AORTIC ANEURYSM OVERVIEW
• Aorta is the largest artery in our body and has a diameter similar to a garden hose. It originates from the left heart and carries oxygen rich blood to all parts of the body.
• An aneurysm is a localized bulge or dilatation in a blood vessel due to weakening of the wall by various causes. Aneurysm of the aorta can occur due to various causes
• An aneurysm can increase in size and can rupture with potentially fatal bleeding

TYPES OF AORTIC ANEURYSM
• Aortic aneurysm can involve the thoracic portion of the aorta which runs within the chest or the abdominal portion of the aorta.
• Abdominal aortic aneurysms (AAA) are more common than thoracic aortic aneurysms

CAUSES & RISK FACTORS
• Abdominal aortic aneurysms are more common in smokers, persons with family history of the condition, history of high blood pressure (hypertension) and atherosclerotic disease or hardening of the blood vessel and rarely bacterial or fungal infections in the aorta

• Thoracic aortic aneurysms are common in persons having inherited conditions that cause weak blood vessel walls, for example Marfan syndrome and Ehlers Danlos syndrome. Persons born with an abnormal aortic valve can get thoracic aortic aneurysm. Motor vehicle injuries can also cause weakening of the thoracic aorta wall

CLINICAL FEATURES OF UNRUPTURED AORTIC ANEURYSM
• Small aneurysms in the initial stages are usually asymptomatic.
• With time they may increase in size and cause chest pain, abdominal or back pain (pressure on vertebrae), difficulty in breathing or swallowing due to pressure of the enlarging aneurysm on the trachea or esophagus, and cough
• In AAA a pulsatile lesion can be palpated
• In fact small aneurysms may be incidentally discovered during investigations or imaging for other conditions

CLINICAL FEATURES OF RUPTURED AORTIC ANEURYSM
It is a medical emergency due to the severe internal bleeding and patient presents with
• Sudden, severe and constant abdominal and back pain
• Pulsatile mass in the abdomen
• Giddiness and light headedness due to bleeding
• Cold clammy skin
• Rapid and thready pulse
• Falling blood pressure
• Tightness of chest and breathing difficulty
• Loss of consciousness

Other conditions that should be considered in the differential diagnosis of ruptured aneurysm

DIAGNOSIS OF AORTIC ANEURYSM
ASYMPTOMATIC ANEURYSM
Asymptomatic thoracic and abdominal aortic aneurysms may be detected incidentally during imaging investigations such as Chest x-ray, Echocardiogram, Abdominal ultrasound, CT scan and Magnetic resonance angiography (MRA) for other conditions

SYMPTOMATIC ANEURYSM
In the presence of symptoms mentioned above and associated risk factors, if a diagnosis of aneurysm is suspected, it can be confirmed or ruled out by imaging tests

RUPTURED ANEURYSM
A ruptured aneurysm is diagnosed mainly by history and clinical examination by finding a tender pulsatile lesion in a hypotensive patient (Classical Triad of AAA)

TREATMENT OF UNRUPTURED AORTIC ANEURYSM
The aim of treatment is to prevent rupture of the aneurysm. Generally, treatment options are either medical monitoring or surgery. The treatment decision decision depends on the size of the aortic aneurysm and how fast it is increasing in size.

MEDICAL MONITORING
• If the abdominal aortic aneurysm is small and not causing any symptoms, your doctor may advise medical monitoring, which includes regular followup appointments to monitor the size of the aneurysm, and concurrent management of other medical conditions that could aggravate the aneurysm.

• The patient is asked to look out for any signs or symptoms that could be related to the aneurysm

• Regular imaging tests are advised to check on the size of the aneurysm, perhaps an abdominal ultrasound at least every six months after your aneurysm is diagnosed

• The frequency of imaging tests depends on the size of the aneurysm, whether it is enlarging and if so, how quickly

• Similarly for thoracic aortic aneurysm, regular followup with clinic visits and imaging may be advised if the aneurysm is small. Management of other medical medications that can aggravate the aneurysm such as hypertension and hypercholesterolemia is also indicated

SURGICAL MANAGEMENT
• For abdominal aortic aneurysm, surgery is generally recommended if the aneurysm is about about 5 to 5.5 centimeters or bigger.

• Surgery may be preferred if the aneurysm is growing quickly symptoms are present such as stomach or back pain or the aneurysm is noted on imaging to be leaking

• Types of surgery include open abdominal repair or endovascular surgery which is a less invasive procedure. The decision depends on the size and location of the aneurysm, age and fitness of the patient including underlying medical conditions

• For thoracic aortic aneurysm, surgery is generally recommended if the aneurysm measures about 5 to 6 centimeters and larger.

• However, if there are associated conditions such as Marfan syndrome ( a type of connective tissue

disease), a bicuspid aortic valve or a family history of aortic dissection, surgery may be recommended for much smaller aneurysms due to the increased risk of having an aortic dissection.

• Most people with a thoracic aortic aneurysm have open-chest surgery, but in some select cases if the patient is fit and eligible for a less invasive repair an endovascular surgery using a catheter may be performed.

TREATMENT OF RUPTURED AORTIC ANEURYSM
Ruptured aortic aneurysm is a medical emergency and carries a high mortality rate. Urgent surgical management either by open approach or endovascular repair as appropriate is called for

It is very important for concurrent management of the patient’s hemodynamic status and treatment of shock and hypotension to improve outcome