortic valves) to malfunction, so the valve begins to leak (when it closes, some of the blood flows back into the ventricle). About 50 percent of patients with this change have Marfan syndrome or a variant. In the remaining 50 percent, the change has no apparent cause, but many of these patients have high blood pressure.



Symptoms

Thoracic aortic aneurysms can become giant without causing symptoms. Symptoms appear due to the pressure of the enlarged aorta on the surrounding area. Symptoms include pain (usually in the upper back), cough, and wheezing. The patient may cough up blood due to pressure on the trachea, nearby airways, or ulcers. Pressure on the esophagus, through which food passes into the stomach, sometimes makes swallowing difficult.

Pressure on the nerve that innervates the larynx causes hoarseness. The patient may experience a cluster of symptoms (Homer's syndrome), including a narrowed pupil, a droopy eyelid, and sweating on only one side of the face. A chest X-ray may show a pushed-down trachea. Abnormal pulsation of the chest wall can also be a sign of a thoracic aortic aneurysm.

Video content: Questions and answers about thoracic aortic aneurysms.

If a thoracic aortic aneurysm ruptures, there is usually severe pain in the back. As the tear progresses, the pain may radiate down the back and into the abdomen. The patient can also feel it in the chest and arms, which imitates the pain of a heart attack. The victim may quickly go into shock and bleed to death.



Diagnosis

A doctor diagnoses a thoracic aortic aneurysm based on symptoms or accidentally discovers it during an examination. A chest X-ray taken for another reason may reveal an aneurysm. Computed tomography (CT), magnetic resonance imaging (MRS), or ultrasound examination through the esophagus (transesophageal ultrasound) is used to determine the exact size of the aneurysm. Aortography, an X-ray after the injection of a contrast medium (which shows the outline of the aneurysm), usually helps doctors decide whether and what kind of surgery is needed.



Treatment

If the thoracic aortic aneurysm is more comprehensive than 7 cm, doctors usually decide on surgical repair with a synthetic implant. Because patients with Marfan syndrome are at greater risk of rupture, surgery is considered even for smaller aneurysms. The risk that a patient will die during the repair of a thoracic aortic aneurysm is high - from 10 to 15 percent. Therefore, your doctor may prescribe beta-blocker therapy to slow your heart rate and lower your blood pressure to reduce the risk of rupture.



Aortic dissection

Aortic dissection (dissecting aneurysm) is an often fatal event in which the inner layer of the aortic wall ruptures, but the outer layer remains intact; blood flows through the tear, dissects (dissects) the middle layer and creates a new channel in the wall of the aorta.



Understanding Aortic Dissection

During aortic dissection, the inner layer of the aortic wall is torn, and blood flows through the tear, splitting the middle layer and creating a new channel in the wall (dissection). Involvement of the arterial wall is responsible for most aortic dissections. The most common cause of such impairment is high blood pressure; two-thirds of people who develop aortic dissection have it.

Image: Involvement of the arterial wall is responsible for most aortic dissections.

dissection.jpg

Other causes include hereditary connective tissue diseases, especially Marfan and Ehlers-Danlos syndrome, congenital heart and vascular defects (e.g., coarctation of the aorta, patent ductus arteriosus, and aortic valve defects), arteriosclerosis, and trauma. In rare cases, the dissection develops accidentally when the doctor inserts a catheter into the artery (e.g., during aortography or angiography) or operates on the heart. Veins.



Symptoms

Almost everyone who experiences an aortic dissection experiences pain - usually, it comes on suddenly and is violent. Most often, patients feel tearing or tearing pain in the chest. It is also common in the back between the shoulder blades. Pain often accompanies the progression of the dissection as it spreads along the aorta. As the dissection progresses, it may occlude the outflow tract of one or more arteries originating from the aorta. Depending on which arteries become blocked, the result can be a stroke, heart attack, sudden abdominal pain, nerve damage that causes tingling, and the inability to move a limb.



Diagnosis

Diagnosis of aortic dissection is usually apparent to doctors due to the characteristic symptoms. During the physical examination, approximately two-thirds of people with aortic dissection find a weak or absent pulse in the arms or legs. Dissection extending back toward the heart may produce an audible murmur with a stethoscope. Blood may pool in the chest. Blood leaking around the heart through the dissection sometimes prevents the heart from beating normally and causes tamponade; this one is deadly.

A chest X-ray shows a dilated aorta in more than 90 percent of symptomatic patients. An ultrasound examination usually confirms the diagnosis, even if the aorta is not enlarged. Computed tomography (CT) performed after injection of contrast medium is reliable and can be performed quickly, which is essential in emergencies.



Treatment

Patients with aortic dissection are admitted to the intensive care unit. Their vital signs (pulse, blood pressure, breathing rate) are carefully monitored there. Death can occur several hours after dissection begins, so doctors, as soon as possible, give drugs that reduce the heart rate and blood pressure to the minimum possible level, which still ensures sufficient blood flow to the brain, heart, and kidneys. Shortly after starting the treatment, the doctor must decide whether surgery is necessary or whether it is indicated to continue only with drug treatment.



