There is a reason aortic aneurysm is known as “the silent killer.” Most people who have an aneurysm have no symptoms at all. Most only discover they have an aneurysm incidentally during imaging for another problem. This poses a real danger because aortic aneurysms can grow in size, and when they are not treated they can dissect or rupture without warning.
“With aneurysm disease, the first symptom is death,” says John Elefteriades, MD, a Yale Medicine heart surgeon and director of the Yale Center for Advanced Thoracic Aortic Disease at Yale New Haven Hospital’s Aortic Institute, part of the hospital’s Heart and Vascular Center, as well as an internationally renowned pioneer in his field.
The good news is that an aortic aneurysm that is diagnosed early can be monitored and, when it grows dangerous, treated successfully. An important question to ask yourself is whether you are at high risk for an aneurysm. “If you have a family member who had an aneurysm anywhere in the body, or a family member who died suddenly—especially at a young age or without a history of heart disease—please ask your doctor to check you for aneurysm,” Dr. Elefteriades says.
What is the aorta?
The aorta is the main artery in the body. It is shaped like a candy cane, with the “ascending” rising up from the heart, the “arch” curving toward the back, and the “stick” descending in front of the backbone into the abdominal area, where it gradually tapers down in size. The aorta’s job is to carry oxygenated blood from the heart, down into the chest and torso, and to supply that blood to 19 major arteries.
What is an aortic aneurysm?
Healthy arteries have strong walls made up of multiple layers. But genetics or other factors can cause a small section of those walls to thin and weaken, causing a balloon-like bulge, or aneurysm, to develop. These bulges, which can occur anywhere along the length of the aorta, may be tube-shaped or rounded. Aneurysms tend to grow over time. If one grows to a dangerous size, or if inflammation and cell death in the area cause the layers to degenerate, the patient may be in grave danger.
There are two ways that an aortic aneurysm can be dangerous. One is when the force of blood pumping through the aorta causes the wall’s weakened layers to split, or dissect, allowing blood to flood between them. “Then the split aorta tears, and that’s when the patient dies,” Dr. Elefteriades says. The second risk is that an aneurysm can rupture, or burst directly (without the split layers), causing bleeding inside the body.
These dissections and ruptures are the reason why aortic aneurysm consistently ranks in the top 20 causes of death here in the U.S. Aneurysm is the 10th leading cause of death in men older than 55. Two-thirds of people who have an aortic dissection are male, but it is important to know that women also can develop aneurysms. Studies from Japan reveal that 8.3 percent of all sudden deaths are due to dissection of the aorta—making aortic aneurysm more common than expected.
How are ascending aortic aneurysms different than descending aneurysms?
While both thoracic and abdominal aneurysms occur in the aorta, there are some important differences.
Thoracic aortic aneurysm (TAA): These occur in the thoracic or chest area. A person’s genetic risk for thoracic aortic aneurysm is present from the moment of conception. Men and women are equally likely to develop a thoracic aneurysm as they age. People at risk for these aneurysms include those with high blood pressure, and people who have connective tissue disorders such as Marfan or Ehlers-Danlos syndromes.
Abdominal aortic aneurysm (AAA): These may be partly genetic, but they are also linked to cigarette smoking, hypertension and high cholesterol—all traditional risk factors for heart disease. While women can develop abdominal aneurysms, they are more common in men, especially if they are 65 or older. Other people at risk for abdominal aortic aneurysm include anyone who has a disease that damages the heart and blood vessels, such arteriosclerosis (hardened arteries), high cholesterol, or high blood pressure. Smoking is a risk factor—in fact, smokers are three to five times more likely than lifelong nonsmokers to develop an abdominal aortic aneurysm.
What are the symptoms of an aneurysm?
Unfortunately, only 5 to 10 percent of people with aortic aneurysms have symptoms prior to dissection or rupture. Pain can be a symptom, but it’s not always easy to differentiate this type of pain from back (or other types of) pain.
