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Aortic aneurysm

An aortic aneurysm is a condition that can develop in secret for many years, without giving any signs of its presence. For this reason, he is sometimes called the “silent killer”. However, knowledge about it should not arouse fear, but mobilize to action. Understanding the nature of this disease, its risk factors and the available methods of diagnosis and treatment is the key to taking control of your own health and preventing tragic complications.

What is an Aortic Aneurysm and Why Should You Know About It?

Definition of aortic aneurysm

The aorta is the largest artery in the human body. Coming out of the left ventricle of the heart, it forms a characteristic arch, resembling the handle of an umbrella, and then runs down through the chest and abdominal cavity, delivering oxygenated blood to all organs and tissues. Its diameter near the heart can reach up to 40 mm. An aortic aneurysm is a pathological, segmental widening of its lumen (diameter) by at least 50% in relation to the normal size for a given fragment. This is the result of the weakening of its wall, which bulges excessively under the pressure of constantly flowing blood.

“The Silent Killer” – the insidious nature of the disease

The insidiousness of an aortic aneurysm is that in most cases it develops slowly and asymptomatically. Many people are not aware for years that a “time bomb” is ticking in their body. The main and most serious threat is the rupture of the weakened aneurysm wall. This leads to massive internal bleeding, which is an immediate life-threatening condition and requires immediate, life-saving surgical intervention.

Purpose of the guide

This guide aims to provide reliable and comprehensive knowledge about aortic aneurysm. We want to equip patients and their relatives with the information necessary to understand the disease, its causes, symptoms, as well as modern methods of diagnosis and treatment. This knowledge allows not only to understand medical recommendations, but also to actively participate in the process of treatment and prevention, which significantly improves the prognosis.

Types of Aortic Aneurysms: Classification and Characteristics

The classification of aortic aneurysms is not just an academic division. It is of fundamental clinical importance, because the type of aneurysm determines its potential risk, symptoms, and the choice of the optimal treatment strategy, which is important in the context of the incidence of aortic aneurysms.

Division by Location

Knowing the location of the aneurysm is crucial because it determines both potential symptoms and planning the surgery.

• Abdominal Aortic Aneurysm (AAA): This is the most common location, accounting for the majority of all aortic aneurysms. It develops in the section of the aorta that runs below the diaphragm. Due to the large space in the abdomen, these aneurysms can reach a significant size before they start to show symptoms. They often co-occur with iliac artery aneurysms.
• Thoracic Aortic Aneurysm (TAA): Occurs in the section of the aorta located in the chest. It can affect its ascending part (just behind the heart), the aortic arch (from where vessels depart to the brain and hands) or the descending part (up to the height of the diaphragm). Aneurysms in this location, pressing on adjacent structures, such as the esophagus or airways, are more likely to cause symptoms.
• Thoraco-abdominal aneurysm: This is the most difficult type of aneurysm to treat because it involves both the thoracic and abdominal sections of the aorta.

Division by Wall Construction

The structure of the aneurysm wall has a direct impact on its etiology and stability.

• Aneurysm true: The most common type in which all three layers of the aortic wall (inner, media, and outer membranes) become widening and bulging.
• Pseudoaneurysm: This is not a true dilation of the vessel. It arises as a result of breaking the continuity of the inner layers of the aortic wall, most often as a result of injury or medical intervention. The spilling blood is stopped by the thinnest, outer layer of the wall or by the surrounding tissues, forming a kind of hematoma connected to the lumen of the artery.
• Dissecting aneurysm: It is an emergency condition in which the aortic intima ruptures, requiring immediate surgical intervention. Blood under high pressure flows between the layers of the vessel wall, separating them and creating a second, pathological flow channel. This can lead to closure of the aortic branches and ischemia of organs or to rupture of the outer wall.

Division by Shape

The shape of the aneurysm affects the risk of its rupture.

• Fusiform: It is characterized by an even, symmetrical widening of the entire circumference of the aorta over a certain section. This is the most common shape.
• Sac-shaped: This is an asymmetrical, spherical bulge that covers only part of the circumference of the vessel. These types of aneurysms, although rarer, are considered more unstable and prone to rupture.

Clinical Breakdown

The patient’s clinical condition determines the urgency of the intervention.

