Diseases of Aorta - Aortic Aneurysm

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AORTIC ANEURYSM
Aneurysm is the ballooning of the arterial wall
due to some weakness in it. It can develop in
any artery in the body. When it affects the
aorta, it is known as aortic aneurysm.
HOW IT HAPPENS? Aortic wall has 3 layers
Intima (inner layer), media (middle layer) and
the adventitia (outer layer). Some diseases
affect the media and cause weakness in the layer.
The internal pressure of blood acts constantly
on the aortic wall. When it acts on the weakened
section of the wall, it balloons out. Gradually
an aneurysm forms. The commonest disease that
weakens aortic wall is Atherosclerosis.
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Some of the connective tissue disorders are
genetic and runs in families. (eg.
Marfans syndrome and Ehler-Danlos syndrome)
These conditions cause weakness in the aortic
wall. The affected persons have the risk of
developing aneurysms at a young age. Age related
degeneration can also lead to weakness in the
arterial walls and cause aneurysm. Hypertension
is an aggravating risk factor which hastens the
enlargement of the aneurysm.
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SYMPTOMS As discussed in earlier section,
symptoms of aortic aneurysm vary depending on the
site of the disease. Stretch on the aortic wall
can cause pain usually of dull and aching
variety. Due to the mass effect, it can exert
pressure on the neighboring structures. At the
ascending aorta dyspnea and chest pain can
occur. At the arch and proximal descending aorta
patients can have difficulty in swallowing
(dysphagia), difficulty in breathing or change in
voice due to compression on the nerve (recurrent
laryngeal nerve).
In the abdomen symptoms can be confusing from
mild abdominal pain, colicky pain,
burning micturition and low backache to jaundice
and bleeding. Some patients notice prominent
pulsating swelling in the abdomen.
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When aneurysm is large and threatening to
rupture, pain may be more severe. It may
present with abdominal or back pain. Rupture is
associated with excruciating back or abdominal
pain. Deterioration can be rapid due to blood
loss into peritoneum or chest cavity. Aneurysm
close to intestines can erode into them and
rupture (Aorto-enteric fistula). This is a very
serious complication and treatment is difficult
with poor prognosis in spite of timely surgery.
DIAGNOSIS An Ultrasound of abdomen or an Echo may
detect the aneurysm for the first time. The
precise evaluation is done by a CT-Aortogram.
This contrast CT would provide accurate
information on the size, location, extent and
branch involvement of the aneurysm.
TREATMENT In the initial stages the treatment is
conservative and revolves around risk factor
control. Hypertension should be treated
aggressively. Traditionally treatment is
recommended once the aneurysm grows beyond 5 cm
in diameter. At this point the statistical chance
of rupture starts to increase rapidly.
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• Surgery is the traditional form of treatment.
  Depending on the site the surgical options defer.
• Aortic root Aortic root replacement
• Ascending aorta - Interposition graft
• Arch of aorta Arch repair or replacement
• Descending or Abdominal aorta repair with
  interposition graft with/without branch
  re-implantation

Endo-Vascular Repair of aortic aneurysm using a
stent is a viable option in many situations. It
is suitable for straight segments with no branch
involvement. There should be clear disease free
areas on either side of the disease for the stent
to be seated well (landing zones). Hybrid is a
method of combining surgery with stenting. This
can reduce the morbidity of the treatment and
widen the scope of treatment as the two methods
complement each other.
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reserved.