Abdominal Aortic Aneurysm

Medical Author : Benjamin Wedro, MD, FACEP, FAAEM

Medical Editor : William C. Shiel Jr., MD, FACP, FACR

Abdominal aortic aneurysm facts

  • An aneurysm is an abnormal area of localized widening of a blood vessel.
  • The aorta bulges at the site of an aneurysm like a weak spot on a worn tire.
  • Aortic aneurysms are typically spindle-shaped and involve the aorta below the arteries to the kidneys.
  • The most common cause of an aneurysm is arteriosclerosis. Smoking is a major risk factor.
  • Abdominal aortic aneurysms often do not cause symptoms. If they do, they may cause deep boring pain in the lower back or flank. Prominent abdominal pulsations may be present.
  • X-rays of the abdomen and other radiologic tests including ultrasound, CT, and MRI may be used in diagnosing and monitoring the aneurysm.
  • Rupture of an aortic aneurysm is a catastrophe.
  • Repair of the aneurysm can be done by surgery or endovascular stenting.

What is an aneurysm?

An aneurysm is an area of a localized widening (dilation) of a blood vessel. The word "aneurysm" is borrowed from the Greek "aneurysma" meaning "a widening."

What is an aortic aneurysm?

An aortic aneurysm involves the aorta, the major artery that leaves the heart to supply blood to the body. An aortic aneurysm is a dilation or bulging of the aorta.

What is the thoracic and abdominal aorta?

The aorta is the large artery that exits the heart and delivers blood to the body. It begins at the aortic valve that separates the left ventricle of the heart from the aorta and prevents blood from leaking back into the heart after a contraction, when the heart pumps blood. The various sections of the aorta are named based upon “arch-like” initial design and the location in the body. Thus, the beginning of the aorta is referred to as the ascending aorta, followed by the arch of the aorta, then the descending aorta. The portion of the aorta that is located in the chest (thorax) is referred to as the thoracic aorta, while the abdominal aorta is located in the abdomen. The abdominal aorta extends from the diaphragm to the mid-abdomen where it splits into the iliac arteries that supply the legs with blood.

Where do aortic aneurysms tend to develop?

Aortic aneurysms can develop anywhere along the length of the aorta but the majority are located in the abdominal aorta. Most of these abdominal aneurysms are located below the level of the renal arteries, the vessels that provide blood to the kidneys. Abdominal aortic aneurysms can extend into the iliac arteries.

What shape are most aortic aneurysms?

Most aortic aneurysms are fusiform. They are shaped like a spindle ("fusus" means spindle in Latin) with widening all around the circumference of the aorta. (Saccular aneurysms just involve a portion of the aortic wall with a localized out pocketing).

What is inside an aortic aneurysm?

The inside walls of aneurysms are often lined with a blood clot that forms because there is stagnant blood. The wall of an aneurysm is layered, like a piece of plywood.

Who is most likely to have an abdominal aortic aneurysm?

Abdominal aortic aneurysms tend to occur in white males over the age of 60. In the United States, these aneurysms occur in up to 3.0% of the population. Aneurysms start to form at about age 50 and peak at age 80. Women are less likely to have aneurysms than men and African Americans are less likely to have aneurysms than Caucasians.

There is a genetic component that predisposes one to developing an aneurysm; the prevalence in someone who has a first-degree relative with the condition can be as high as 25%.

Collagen vascular diseases that can weaken the tissues of the aortic walls are also associated with aortic aneurysms. These diseases include Marfan syndrome and Ehlers-Danlos syndrome. 

What are risk factors for aortic aneurysms?

The risk factors for aortic aneurysm are the same as those for atherosclerotic heart disease, stroke, and peripheral artery disease and include:

  • Cigarette smoking: This not only increases the risk of developing an abdominal aortic aneurysm, but also increases the risk of aneurysm rupture. Aortic rupture is a life-threatening event where blood escapes the aorta and the patient can quickly bleed to death.
  • High blood pressure
  • Elevated blood cholesterol levels
  • Diabetes mellitus

What is the most common cause of aortic aneurysms?

The most common cause of aortic aneurysms is "hardening of the arteries" called arteriosclerosis. At a majority of aortic aneurysms are from arteriosclerosis. The arteriosclerosis can weaken the aortic wall and the increased pressure of the blood being pumped through the aorta causes weakness of the inner layer of the aortic wall.

The aortic wall has three layers, the tunica adventitia, tunica media, and tunica intima. The layers add strength to the aorta as well as elasticity to tolerate changes in blood pressure. Chronically increased blood pressure causes the media layer to break down and leads to the continuous, slow dilation of the aorta.

Smoking is a major cause of aortic aneurysm. Studies have shown that the rate of aortic aneurysm has fallen at the same rate as population smoking rates. 

What are other causes of aortic aneurysms?