• Asymptomatic: An aneurysm does not cause any discomfort and is most often detected accidentally during imaging tests performed for other causes.
• Symptomatic: The patient feels discomfort, most often pain, which may indicate rapid enlargement of the aneurysm or imminent rupture. Such a condition requires urgent diagnosis and treatment.
• Ruptured: A life-threatening condition in which the aneurysm wall has been broken, with symptoms of hemorrhage and shock.

Causes and Risk Factors: Who is Most at Risk?

It is worth understanding that aortic aneurysm is rarely an isolated disease. Most often, it is one of the manifestations of the systemic disease of atherosclerosis. Therefore, fighting risk factors is not only about protecting the heart, but a fundamental strategy to prevent the development and rupture of the aneurysm.

Main cause – atherosclerosis

The majority of aneurysms, especially the abdominal aorta (up to 95% of cases), are caused by atherosclerosis. It is a chronic inflammatory process in which atherosclerotic plaques, made mainly of cholesterol, are deposited in the walls of the arteries. This leads to weakness, loss of elasticity and degradation of the structure of the aortic wall, making it susceptible to widening under the influence of blood pressure.

Key risk factors

• Age: The risk of aortic aneurysm increases significantly with age, especially after the age of 65. The peak of incidence falls on the eighth decade of life.
• Male: Men are much more likely to develop an aortic aneurysm, affecting the disease three to even eight times more often than women.
• Smoking: This is the most important modifiable risk factor. The substances contained in tobacco smoke directly damage the vessel walls and activate enzymes (proteases) that destroy elastin and collagen – proteins that make up the “scaffolding” of the aorta. In smokers, aneurysms grow faster.
• Hypertension: Constantly elevated blood pressure exerts constant, excessive pressure on the walls of the aorta, which mechanically weakens them and accelerates the process of their dilation.
• Genetic and Family Predisposition: If an aortic aneurysm occurred in a first-degree relative (parent, sibling), the risk of developing it in us is much higher. There are also rare genetic diseases of the connective tissue, such as Marfan syndrome or Ehlers-Danlos syndrome, which lead to congenital laxity and weakness of the aortic wall, predisposing to the formation of aneurysms, especially in the thoracic region. If a genetic background is suspected, specialist tests are available, e.g. next-generation sequencing (NGS) analysis for mutations in genes associated with familial aneurysms.

Other causes

Although rarer, chronic inflammation of the aortic wall (e.g. in the course of autoimmune diseases), mechanical injuries to the chest or abdomen, and bacterial or fungal infections that can affect the vessel wall can also contribute to aneurysm formation.

Symptoms of an aortic aneurysm: how to recognize the warning signs?

The ability to recognize the subtle signals that the body may send is extremely important, although in the case of an aortic aneurysm, unfortunately, the first symptom is often its rupture.

Abdominal aortic aneurysm (AAA) – a discreet enemy

Most abdominal aortic aneurysms do not give any symptoms and are detected accidentally, e.g. during an abdominal ultrasound ordered for a completely different reason. However, if the aneurysm reaches a large size, it can cause:

• Throbbing sensation in the abdomen: Described by patients as a “heartbeat in the abdomen”, especially felt when lying down.
• Pain: Usually constant, crushing, difficult-to-localize pain in the middle of the abdomen, in the navel area, or in the lower back (lumbosacral region). This pain is sometimes confused with back ailments, such as sciatica, or kidney problems.
• Abdominal pain after a meal may be a signal that should be investigated in the context of asymptomatic aortic aneurysms.: It may indicate that the aneurysm is pressing on the vessels supplying the intestines and lead to their ischemia.

Note: Stroke or leg pain as the first symptom?

Few people realize that an aneurysm, even if it does not hurt, can be a source of serious problems in distant parts of the body. In its lumen, where blood flow is disturbed, thrombi (blood clots) can form. If a fragment of such a thrombus breaks off, it can flow with the blood stream and clog a smaller vessel. Depending on where it stops, it can cause a stroke, kidney infarction, acute ischemia or sudden ischemia of the lower limb (manifested by severe pain, paleness and cooling of the leg). Sometimes it is the first and only symptom of an aortic aneurysm. Therefore, in a person at risk (smoker, hypertensive person) with such symptoms, an aneurysm should always be considered as a potential source of embolism.

