AORTIC ANEURYSM

An aortic aneurysm is a general term for any swelling (dilatation or aneurysm) of the aorta, usually representing an underlying weakness in the wall of the aorta at that location

While the stretched vessel may occasionally cause discomfort, a greater concern is the risk of rupture, which causes severe pain; massive internal hemorrhage; and, without prompt treatment, results in a quick death.

An aortic aneurysm develops from a weakness in the wall of the aorta. This weakness can be present at birth or can develop as the result of disease or injury.

CAUSES:
1) Atherosclerosis: A clogged or damaged artery from a

condition called atherosclerosis is the most common cause of aneurysm.

plaque sticks to the lining of the blood vessel wall, weakening the wall.

2) High blood pressure: High blood pressure puts stress on the wall of the aorta. Over many years, this stress can lead to bulging of the blood vessel wall.
3) Cystic medial necrosis: In this condition, the medial layer of the blood vessel wall degenerates, and an abnormal fibrous layer weakens the supporting structure of the blood vessel wall itself.

Commonly occurs with certain rare inherited conditions such as Marfan syndrome and Ehlers-Danlos syndrome.

4) Mycotic aneurysm occurs when bacteria spread into the arterial system the blood vessel wall, and weaken the vessel. Often the bacteria enter a previous damage or areas weakened since birth.

Inflammatory aneurysm: Inflammatory conditions or 5) vasculitis, such as psoriasis and rheumatoid arthritis, may produce inflammation in the blood vessel wall itself.

6) Injury: Injury to the chest or abdomen, as in a car wreck or bad fall, can damage an area of the aorta. This leaves the aorta vulnerable to bulging

Aortic aneurysms are classified by where on the aorta they occur; 1)An aortic root aneurysm, or aneurysm of sinus of Valsalva, appears on the sinuses of Valsalva or aortic root. 2) Thoracic aortic aneurysms are found on the thoracic aorta; these are further classified as ascending, aortic arch, or descending aneurysms depending on the location on the thoracic aorta involved. 3)Abdominal aortic aneurysms, the most common form of aortic aneurysm, are found on the abdominal aorta, and thoracoabdominal aortic aneurysms involve both the thoracic and abdominal aorta. There are other classifications that might help treatment.

AORTIC ROOT ANEURYSM

Aortic root aneurysm

Thoracic aortic aneurysm

Aneurysm of descending thoracic aorta

AAA
Abdominal aortic aneurysm (AAA)is a localized dilatation of the abdominal aorta exceeding the normal diameter by more than 50 percent. It is caused by degeneration of the aortic wall, but the exact etiology remains unknown. Some 90 percent of abdominal aortic aneurysms occur infrarenally (below the kidneys), but they can also occur pararenally (at the level of the kidneys) or suprarenally (above the kidneys). Such aneurysms can extend to include one or both of the iliac arteries in the pelvis.

Abdominal aortic aneurysms occur most commonly in individuals between 65 and 75 years old and are more common among men and smokers. They tend to cause no symptoms, although occasionally they cause pain in the abdomen and back (due to pressure on surrounding tissues) or in the legs (due to disturbed blood flow). The major complication of abdominal aortic aneurysms is rupture, which can be life-threatening as large amounts of blood spill into the abdominal cavity, and can lead to death within minutes.[1]

Abdominal aortic aneurysm

The vast majority of aneurysms are asymptomatic. However, as abdominal aortic aneurysms expand, they may become painful and lead to symptoms such as strong pulsations in the abdomen or pain in the chest, lower back, or scrotum Complications include rupture, peripheral embolisation, acute aortic occlusion, and aortocaval (between the aorta and inferior vena cava) or aortoduodenal (between the aorta and the duodenum) fistulae

Signs and symptoms

The clinical manifestation of ruptured AAA usually includes excruciating pain of the lower back, flank, abdomen and groin. The bleeding usually leads to a hypovolemic shock with hypotension, tachycardia, cyanosis, and altered mental status. The bleeding can be retroperitoneal or intraperitoneal, or the rupture can create an aortocaval or aortointestinal (between the aorta and intestine) fistula.Flank ecchymosis is a sign of retroperitoneal hemorrhage, and is also called Grey Turner's sign.

DIAGNOSIS An abdominal aortic aneurysm is usually diagnosed by physical exam, ultrasound, or CT. Plain abdominal radiographs may show the outline of an aneurysm when its walls are calcified.Ultrasonography is used to screen for aneurysms and to determine the size. Additionally free peritoneal fluid can be detected. CT scan has a nearly 100% sensitivity for aneurysm and is also useful in preoperative planning, detailing the anatomy and possibility for endovascular repair. In the case of suspected rupture, it can also reliably detect retroperitoneal fluid. Alternative less often used methods for visualisation of the aneurysm include MRI and angiography.

MANAGEMENT

Medical therapy of aortic aneurysms involves strict blood pressure control. This does
not treat the aortic aneurysm per se, but control of hypertension within tight blood pressure parameters may decrease the rate of expansion of the aneurysm

Surgery
Open repair Endovascular repair

Pre-procedure evaluation is performed by a combination of contrast enhanced spiral CT and abdominal aortography with special marker catheters. A few of the critical anatomic determinations which must be made in planning graft implantation are: diameter and length of the infrarenal aorta and neck of the aorta; diameter and length of the iliac attachments (landing zones); tortuosity and size of the access vessels and critical accessory vessel anatomy.

Endovascular Repair
As with conventional surgical therapy of AAA, the goal of endovascular treatment of AAA is to provide a durable repair maintaining prograde flow in the graft while excluding flow within the aneurysm. Endovascular treatment offers a less invasive alternative to standard surgical repair with the potential to reduce hospitalization, morbidity and mortality

Interventional radiologists are D experts who offer minimally invasive treatment for abdominal aorticaneurysm
This minimally invasive technique is performed by an interventional radiologist using imaging to guide the catheter and graft inside the patient's artery. For the procedure, an incision is made in the skin at the groin through which a catheter is passed into the femoral artery and directed to the aortic aneurysm. Through the catheter, the physician passes a stent graft that is compressed into a small diameter within the catheter. The stent graft is advanced to the aneurysm, then opened, creating new walls in the blood vessel through which blood flows.

Endoleak is a common complication of EVAR found in up to

40% of patients. It is seen on CTA, MRA and DSA as contrast opacification of the aneurysm sac outside the graft. Flow in the sac may also be detected on ultrasound. When an endoleak occurs, flow within the aneurysm sac is at systemic or nearsystemic pressure. If untreated, the aneurysm may expand and is at risk of rupture. Aneurysm expansion following EVAR always warrants investigation for endoleak