But there are clear symptoms when an aneurysm is dissecting or rupturing. The pain caused by these conditions is intense. It should be considered a medical emergency and warrants an immediate call to 9-1-1 and a trip to the emergency room. These symptoms may include the following:
- Extreme pain—usually sharp, stabbing or radiating—under the breastbone, or in the back between the shoulder blades
- Sudden weakness of an arm or leg
- Fainting (loss of consciousness)
- Shortness of breath or trouble breathing
- Rapid heart rate
How can you screen for an aortic aneurysm?
Right now, most thoracic aneurysms (in the chest) are what are known as “incidental findings.” This usually means a doctor has ordered an X-ray, CT scan, echocardiogram or MRI for another reason—maybe the patient has been a smoker and has developed a cough—and an aneurysm turns up on the film.
Unfortunately, insurance might not cover screening solely for the purpose of detecting aneurysms for everyone. Currently, the U.S. Preventive Services Task Force only recommends ultrasound screening for men ages 65 to 75 who have smoked at some point in their lives, whether or not they have ever had symptoms.
However, if you don’t fit the above criteria, and you have a strong family history of either aneurysm or sudden cardiac death, especially at young ages, it’s still worth talking to your doctor about your options for screening. The Aortic Institute at Yale New Haven Hospital can provide a document confirming for physicians or insurers the critical importance of screening family members of individuals who have had aneurysms.
What are the treatments for aortic aneurysm?
Sometimes, medication can help by lowering blood pressure and reducing the risk of rupture. For a fortunate few, the aneurysm won’t grow to a dangerous size, so blood pressure treatment may be sufficient. But generally, medical management has been unsatisfying and unproductive in preventing growth and rupture. Since you don’t know if you’ll be one of the lucky ones, it’s important to schedule regular checkups and keep monitoring the aneurysm.
Current guidelines recommend surgery for an aneurysm when it reaches 5 to 5.5 centimeters in size—a little smaller than the diameter of a soda can. This is the point where the aneurysm reaches a high risk of sudden dissection or rupture.
Thoracic aneurysm surgery is generally a traditional open surgery to replace the weakened section of the aorta. Abdominal aneurysm may be treated using an open surgical approach, with an abdominal incision, or by endovascular repair, which is a minimally invasive procedure that uses a catheter. Traditionally, the surgeon will open the chest or the stomach, depending on the aneurysm’s location, and stop the blood flow to the area where the aneurysm is located. If the aneurysm is thoracic, the surgeon will attach the patient to a heart-lung machine, which temporarily takes over heart and lung function during surgery. The surgeon will remove the damaged section of the aorta and replace it, usually with a fabric tube called a graft. It should last for the rest of the patient’s life. For abdominal aortic aneurysms, the heart-lung machine is generally not required.
In an endovascular repair, your doctor will place a stent, or small tube, in your aorta to support the weak artery wall. But this is not appropriate in every situation.
Open procedures usually provide permanent, lasting correction, while the stent procedures generally provide a durability of repair for three to five years.
What is the recovery like from aneurysm surgery?
An aneurysm operation is major surgery, and you will typically stay in the hospital for five or six days. That will include two or more days in the intensive care unit immediately after surgery. Walking indoors and out will be the key to your recovery, and you will probably be able to return to work in one or two months.
How is Yale Medicine unique in its care of aortic aneurysm?
The Yale Center for Advanced Thoracic Aortic Disease at Yale New Haven Hospital’s Aortic Institute, part of the hospital’s Heart and Vascular Center, is one of the largest centers in the world for the clinical care of patients with aortic aneurysm. Our specialists often manage the most complex cases.
Our researchers have impacted the way aneurysms are diagnosed and treated. A key component has been the development of a database of 5,200 patients, one of the largest organized databases of its kind in the world. The database allows researchers to see patterns in patient populations, and this has helped to clarify such information as the size of aortic aneurysm that should be treated surgically, and to identify “triggers” of aortic dissection, such as extreme physical exertion or intense emotional experiences. “There is an almost endless amount of useful analysis that can be performed from that database,” Dr. Elefteriades says.
Yale Medicine is also interested in preventing sudden death from aneurysm among its patients’ family members. We strongly recommend family members of affected patients be screened, and we are equipped to arrange for this at the time of the visit.