Thoracic aortic aneurysm (TAA) – louder neighbor

Aneurysms located in the chest are more likely to cause symptoms because they press on adjacent organs as they grow. Common symptoms include:

• Pain: Constant, deep, often severe and stabbing pain in the chest that can radiate to the back, especially to the interscapular region.
• Respiratory symptoms: Persistent cough, shortness of breath (sometimes worsening in a specific body position) and hoarseness (resulting from pressure on the recurrent laryngeal nerve, responsible for the mobility of the vocal cords).
• Difficulty swallowing (dysphagia): Caused by the compression of the enlarged aorta against the esophagus.
• Superior vena cava syndrome: Swelling and redness of the face, neck and shoulders, as well as widening of the veins on the chest, which is the result of pressure on the superior vena cava draining blood from the upper body.

Simple screening test – thumb test

Researchers at Yale University have developed a simple test that can help identify people at risk, especially those with congenital connective tissue diseases. It should be emphasized that this is not a test to diagnose an aneurysm, but only an indication suggesting the possible need for medical consultation.

To perform it, you need to raise your arm and straighten your hand, and then bend your thumb as far across your hand as possible. If the tip of the thumb is able to extend beyond the outer edge of the hand, it may indicate excessive laxity of the connective tissue, which is a risk factor for the development of an aneurysm. A positive test result should prompt you to talk to your doctor.

Greatest Risk: Aortic Rupture and Dissection – Emergency

A rupture or dissection of an aortic aneurysm is a medical disaster that develops within minutes and has a very high mortality rate, reaching up to 40-60% in the case of a ruptured abdominal aortic aneurysm. Recognizing the symptoms and reacting immediately can save lives.

Classic symptoms of rupture/delamination

The occurrence of the following symptoms, especially in a person at risk or with an already diagnosed aneurysm, requires absolutely urgent intervention.

• PAIN: Sudden, unusually severe, often described by patients as “excruciating,” “stabbing,” or “the strongest in life.”
  • The location of the pain depends on the location of the rupture: it can be the chest, abdomen or back (lumbar region). The pain often radiates to the perineum, buttocks, thighs or between the shoulder blades.
• SYMPTOMS OF HEMORRHAGIC SHOCK: They are the result of massive, internal blood loss. These include:
  • A sharp drop in blood pressure.
  • Very fast, but hardly perceptible heart rate (tachycardia).
  • Pallor and stickiness of the skin, cold sweats.
  • Fainting, dizziness, and loss of consciousness may be symptoms of aortic dilation by more than 50.
• OTHER ALARM SIGNALS: Other symptoms may also appear, such as a hematoma in the scrotum or perineum area (usually a few hours after rupture into the retroperitoneal space), nausea and vomiting, and in the case of dissection involving the cephalic arteries, neurological symptoms resembling a stroke (e.g. paralysis of half the body, difficulty speaking).

ABSOLUTE ORDER TO ACT

If the above symptoms occur, time is of the essence. You must not wait for it to “go away by itself”.

1. CALL AN AMBULANCE IMMEDIATELY – by calling 112 or 999.
2. CLEARLY INFORM THE DISPATCHER of suspected ruptured aortic aneurysm. If you have previously been diagnosed with an aneurysm, be sure to provide this information to assess the condition of your aorta. This will allow the ambulance to be referred to the appropriate hospital with a vascular surgery or cardiac surgery department.
3. PLACE THE PATIENT in a supine position with slightly bent legs, which may slightly reduce abdominal tension and pain. Do not give any medication, food or drink.

Diagnostics: How to detect an aortic aneurysm?

The diagnostic process of an aortic aneurysm is logical and proceeds in stages – from simple, non-invasive screening tests to advanced imaging techniques necessary for precise treatment planning.

Screening – The Gold Standard for AAA

The purpose of screening tests is to detect asymptomatic aneurysms in people at higher risk before serious complications occur.

• Abdominal ultrasound: This is a basic, widely available, cheap and completely safe test that allows you to detect and measure an abdominal aortic aneurysm with high accuracy. It is ultrasound that is the gold standard in screening programs and monitoring of small aneurysms.
• Screening Recommendations: According to the guidelines of scientific societies, a single abdominal ultrasound examination for an aneurysm is recommended in:
  • Men aged 65 years and older are at high risk, given the incidence of aortic aneurysms., especially those who have ever smoked cigarettes in their lives.
  • Men and women over 60. years of agewho have had an aortic aneurysm in a first-degree relative (parent or sibling).