Video content: Aortic dissection operation.

Doctors almost always recommend surgery for dissections in the area of the first ten centimeters of the aorta, closest to the heart, unless the risk of surgery due to complications of the dissection is too great. Dissections that are more distant from the heart usually continue with medical treatment, except for dissections that cause bleeding and dissections in people with Marfan syndrome. In these cases, surgery is required.

During the operation, the surgeon removes as much of the dissected aorta as possible, prevents blood from reaching the wrong lumen (channel created by separating the layers), and restores the aorta with a synthetic implant if the aortic valve is leaking, repair or replace it.



Forecast

About 75 percent of untreated aortic dissection patients die within the first two weeks. In contrast, 60 percent of treated patients who survive the first two weeks are still alive five years after treatment, and 40 percent survive at least ten years. Of the patients who die after the first two weeks, about one-third succumb to complications of the dissection, and the remaining two-thirds die from other illnesses.

Mortality in operations in large medical centers is now around 15 percent in aortic dissections closer to the heart and slightly more significant in those more distant. Doctors give long-term blood pressure-lowering drugs to all patients with aortic dissection, even those who have undergone surgery, to reduce the strain on the aorta. Doctors monitor patients carefully for possible late complications; the three most common are re-dissection, aneurysm formation in a weakened aorta, and progressive aortic valve regurgitation. Any of these may require surgical treatment.



Diseases of veins and lymphatic vessels

Blood from all body organs returns to the heart through the veins. Among the main problems that can affect veins are inflammation, clots, and malfunctions that lead to enlargement and varicose veins. The lymphatic system is formed by thin-walled lymph vessels (lymphatic vessels), which drain fluid, proteins, minerals, nutrients, and other organ substances into the veins.

The lymph fluid (mesh) passes through the lymph nodes, which protect against the spread of infections and cancer, and finally flows into the venous system in the neck area. The main problems related to the lymphatic system occur when the lymph nodes cannot drain all the fluid that flows into them when they become blocked by trimeric or inflamed.

Image: Deep veins play an essential role in pushing blood upwards.

vein diseases.jpg

There are one-way valves in the deep veins to keep the blood flowing up, not down. Each valve has two halves, the leaflets, which meet at the edges. Pushed blood spreads the leaf like the wings of a swinging door; gravity pushes blood in the opposite direction. Deep veins play an essential role in pushing blood upwards. As they lie between the strong sword muscles, they are squeezed hard with every step. For example, squeezing the tube squeezes out the toothpaste, and squeezing the deep veins pushes the blood upwards. Through these veins, 90 or more percent of the blood from the legs returns to the heart.



Questions and answers

Which type of aneurysm is the most common?

Aortic aneurysms are by far the most common. They are made in your aorta, your body's largest artery. Your aorta carries blood away from the heart. Aneurysms that develop in arteries other than your aorta are called peripheral aneurysms[1].



Is an aneurysm in the area of the abdominal aorta challenging to treat?

Smaller, slow-growing aortic aneurysms can be treated with waiting, lifestyle changes, and medications. Large or rapidly growing aortic aneurysms may require surgery[2].



How easy is aortic dissection to be detected?

Diagnosis of aortic dissection is usually apparent to doctors due to the characteristic symptoms. During the physical examination, approximately two-thirds of people with aortic dissection find a weak or absent pulse in the arms or legs.



What are the symptoms of a thoracic aortic aneurysm?

Typical symptoms are pain (usually in the upper back), cough, and wheezing. The patient may cough up blood due to pressure on the trachea, nearby airways, or ulcers. Pressure on the esophagus, through which food passes into the stomach, sometimes makes swallowing difficult. Pressure on the nerve that innervates the larynx causes hoarseness. The patient may experience a cluster of symptoms (Homer's syndrome), including a narrowed pupil, a droopy eyelid, and sweating on only one side of the face. Abnormal pulsation of the chest wall can also be a sign of a thoracic aortic aneurysm.



What can aneurysms be?

Aneurysms can be bag-shaped (saccular) or spindle-shaped (fusiform). Most are spindly.



How successful is aneurysm surgery?

The chance of survival is much higher if you have surgery before the rupture. In this case, the chance of survival after aneurysm surgery is 95 to 98 percent. Open surgery is more risky for people with other severe medical conditions[3].



How long does it take to recover from thoracic aortic aneurysm surgery?

You will feel more tired than usual for a few weeks after surgery. After 4 to 6 weeks, you can do many everyday activities[4].



Sources and references

An extensive health manual for home use, Youth Book Publishing House

  1. Aneurysm - https://my.clevelandclinic.org
  2. Abdominal Aortic Aneurysm - https://www.hopkinsmedicine.org
  3. Aneurysm Surgery: Traditional Open Surgery - https://my.clevelandclinic.org
  4. Thoracic Aortic Aneurysm Repair Surgery: What to Expect at Home - https://myhealth.alberta.ca



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