An aortic aneurysm is a bulging or dilation in the wall of the aorta which is a major blood vessel that carries blood from heart to body. An aneurysm is caused due to weakness or degeneration that develops in a portion of the aortic wall. Aortic aneurysms include abdominal aortic aneurysms (in the abdomen) and thoracic aortic aneurysms (in the chest cavity). Abdominal pain is the most common symptom of an abdominal aortic aneurysm. The pain associated with an abdominal aortic aneurysm may be located in the abdomen, chest, lower back or groin area. Sudden, severe pain in the abdomen with tearing sensation might indicate the aneurysm is about to rupture. This is a life-threatening medical emergency. If ruptured aortic aneurysm could not be accurately diagnosed and effectively treated in time, it can cause life-threatening internal bleeding, leading to the increased chances of sudden death. Therefore, timely and effective treatment for abdominal aortic aneurysm does not only play a major role in the reduction of mortality rates, but it also significantly enhances long-term improvements of patient’s quality of life. Knowing the warning signs of aortic aneurysm remains crucial. If abdominal pain shows up, immediate medical assistance must be sought as soon as possible.

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An aortic aneurysm is a bulging or dilation in the wall of the aorta which is a major blood vessel that carries blood from the heart to the body. The dilating wall of aorta is caused by the weakness or degeneration that develops in some portion of the aortic wall. Aortic aneurysms include abdominal aortic aneurysm (in the abdomen) and thoracic aortic aneurysm (in the chest cavity). An aneurysm might enlarge and the wall of the aorta cannot stretch any further. At this point, an aneurysm is at risk of rupturing, leading to fatal conditions. Men, especially aged 65-75 are more likely to develop abdominal aortic aneurysms much more often than women do. A number of factors can play a major role in developing an aortic aneurysm including: 

• High blood pressure (hypertension);
• High blood cholesterol (hypercholesterolemia);
• Lifestyle habits e.g. smoking; and
• Genetic alterations that can weaken the aorta’s walls.

The danger of abdominal aortic aneurysms is no warning signs and symptoms to suggest that disease develops. When symptoms present, it usually indicates the ruptures that cause irregular blood circulation and other life-threatening complications. If abdominal aortic aneurysm is not diagnosed and treated in time, risks of death significantly rise.

Warning signs and symptoms 

The most common type of abdominal pain that likely indicates abdominal aortic aneurysms is sudden or intense abdominal pain with pulsating enlargement or tender mass in an abdomen caused by a bulge of aortic wall in the abdominal areas. Nevertheless, abdominal pain might vary among individuals. If aneurysm enlarges, the wall of the aorta cannot stretch any further. At this point, an aneurysm is at risk of rupturing. If left untreated, aneurysm ruptures from the innermost layer to the middle layer and eventually to the outermost layer which attaches the vessel to the surrounding tissue. The ruptured aortic aneurysms cause internal  bleeding. The mortality rates dramatically increase up to 70-80% if ruptures happen in the abdominal cavity.

However, instead of developing abdominal pain, some patients with abdominal aortic aneurysm might exhibit other symptoms such as leg pain caused by blood clot from an abdominal aortic aneurysm that breaks and lodges into the arteries of the leg, resulting in blockage of blood circulation and sudden and severe leg pain. More importantly, disease severity depends on the size of the aneurysm and its growth rate. Abdominal aortic aneurysms sometimes grow slowly without noticeable symptoms, therefore some patients might not have clinical manifestations. In order to make an accurate diagnosis, additional imaging tests might be required such as abdominal aortic ultrasound and computerized tomography or CT scan.

Patients with high risk 

• Patients with high blood lipids
• Patients with hypertension
• Patients who smoke
• Patients who have family members diagnosed with abdominal aortic aneurysms
• Elderly patients aged over 65

Diagnosis 

To diagnose abdominal aortic aneurysm, tests involve: 

1. Reviewing of medical history and physical examination.
2. Abdominal ultrasound.
3. 256-Slice CT scan. This imaging test provides clear images of aorta and it can detect the size and shape of an aneurysm.
4. 256-Slice CT scan for coronary calcium score to detect the presence, location and extent of calcified plaque in the cardiac vessels.

Treatment

In case that abdominal aortic aneurysm develops, the chances of ruptures increase if the condition is left untreated. The goal of treatment is to prevent aneurysm from rupturing. However, the selected approach to repair abdominal aortic aneurysm depends upon several factors including the location, size and shape of the aneurysm as well as the symptoms and physical conditions of individual patient. To surgically repair abdominal aortic aneurysm, 2 main options include an open incision (open aneurysm repair) and minimally invasive surgery called endovascular aneurysm repair.

1. Open abdominal surgery. Open surgery is conducted through an open cut (incision) made between the epigastric region to the groin. This approach involves removing the damaged section of the aorta and replacing it with a synthetic tube (graft) which is sewn into place. This approach is often performed in patients presenting with large ruptures, causing substantial blood loss.
2. Endovascular aneurysm repair. This is a minimally invasive method to treat an aortic aneurysm with superior advantages covering smaller incision, less pain, fewer post-operative complications, faster recovery time and shorter hospital stay as well as cosmetic benefits. During the endovascular aneurysm repair, the cardiothoracic surgeon first inserts a catheter into an artery through small incisions made in the groin and threads it to the aortic aneurysm. Then, using an x-ray to see the aorta, the surgeon threads a stent graft (a fabric tube supported by metal wire stents) into the aneurysm. The graft is subsequently expanded inside the wall of aorta and fastened in place to form a stable channel for blood flow. The graft reinforces the weakened section of the aortic wall to prevent the aneurysm from rupturing. However, not all aneurysms are suitable for endovascular repair. The location or size of the aneurysm in some patients may prevent a stent graft from being safely or reliably placed inside the aneurysm. In this case, open surgery might be advised.

Prevention

The best possible way to reduce risk of abdominal aortic aneurysm is to strengthen the wall of aorta by reducing lipid and plaque accumulations. Lifestyle changes to prevent abdominal aortic aneurysms include: 

• Eating a healthy diet. Focus on eating a variety of fruits and vegetables, low-fat dairy products. High-fat diets must be avoided;
• Regular exercise;
• Smoke cessation, if smoke;
• Keeping blood pressure, blood sugar and cholesterol under control;
• Having annual health check-ups;
• Maintaining healthy weight.

If patients exhibit severe and sudden abdominal pain with tearing sensation in the abdomen, abdominal aortic aneurysm might be highly suspected. In such a case, sugery to repair aneurym must be urgently conducted. Our operating room at Bangkok Heart Hospital is an advanced surgical theatre that is well equipped with cardiovascular operating room and cardiac catheterization laboratory. Not only reducing disease severity and complications, but timely and effective treatments also help improving patient’s quality of life. More importantly, abdominal aortic aneurysm can strike younger patients who have family history of aortic aneurysm at anytime, although no warning signs exhibit. To lower the risk of developing the disease, it is highly recommended to have regular health check-ups combined with lifestyle modification.