Advanced Diagnostic Imaging

When the screening test shows the presence of an aneurysm or when there is a suspicion of a thoracic aortic aneurysm, more detailed tests are necessary.

• CT angiography (computed tomography with contrast): This is currently the most important and accurate examination in the diagnosis of aneurysms. It allows you to create a three-dimensional image of the aorta and precisely assess the size, shape and extent of the aneurysm. Crucially, it shows its attitude to the departing arteries, especially the renal arteries, which is the information necessary to qualify the patient for surgery and choose the appropriate technique.
• Contrast magnetic resonance imaging (MRI): This is an alternative to CT angio, especially in patients who are allergic to the iodine-based contrast medium used in CT or in people with advanced renal insufficiency. It is a safe test, it does not use X-rays.

Other research

• Chest X-rayIt may accidentally show a widening of the mediastinal shadow, which raises the suspicion of a thoracic aortic aneurysm, but this examination is not very precise and does not replace a thorough assessment of part of the aorta.
• ECHOCARDIOGRAPHY: Cardiac ultrasound, especially in the transesophageal version (TEE), is very useful for assessing the ascending aorta (initial section, just behind the heart), the aortic arch and the function of the aortic valve, which often accompanies aneurysms in this area.

Treatment Methods: From Observation to Advanced Surgery

The decision on how to treat an aortic aneurysm depends on many factors: its size, location, growth rate, the presence of symptoms, and the patient’s general health and age.

Watchful Waiting

In the case of small, asymptomatic aneurysms, the diameter of which has not yet reached the threshold qualifying for surgery, the so-called vigilant waiting strategy is the basis. However, this does not mean passivity. This is a period of active action to slow down the growth of the aneurysm.

• Regular Monitoring: The patient must undergo regular imaging tests (usually ultrasound for AAA or CT/MRI for TAA) to assess the diameter of the aneurysm. The frequency of examinations depends on the size of the lesion: aneurysms with a diameter of 4.0-5.4 cm are checked every 6-12 months, and smaller aneurysms (3.0-3.9 cm) every 2-3 years.
• Drug Treatment: The goal is to control risk factors.
  • High blood pressure medications: Keeping blood pressure below 140/90 mmHg is absolutely crucial.
  • Beta-blockers: These drugs (e.g. metoprolol, bisoprolol) slow down the heart rate and lower the pressure, which reduces the force of the blood hitting the aortic wall. They can slow down the growth rate of aneurysms with a diameter of more than 4 cm.
  • Statins: Cholesterol-lowering drugs (e.g. atorvastatin, rosuvastatin) are recommended in any patient with an atherosclerotic aneurysm to stabilise plaques.
  • Losartan: This hypertension drug has been shown to be particularly effective in inhibiting aortic dilation in patients with genetically determined Marfan syndrome.
• Lifestyle Modification: The most important intervention is absolute smoking cessation.

Invasive treatment – when to operate?

Surgical intervention becomes necessary when the risk of aneurysm rupture outweighs the risks associated with the surgery itself. Indications for invasive treatment are clearly defined, especially in the context of aortic diameter.

• Large aneurysm diameter: Typically above 55 mm in men and 50-52 mm in women for abdominal aortic aneurysm, highlighting the importance of monitoring aortic diameter. and over 55-60 mm in the case of thoracic aortic aneurysm.
• Rapid growth rate: Aneurysm widening by 5 mm within 6 months or 10 mm within a year.
• Presence of symptoms: Any symptomatic aneurysm (causing pain) is eligible for treatment, regardless of its diameter.
• Rupture or dissection: This is an indication for immediate life-saving surgery.

Two main surgical methods

Modern vascular surgery offers two basic methods of treating aneurysms. Choosing between the two is a key decision made by the medical team based on the anatomy of the aneurysm and the patient’s condition. They can be compared to replacing a broken part of a car with a new one (classic surgery) or installing an internal reinforcement that requires regular inspections (endovascular treatment).

