definition

An aortic aneurysm is an outgrowth of the vessel wall or vessel walls. At least one shift must be affected to meet the definition.

symptoms

An aortic aneurysm is a pathological enlargement of the main artery ( aorta ). It occurs either in the chest or abdomen. In the abdomen, there are no symptoms at first, so it is difficult to recognize the aneurysm early. The nonspecific symptoms can easily be confused with other illnesses such as a heart attack. When it grows in size it presses on the surrounding organs and can lead to discomfort.

Above a certain size, it is possible in some cases to feel the aneurysm pulsing on the abdomen. It can also lead to diffuse back pain. A chest aortic aneurysm causes symptoms such as cough, hoarseness, chest pain, dyspnoea, and dysphagia.

A rupture causes very severe pain in the abdominal or chest area with radiation in the back. The following high blood loss leads to a circulatory collapse with shock symptoms and represents an acute life-threatening situation.

Which pain causes an aortic aneurysm?

An aneurysm in the abdomen initially causes no discomfort. When it grows in size, it can lead to pain in the lower abdomen, which can radiate into the legs. Diffuse back pain is also possible. In the chest, an aneurysm causes chest pain. In addition, dysphagia and respiratory distress may occur. A rupture of the aneurysm causes, depending on the localization, extremely severe pain in the chest or abdomen.

hoarseness

Hoarseness can be a symptom of chest aortic aneurysm. Above a certain size, the aneurysm may affect the recurrent laryngeal nerve. This nerve innervates a large part of the muscles of the larynx. If the aneurysm now presses on this nerve, recurrent nerve palsy occurs, resulting in hoarseness.

diagnosis

First and foremost is the patient survey ( anamnesis ) and the clinical examination. When taking an anamnesis, you should ask for possible comorbidities. If the patient indicates that they have coronary artery disease, the suspicion of an aortic aneurysm must be considered (55% of the cases). Other diseases that are commonly found to be concomitant include hypertension and arterial disease, heart failure and diabetes mellitus.

During physical examination, the doctor must examine the abdomen more closely. The palpation and the listening of the abdomen with the stethoscope (outgrowth) may indicate an abdominal aortic aneurysm (typical: buzzing, hissing, pulsating).

If an aortic aneurysm is suspected, an ultrasound scan must be performed. This can be seen in many cases, an outpouring of the aorta. A special setting (color Doppler) allows the doctor to color-control the blood flow in the vessel. Unnaturally large turbulences would also speak in favor of an aneurysm. Another important factor in the ultrasound examination is the aortic diameter. If a standard value of 2.5 cm is exceeded, it is called an aortic ectasia (2.5cm-3cm). A diameter over 3 cm is then called aneurysm. Also, during the ultrasound examination, do not forget to search for free fluid, the presence of which could suggest an already ruptured aneurysm.

With the help of computed tomography ( CT ), which in this case should be performed with contrast agent, one can also make an aneurysm visible. The CT cross-sectional image usually shows a crescent-shaped outlier or a so-called "mirror image", which is missing in the other areas of the vessel. Cryogenic blood (thrombotic material) already produced on the aneurysm can also be visualized in the CT scan. Also important is the control of the outgoing vessels (eg renal vessels), as the blood supply of the adjacent organs must be ensured. Alternatively, a magnetic resonance tomography ( MRI ) can be performed. However, this takes much longer than the CT and is especially in emergency situations (ruptured aortic aneurysm) rather method of second choice. In the further course it is essential to examine further arteries for aneurysm formation. In addition to the aortic aneurysm, many patients also have renal artery and carotid artery aneurysms. The diagnostic tool of choice here is the ultrasound examination.

treatment

There are basically two different ways to treat an aortic aneurysm. For smaller aneurysms one can wait and carry out regular ultrasound checks. In addition, risk factors that favor an aneurysm or its rupture should be treated or avoided. This includes keeping the blood pressure in the normal range of about 120/80, in some cases also by antihypertensive drugs. Also, diabetes and lipid metabolism disorders need to be treated.

In the case of larger aneurysms in the abdominal cavity, either an open operation is available, in which the expanded part of the aorta is removed and replaced by a prosthesis. There is also the possibility of introducing a kind of stent over the artery in the groin and placing it in place of the aneurysm. As a result, the blood no longer flows into the aneurysm but over the stent. In the chest, an open surgery is usually performed. If the aneurysm is close to the heart, it may be necessary to replace the aortic valve.

  • Artificial heart valves
  • Therapy of an aortic aneurysm

When do you need an operation?

An aneurysm in the thoracic region should be performed on 55 mm or larger surgery. If connective tissue disease is present (eg Ehlers-Danlos syndrome or Marfan syndrome) the limit is 50 mm.

