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Aortic Aneurysm: A ticking time bomb

Mary McGreal DNP, RN, ANPC

Objectives

• Discuss the incidence of aortic aneurysm?

• Discuss the pathogenesis of aortic aneurysm?

• Discuss clinical manifestation of aortic aneurysm?

• Discuss  the diagnostic criteria for  aortic aneurysm and outline the treatment modalities?

Disclosure

• No disclosures

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Background

• Aortic aneurysms strike 1.5 to 2 million Americans and cause 15,000 deaths each year

• Aortic Aneurysm is known as silent killer

• Incidental finding during work-up for another condition• The burden of aneurysmal disease is on the rise due to:

• Demographic transition that is occurring

• Improved imaging techniques • Creating awareness about aortic aneurysms is important

Aortic Aneurysm• The term ANEYRYSM is derived from the Greek word

ANEURYSMA meaning “a widening”

• A permanent localized dilation of the aorta artery having at least 50% increase in diameter compared with the expected diameter.

• Normal artery diameter is dependent on age, gender, and body size

• Aortic aneurysms arise as a result of a failure of the major structural proteins of the aorta (elastin and collagen)

• The inciting factors are not known, but a genetic predisposition

clearly exists

Anatomy

• The aorta is the largest artery in the body• It is divided in 2 main sections

��Thoracic aorta

Aortic rootAscending aortaArch

Descending� Abdominal aorta

• The diameter of the aorta decreases from its thoracic portion to its abdominal portions

Caleron & Illig (2016)

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Aorta

Salameh et al.2018

Anatomy

• The aortic wall is composed of the three layers:

• The inner tunica intima lined by the endothelium

• The thick tunica media ---collagen and smooth muscle

• The outer adventitia---- mainly collagen

Caleron & Illig (2016)

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Classification• The aneurysms are classified as

either:• Saccular- ballooning of a focal

area of the aorta• Fusiform--circumferential dilation

of the aorta• Aneurysms are either true or

false. The wall of a true aneurysm involves all three layers, and the aneurysm is contained inside the endothelium. The wall of a false or pseudo aneurysm only involves the outer layer and is contained by the adventitia

Caleron & Illig (2016)

Aorta Diameter

Caleron & Illig (2016)

Thoracic Aortic Aneurysm

• 60 % involve aortic root/ascending aorta

• <10% involve the aortic arch

• 35% involve the descending aorta

Salameh et al.2018

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Risk Factors Thoracic Aortic Aneurysm

• Arteriosclerosis• Hypertension—increase wall

stress• Bicuspid aortic valve• Extreme weight lifting• Trauma• Genetic syndromes

• Marfan disease• Loeys-Dietz• Ehlers-Danlos

• Cystic media degeneration is the basis for the pathology in many of these conditions

Transverse Aorta

Salameh et al.2018

Abdominal Aortic Aneurysm

• Most common form of aortic aneurysm

• It is defined as increase in size >3.0cm

• Infrarenal – 80%

• M : F --- 5:1

Rahimi (2017).

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Risk factors for Abdominal Aneurysm

• Arteriosclerosis

• Advanced age

• Hypertension

• Smoking

• Male gender

Symptoms 

• Hoarseness due laryngeal nerve palsy

• Cough

• Chest pain

• Shortness of breath

• Pulsatile mass

• Early satiety

• Unimpressive back, abdominal, flank pain

Screening

• Early detection of aortic disease is proven to save lives.

• The goal of national screening programs of abdominal aortic aneurysms is to impact rupture rate and mortality

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Screening Guidelines

• The U.S. Preventive Services Task Force recommends a one-time ultrasound screening for males aged 65 to 75 who have ever smoked

• There is no recommendation for men who don't smoke

• They recommend against screening for women because of the rarity of abdominal aortic aneurysm in women

https://www.uspreventiveservicestaskforce.org/

Diagnostic

• CT‐ CAP/ CTA

• MRI

• Abdominal Ultrasound for AAA’s

• Echo

Medical Management

• Watchful waiting period• Surveillance imaging q 3months - yearly

• Blood pressure control

• Smoking cessation

• Avoidance of competitive sports

• Avoidance of heavy lifting

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Surgical Management

• Surgical repair indicated

• TAA >5.5 cm and Genetic syndromes 5.0 cm

• AAA >5.5 cm

• Open surgical repair

• Endovascular repair

• TEVAR – groin access

• EVAR – groin access

Surgical Repair TechniquesThoracic Abdominal

Swerdlow, et al. (2019)

Swerdlow, et al. (2019)

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Open Repair versus Endovascular Repair

Open Repair

• Longer recovery time

• Longer hospital stay• Younger patient typically

• 90% success rate

Endovascular Repair

• Shorter length of stay

• Older patient• Need long term follow-up

• May need secondary procedure for endoleaks

Surveillance Post Intervention

• After TEVAR or EVAR 

• CT scan is recommended after 1, 6, 12 months

and then yearly  or sooner for cause

• After open surgical procedure  surveillance 

• CT scan q12 months or as indicated by surgeon

Aortic Dissection

• An aortic dissection occurs following a tear in the intimal layer of the aortic wall causing blood to flow between the layers of the aortic wall

• There 2 classification systems

• De Bakey

• StanfordRagavendra et al. (2014)

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De Bakey Classification• Categorizes dissections into types I, II, and III.

• Type I: Originates in the ascending aorta and spreads distally to include the aortic arch and typically the descending aorta

• Type II: Originates in and is confined to the ascending aorta

• Type III: Originates in the descending aorta and spreads distally

Ragavendra, et al. (2014)

Stanford Classification System

• Divides dissections into 2 categories

• Those that involve the ascending aorta and those that do not

• Type A: All dissections involving the ascending aorta

• Type B: All dissections that do not involve the ascending aorta

Ragavendra, et al. (2014)

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References

• Caleron, A &, Illig, K.A (2016). Overview of aortic aneurysm management in the endovascular era. Seminar in Vascular Surgery 29: 3-17.

• Ragavendra R., et al. (2014).The Role of Imaging in aortic dissection and related syndromes. Retrieved July, 2019 from http://imaging.onlinejacc.org/

• Rahimi, S. (2017). Abdominal aortic aneurysm. Medscape. Retrieved July, 2019, from http://emedicine.medscape/article/1979501-overview

• Saliba E., Sia Y. ( 2015). The ascending aortic aneurysm: When to intervene?

Int J Cardiol Heart Vasc ; 6: 91–100.

• Salameh, M., Black, J., Ratchford, E. (2018). Thoracic aortic aneurysm. Vascular Medicine: 23(6) 573–578.

• Swerdlow, N., Wu, W., Schermerhorn, M. (2019). Open and endovascular management of aortic aneurysms. Circulation Research: 124:647–661

• US Preventative Task force (2017) Abdominal aneurysm screening guideline. Retrieved July, 2019

from www.uspreventiveservicestaskforce.org/abdominal-aortic-aneurysm-screening

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