Feature	Classic Operation (Open)	Endovascular Therapy (EVAR/TEVAR)
Access	A large incision in the abdomen (laparotomy) or chest (sternotomy/thoracotomy) to directly reach the aorta is crucial in surgical treatment.	Two small (a few centimeters) incisions in the groin to gain access to the femoral arteries.
Procedure	Surgical excision of the affected section of the aorta and manual sewing of a vascular prosthesis, usually made of dacron, in its place.	Insertion of a stent graft (vascular prosthesis reinforced with a metal frame) rolled in the catheter through the femoral arteries and then its controlled expansion inside the aneurysm. The stent graft creates a new channel for the blood, excluding the aneurysm from circulation.
Invasiveness	Large. It is an extensive procedure that puts a significant strain on the body.	Minimally invasive. The procedure is much less burdensome, making it a preferred option for elderly patients and patients with numerous comorbidities.
The duration of hospitalization is important in the context of assessing risk factors for cardiovascular diseases.	Longer. Usually from 5 to even 16 days.	A short hospitalization time may be sufficient in the case of suspected aortic aneurysm. Most often, the patient returns home after 2-3 days.
Recovery time	Long. It can take 1 to 3 months for a full return to normal activity.	Short. It is possible to return to most daily activities after 2-4 weeks.
Long-term control	After successful surgery and recovery, the problem is largely resolved. Imaging check-ups (ultrasound/CT) are recommended, e.g. after a month, and then every 5 years.	It requires immediate surgical intervention if an aortic aneurysm is detected. lifelong, regular imaging control (CT angio-CT, X-ray) after 1, 6 and 12 months, and then every year. The aim is to detect potential complications early, such as blood leaks into the aneurysm sac (so-called endoleak) or displacement of the stent graft.

Modern and Innovative Techniques

Medicine is constantly evolving, offering safer and more effective solutions:

• Robot-assisted minimally invasive surgery (RAT): Allows classic aneurysm excision and prosthesis implantation with a much smaller incision (e.g., in the intercostal space), which combines the durability of open surgery with the advantages of less invasiveness, such as shorter recovery and less pain.
• Tailor-made stent grafts (fenestrated or branched – fEVAR, bEVAR): These are highly advanced endovascular prostheses, designed individually for the patient. They have special openings (fenestrations) or branches that allow blood flow to be maintained in key arteries departing from the aorta (e.g. renal, visceral), which allows the treatment of very complex aneurysms using a minimally invasive method.
• Hologram surgeries: This is a science fiction technology that is already entering the operating room. It allows for the display of a precise, three-dimensional hologram of the patient’s aorta during the procedure. This allows the operating surgeon to have a better insight into the anatomy, and an expert from another center in the world can remotely assist and advise in real time.

Life after Diagnosis and Surgery: Recommendations and Prevention

A diagnosis of an aortic aneurysm or a previous surgery is not the end, but the beginning of a new stage, in which a conscious change in lifestyle plays a key role. The surgery repairs the damaged section of the aorta, but does not cure atherosclerosis – the disease that underlies the problem. Therefore, long-term success depends on the partnership between the patient and the medical team and continuous care of the entire circulatory system.

Diet – Fuel for Healthy Arteries

The basis should be an anti-atherosclerotic diet, based on the principles of the Mediterranean diet or the DASH diet (Dietary Approaches to Stop Hypertension).

• Recommended products:
  • Vegetables and fruits: Rich in fiber, vitamins and antioxidants. They should be the basis of every meal.
  • Whole grain products: Wholemeal bread, coarse groats (buckwheat, pearl barley), brown rice, oatmeal.
  • Healthy fats: Fatty sea fish (salmon, mackerel, herring) rich in omega-3s, olive oil, flaxseed oil, avocado, nuts and seeds.
  • Lean protein sources: Skinless poultry, fish, legumes (beans, lentils), lean dairy.
• Products to Contain/Avoid:
  • Salt: Significantly reduce your salt intake (up to <5 g per day), avoid adding salt to your food and choose low-sodium foods. Salt raises blood pressure.
  • Saturated and trans fats: Red, fatty meats, cured meats, offal, butter, lard, palm oil, as well as fast foods, confectionery and confectionery containing hydrogenated vegetable fats.
  • Simple sugarsSweets, sweetened drinks, white bread can affect health, which is important in the context of risk factors for cardiovascular diseases. Excess sugar in the diet promotes the development of atherosclerosis.
• Cooking Techniques: Instead of deep-frying, choose cooking (traditional and steamed), baking in foil or casserole dish, and stewing.