Even with a rapid growth of more than 2 mm a year, an intervention is indicated. An abdominal aortic aneurysm should be operated at a size of 60 mm. Other indications include a rapid increase in size of more than 0.5 cm in three months, symptoms caused by the aortic aneurysm and a high risk of rupture, for example in poorly adjustable high blood pressure.

aortic

An aortic prosthesis is a tissue tube used in the treatment of the aortic aneurysm. Above a certain size surgery of the aneurysm should be performed, because the larger the diameter, the greater the risk of rupture. The prosthesis can be introduced in two ways. On the one hand, during surgery, the affected piece of aorta is replaced by the prosthesis, on the other hand, there is a minimally invasive method using a catheter. Here, the prosthesis is folded and advanced over a vessel to the affected area. Here it unfolds and thus removes the aneurysm from the bloodstream.

Complication: rupture of the aneurysm

The rupture of an aortic aneurysm is a life-threatening complication. Once an anterior wall of the vessel wall has formed, it usually continues to expand. With more than 55 mm diameter in the chest area and more than 60 mm in the abdomen, the risk of rupture is particularly high. The bursting of the aneurysm causes extreme pain in the abdomen or chest, often accompanied by nausea and vomiting. It comes to internal bleeding, in which the person can lose very large quantities of blood within a very short time. The result is circulatory shock and, in most cases, death.

Chances of survival

The chances of survival of a rupture of the aortic aneurysm are poor. In the event of a rupture outside a hospital, half of those affected die on their way to the clinic. A quarter can then no longer be treated successfully in the clinic because the blood loss is already too large. Of the patients who undergo surgery, 40% do not survive. Only in a few cases is there a real chance of survival, since the time for a successful intervention is very tight. In contrast, an early recognized and treated aortic aneurysm has a good prognosis.

Does one have a reduced life expectancy with an aortic aneurysm?

Life expectancy with an aortic aneurysm depends on many factors. First, it is important that the aneurysm is discovered and treated in good time. If this happens too late, there is a risk of rupture, which in most cases results in death. After a successful procedure, the risk of rupture is very low. However, life expectancy now depends on the underlying disease, such as arteriosclerosis. Because the surgery "repairs" the aneurysm, but does not address the cause. Arteriosclerosis therefore continues to exist and can lead to further illnesses.

causes

In most cases, the cause is hypertension and the resulting arteriosclerosis. In particular, undetected and untreated hypertension, which persists over a longer period of time, are responsible for the formation of an aortic aneurysm.

Another cause of the aortic aneurysm may be trauma due to car accidents (acceleration injury) or in a medical vascular puncture. In general, it can be said that previous vascular injuries of any kind can lead to an aortic aneurysm. Inflammatory causes, such as inflammation of the arteries

( Arteriitiden ), bacterial infections ( lues ) or infections by fungi are a rare cause. Very rarely an aortic aneurysm results from the so-called cystic median necrosis or the rare Kawasaki syndrome.

If there is a constriction of the aorta for whatever reason, usually the area behind the constriction begins to expand. An aneurysm arises.

An aortic aneurysm can also be innate. There are some diseases concerning collagen system of an organism. Since collagen is also present in the vessel walls, a disruption of collagen synthesis leads to instability, which can result in an aneurysm. To mention here are the so-called Ehlers-Danlos syndrome (sufferers are usually due to an unnatural hyperextensiveness of the joints). Marfan syndrome is a malformation syndrome of the mesenchyme. This often results in a final inability of the heart valves (mitral regurgitation) and / or an aortic aneurysm.

Furthermore, one also assumes a hereditary component that promotes the development of aortic aneurysms.

classification

In principle, three forms of the aortic aneurysm can be distinguished.

  1. Aneurysm verum,
  2. Aneurysm dissecans and that
  3. Aneurysm spurium .

1. The aneurysm verum is also called a true aneurysm. It is a sack- or spindle-shaped overstretching and Aussackung all three wall layers (the so-called Intima, Media and Adventitia).

2. Aneurysm dissecans causes only an intimal tear. The blood passes through the tear into the inner vessel wall and splits it (dissection, scalding). This creates a double lumen that may range from the main artery (aorta) of the chest to the abdominal aorta. This leads to an overstretching of the outer wall of the vessel ( adventitia ), which may be able to squeeze the outgoing vessels. In this case, then certain areas of the body are no longer supplied with blood (descending ischemia syndrome). The blood between the layers may possibly re-enter the regular vessel through a window. There is also the possibility of self-healing in aneurysm dissecans . A later tearing is not excluded and must be feared.

3. The aneurysm spurium is also referred to as a false aneurysm ( aneurysm falsum ). Due to a leak in the arterial wall, blood comes out of the blood vessel and forms a bruise (hematoma). After some time around the hemorrhage forms a capsule of connective tissue, which then emerges as Aussackung. Since this is not, as with the other aneurysms, vascular wall, this is also called a false aneurysm.