Other causes of aortic aneurysms include:

  • Genetic/hereditary: Genetics may play a role in developing an aortic aneurysm. The risk of having an aneurysm increases if a first-degree relative also has one. The aneurysm may present at a younger age and is also at a higher risk of rupture.
  • Genetic disease: Ehlers-Danlos syndrome and Marfan syndrome are two connective tissue diseases that are associated with the development of aortic aneurysm. Abnormalities of the connective tissue in the layers of the aortic wall can contribute to weakness in sections of the aorta.
  • Post-trauma: Trauma can injure the aortic wall and cause immediate damage or it may cause an area of weakness that will form an aneurysm over time.
  • Arteritis: Inflammation of blood vessels as occurs in Takayasu disease, giant cell arteritis, and relapsing polychondritis can contribute to aneurysm.
  • Mycotic (fungal) infection: A mycotic or fungal infection may be associated with immunodeficiency, IV drug abuse, syphilis, and heart valve surgery.

What are the symptoms of an abdominal aortic aneurysm?

Most abdominal aortic aneurysms produce no symptoms (they are asymptomatic) and are discovered incidentally when an imaging test of the abdomen (CT scan or ultrasound) is performed. They can also be detected by physical examination when the health care professional feels the abdomen and listens for a bruit, the sound made by turbulent blood flow.

Pain is the most common symptom when the aneurysm expands or ruptures. It often begins in the central abdomen and radiates to the back or flank. Other symptoms can occur depending upon where the aneurysm is located in the aorta and whether nearby structures are affected.

Abdominal aortic aneurysms can remain asymptomatic or produce minimal symptoms for years. However, a rapidly expanding abdominal aneurysm can cause sudden onset of severe, steady, and worsening middle abdominal and back or flank pain. Rupture of an abdominal aortic aneurysm can be catastrophic, even lethal, and is associated with abdominal distension, a pulsating abdominal mass, and shock due to massive blood loss. 

How is an abdominal aortic aneurysm diagnosed clinically?

Physical examination can be the initial way the diagnosis of abdominal aortic aneurysm is made. The health care professional may be able to feel a pulsatile mass in the center of the abdomen and make the clinical diagnosis. In obese patients with a large girth, physical exam is less helpful. In very thin patients, the aorta can often be seen to pulsate under the skin and this may be a normal finding. Listening with a stethoscope may also reveal a bruit or abnormal sound from turbulence of blood within the aneurysm.

What tests help in the diagnosis of an abdominal aortic aneurysm?

 

In about most cases, X-rays of the abdomen show calcium deposits in the aneurysm wall. But plain X-rays of the abdomen cannot determine the size and the extent of the aneurysm. Ultrasonography usually gives a clear picture of the size of an aneurysm. Ultrasound has about 98% accuracy in measuring the size of the aneurysm and is safe and noninvasive. Computerized tomography of the abdomen is highly accurate in determining the size and extent of the aneurysm and its location in the aorta. To help plan repair, if needed, it is important to know whether the aorta is above or below where the renal arteries branch off to go to the kidneys and whether the aorta extends towards the chest or down into the iliac arteries into the legs. CT scans require dye to be injected to evaluate the blood vessels (including the aorta). Patients with kidney disease or dye allergies may not be candidates for CT. MRI/MRA (magnetic resonance imaging and arteriography) may be an alternative.

An aortogram, an X-ray study where dye is directly injected into the aorta, was the test of choice, but CT and MRI have taken its place.

What is the natural history of abdominal aortic aneurysms?

 

Abdominal aortic aneurysms gradually expand over time. The larger the aneurysm, the greater the risk of rupture and death. Small aneurysms can be observed and followed with repeated ultrasounds or other imaging.

Guidelines for following an aneurysm are as follows:

  • A normal aorta measures up to 1.7 cm in a male and 1.5 cm in a female.
  • Aneurysms that are found incidentally or by accident that are less than 3.0 cm do not need to be re-evaluated or followed.
  • Aneurysms measuring 3.0 to 4.0 cm should be rechecked by ultrasound every year to monitor for potential enlargement and dilation.
  • Aneurysms measuring 4.0 to 4.5 cm should be monitored every 6 months by ultrasound.
  • Aneurysms measuring greater than 4.5 cm should be evaluated by a surgeon for potential repair. 

What are the complications with an abdominal aortic aneurysm?

An aortic aneurysm can leak causing an increase in the patient's abdominal pain. When pain is felt in the back or flank, the symptoms can be misdiagnosed as a kidney stone. If the diagnosis is missed or if the patient does not present for care, the aneurysm can burst or rupture causing potential catastrophe and death.

Since aneurysms are associated with atherosclerosis and plaque along the aortic wall and since aneurysms often contain a clot, debris can travel, or embolize, into smaller blood vessels and cause symptoms due to decreased blood flow.

Aneurysms can rarely become infected.

How are abdominal aortic aneurysms repaired?

Each patient is different and the decision to repair an abdominal aortic aneurysm depends upon the size of the aneurysm, the age of the patient, underlying medical conditions, and life expectancy.

There are two approaches for repair:

The first is the traditional surgical approach. A large incision is made in the abdomen, the aortic aneurysm is identified and cut out or resected. The missing piece of aorta is replaced with a synthetic graft.