Sample menu for one day:

• Breakfast: Oatmeal cooked in water or skim milk with fresh fruit (e.g. blueberries, banana) and a handful of walnuts.
• Dinner: Cod fillet baked in herbs, buckwheat, a large portion of arugula, tomatoes and cucumber salad with an olive oil-based sauce.
• Dinner: Heavy meals should be avoided, which can affect the condition of the aorta, especially if an aortic aneurysm is suspected. Two slices of sourdough rye bread with avocado and low-fat cottage cheese paste, with slices of radish and tomato.

Physical Activity – Movement is Health (with caution)

Regular physical activity is safe and recommended both in patients with small, observed aneurysms and after surgery. It improves heart condition, blood pressure control and overall well-being.

• Recommended type of exercise: Moderate endurance (aerobic) training. At least 30 minutes of activity is recommended most days of the week (e.g., 3-5 times) more than in the general population, indicating an increasing incidence of aortic aneurysms. The ideal forms are:
  • Brisk walking
  • Indoor or off-road cycling
  • Swimming
  • Nordic.
• WHAT SHOULD BE STRICTLY AVOIDED:
  • Intense strength training: Lifting heavy weights causes a rapid increase in pressure in the aorta, which is dangerous for its weakened wall.
  • Valsalva manoeuvre: Breath-holding and abdominal muscle contracting efforts (e.g. when lifting weights, but also when constipated) should be avoided as they drastically increase the pressure in the chest and abdomen, which can affect the condition of the aorta.
  • Contact and trauma sports: Activities that carry the risk of chest or abdominal injury should be avoided.

Rehabilitation after surgery

The recovery process, especially after classic surgery, is crucial and should be carried out under the supervision of specialists.

• Early postoperative (in-hospital) period:
  • Pulmonary rehabilitation: It is absolutely fundamental to prevent dangerous postoperative pneumonia. It includes learning the correct breathing path, exercising with the use of special devices (e.g. ball braces) and learning how to cough effectively and safely for the wound.
  • Anticoagulant prophylaxis: Simple foot and leg exercises, even performed in bed, prevent the formation of blood clots in the deep veins.
  • Gradual upright positioning: Standing up and walking should be started as early as possible, initially with the assistance of a physiotherapist and often with the use of an abdominal belt, which stabilizes the postoperative wound and gives the patient a sense of security.
• The recovery period at home can be crucial for monitoring the condition of part of the aorta.: Return to full activity is much faster after endovascular surgery (approx. 2-4 weeks) than after open surgery (up to 3 months). Always strictly follow the individual recommendations of the doctor and physiotherapist. It is worth taking advantage of cardiac rehabilitation programs that help you get back in shape safely.

Key findings

Aortic aneurysm is a serious disease of the cardiovascular system, which, due to its often asymptomatic nature, is a real threat to life. Its rupture or delamination is an emergency condition with a high mortality rate.

However, modern medicine provides effective tools to fight this “silent killer”. The key conclusions that should accompany every patient and their family are:

1. Awareness and prevention are paramount: Controlling risk factors such as smoking, high blood pressure and high cholesterol are fundamental steps to prevent aneurysms from forming and growing.
2. Screening saves lives: A simple, painless abdominal ultrasound can detect an aneurysm early in at-risk individuals, giving you time to take action before tragedy strikes.
3. Treatment is effective: Modern vascular surgery and cardiac surgery offer advanced treatment methods – from proven classic surgeries to increasingly perfect and less invasive endovascular techniques (stent grafts) that allow you to return to health and normal life.
4. The patient is an active partner in treatment: The success of therapy depends not only on doctors, but also on the patient’s commitment. Regular check-ups, adherence to pharmacological recommendations and permanent lifestyle changes (diet, physical activity) are essential to ensure long-term health.

An aortic aneurysm does not have to be a death sentence. With knowledge, early diagnosis and modern treatment, you can effectively manage risk and enjoy a long, active life.