In addition to this classification, the aortic aneurysms are also classified according to their height localization at the aorta. The main artery (aorta) from the heart, which passes over the aortic arch into the abdominal aorta, is divided into 5 segments. After the classification of DeBakey, a type 1 aortic aneurysm may affect the whole aorta. Aortic aneurysm type 2 is restricted to the ascending aorta only. Aortic aneurysm type 3 affects the area below the left subclavian artery.

A further classification of the aortic aneurysm can be made according to Stanford. Here only two groups are distinguished. While Type Aam arch and ascending aorta are located, Type B is located at the descending aorta behind the exit of the subclavian artery .
Finally, one can also classify the aneurysms descriptively according to their shape. The aneurysm sacciforme is rather bag-shaped, the aneurysm fusiform rather spindle-shaped and the aneurysm saccifusiforme is mixed. A bar-shaped form would be called an aneurysm cuneiforme and a snake-shaped one consisting of various aneurysms ( aneurysmosis ) as aneurysm serpentinum .

As some of the potential complications may be an aortic dissection, a rupture of the inner wall of the aorta. This is accompanied by sudden, stabbing pain of the strongest intensity.

Why does the aneurysm appear particularly in the abdomen?

An aortic aneurysm occurs most often in the abdomen. In 90% of cases, it forms below the renal artery. The exact reason for this is not yet completely clear. It could be because the structures and organs surrounding the aorta favor a prolapse of the aortic wall at this point, or that the pressure in the vessel is particularly high here due to certain factors. Another reason is probably processes that take place at the cellular level, but which have not yet been fully understood.

Can I do sports with an aortic aneurysm and which one?

Basically, sports with an aortic aneurysm is possible. However, it depends greatly on the diameter of the aneurysm and the causative disease. It must therefore be decided individually for each patient. In general, it can be said that in an aortic aneurysm exercise, in which the blood pressure rises sharply to avoid. An example of this is weight training. An increase in blood pressure increases the pressure on the aortic wall and thus favors a life-threatening rupture. Aerobic endurance sport such as Nordic walking is recommended.

Epidemiology

Mostly men are affected by the aortic aneurysm (ratio to women 6: 1). The age peak is between the 65th and 75th year of life. Since there is no check-up in the sense of an aortic aneurysm, a relatively high number of unreported cases can be expected even among younger patients. In 10% of elderly patients suffering from high blood pressure, an aortic aneurysm can be detected.

MRI of the aorta

Important for the planning of the treatment of the aortic aneurysm is an imaging procedure to assess the aneurysm and the vessel wall. For this one uses either the CT or the MRI with contrast agent. MRI is superior to CT because it can better visualize the condition of the vessel wall and there is no radiation exposure to the patient, but due to the increased time required, it is not applicable in emergency situations. Because magnetic radiation is used on MRI, it can not be used on patients with cardiac pacemakers or metallic stents.

Summary

Aneurysm is an outgrowth of the vessel wall. A distinction is made between the aneurysm verum (true aneurysm), in which the entire vessel wall is everted, the aneurysm dissecans, in which there is a hemorrhage between the two vascular layers and the aneurysm spurium in which there is a rupture of all wall layers with simultaneous hemorrhage into surrounding Tissue is coming.
This type of aneurysm later forms a covering around the hemorrhage, which in turn can exert pressure and dysfunction on surrounding organs.

Besides various inherited disorders of collagen and connective tissue synthesis, the main cause of an aortic aneurysm is hypertension and arteriosclerosis. For this reason, optimal blood pressure adjustment is essential in these patients. Aneurysm is usually diagnosed by the ultrasound examination of the blood vessels.
Exact location and further information is provided by computed tomography (CT) or magnetic resonance tomography (MRT). 30% of the aneurysms do not cause discomfort and are detected, if at all, by a random ultrasound scan. 45% cause back and flank pain.

In case of tearing of the aortic aneurysm (rupture) of an aneurysm diameter of more than 5 cm, an urgent operation is indicated. Hereby, the thorax is opened, the main artery is disconnected from the blood circulation and either after aneurysm removal the open spot is sutured or a plastic-coated tube (stent) is inserted.

All aortic aneurysms smaller than 4 cm and not causing symptoms should be closely monitored by ultrasound. An increase in size must not exceed 0.4 cm per year. If this is the case, surgery is also indicated.

Without therapy, 50% of asymptomatic aneurysms will break down within the next 10 years. Symptomatic aneurysms break down on average after one to two years (90%). At planned operation 4-7% of patients die, in emergency operation up to 50-90%.

Aortic aneurysm is a serious disease that has greatly increased its chances of recovery in recent years through better materials and surgical procedures.


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