The second approach is placing an endovascular graft. A catheter or tube is threaded into the femoral artery in the groin and the graft is positioned so that it spans and sits inside the aneurysm and protects it from expanding (endovascular: endo = inside + vascular = blood vessel).

The approach to treatment needs to be tailored to the individual patient and very much depends upon the location, size, and shape of the aneurysm. Continue Reading

Picture of grafted stent to repair an abdominal aortic aneurysm.
Picture of grafted stent to repair an abdominal aortic aneurysm.
 

What is done if an abdominal aortic aneurysm threatens to rupture?

Threatened rupture of abdominal aneurysms is a surgical emergency. Once an aneurysm ruptures, 50% of patients die before their reach the hospital. The longer it takes to get to the operating room, the higher the mortality.

What is the medical management (nonsurgical management) of abdominal aortic aneurysm?

Once an aneurysm is detected, the goal is to try to prevent it from enlarging. Life-long control of risk factors is a must and includes the following:

  • Stopping cigarette smoking.
  • Controlling high blood pressure: Beta blocker medications may be used to control both blood pressure and to decrease the pressure within the aneurysm.
  • Controlling blood cholesterol.
  • Keeping diabetes under control.
  • Routine monitoring of the size of the aneurysm:
    • A normal aorta measures up to 1.7 cm in a male and 1.5 cm in a female.
    • Aneurysms that are found incidentally or by accident that are less than 3.0 cm do not need to be re-evaluated or followed.
    • Aneurysms measuring 3.0 to 4.0 cm should be rechecked by ultrasound every year to monitor for potential enlargement and dilation.
    • Aneurysms measuring 4.0 to 4.5 cm should be monitored every 6 months by ultrasound.
    • Aneurysms measuring greater than 4.5 cm should be evaluated by a surgeon for potential repair.

Angelman syndrome facts*

*Angelman syndrome facts medically edited by:

  • Angelman syndrome is a genetic disorder with characteristic features that include severe speech impairment, developmental delay, intellectual disability, and ataxia (problems with movement and balance).
  • Angelman syndrome is named after the physician Harry Angelman who first delineated the syndrome in 1965.
  • Angelman syndrome affects an estimated 1 in 12,000 to 20,000 people.
  • Most children with Angelman syndrome have microcephaly (small head size) and epilepsy (recurrent seizures).
  • The developmental delay of Angelman syndrome generally becomes noticeable by the age of 6 to 12 months.
  • Adults with Angelman syndrome have facial features that are distinct and are often described as "coarse."
  • Some of the characteristic features of Angelman syndrome are a result from the loss of function of a gene called UBE3A.
  • The life expectancy for individuals with Angelman syndrome appears to be nearly normal.

What is Angelman Syndrome?

Angelman syndrome is a genetic disorder that primarily affects the nervous system that causes developmental delay and neurological problems. The physician Harry Angelman first delineated the syndrome in 1965, when he described several children in his practice as having "flat heads, jerky movements, protruding tongues, and bouts of laughter."

What are the characteristics, signs, and symptoms of Angelman syndrome?

  • Infants with Angelman syndrome appear normal at birth, but often have feeding problems in the first months of life and exhibit noticeable developmental delays by 6 to 12 months.
  • Seizures often begin between 2 and 3 years of age.
  • Speech impairment is pronounced, with little to no use of words. Individuals with this syndrome often display the following that can have severe functional deficits:
  • Children with Angelman syndrome typically have a happy, excitable demeanor with frequent smiling, laughter, and hand-flapping movements.
  • In addition to hyperactivity, a short attention span, and a fascination with water are common.
  • With age, people with Angelman syndrome become less excitable, and the sleeping problems tend to improve. However, affected individuals continue to have intellectual disability, severe speech impairment, and seizures throughout their lives.
  • Adults with Angelman syndrome have distinctive facial features that may be described as "coarse." Other common features include unusually fair skin with light-colored hair and an abnormal side-to-side curvature of the spine (scoliosis). The life expectancy of people with this condition appears to be nearly normal.

Angelman syndrome results from absence of a functional copy of the UBE3A gene inherited from the mother.

Is there any treatment for Angelman syndrome?

There is no specific therapy for Angelman syndrome. Medical therapy for seizures is usually necessary. Physical and occupational therapies, communication therapy, and behavioral therapies are important in allowing individuals with Angelman syndrome to reach their maximum developmental potential.

What is the prognosis for Angelman syndrome?

Most individuals with Angelman syndrome will have severe developmental delays, speech limitations, and motor difficulties. However, individuals with Angelman syndrome can have normal life spans and generally do not show developmental regression as they age. Early diagnosis and tailored interventions and therapies help improve quality of life.

What research is being done on Angelman syndrome?

The NINDS supports and conducts research on neurogenetic disorders such as Angelman syndrome, to develop techniques to diagnose, treat, prevent, and ultimately cure them.

Organizations for Angelman syndrome

 

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