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Comprehensive Cardiovascular Medicine in the Primary Care Setting pp 391–409Cite as

Aortic Aneurysms

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Part of the book series: Contemporary Cardiology ((CONCARD))

Abstract

Aortic aneurysms are relatively common, and their management frequently involves cardiologists, primary care physicians, and surgeons. It is therefore important not only to understand the basic pathological mechanism and current treatment recommendations but also to recognize the different variants and their complications and to know the indications for aortic repair. This chapter will focus on the pathogenesis of aortic aneurysm, different types and classifications, prevalence and mortality associated with it, and current medical and surgical management guidelines.

Key Points

Thoracic Aneurysms

• Thoracic aortic aneurysms are much less common than abdominal aortic aneurysms and occur most commonly in the sixth and seventh decades of life.

• Cystic medial degeneration is the major pathophysiology of thoracic aortic aneurysms and is common in Marfan syndrome, Ehlers–Danlos syndrome, familial aortic aneurismal disease clusters, and bicuspid aortic valve patients.

• The vast majority of thoracic aortic aneurysms is clinically silent and discovered incidentally. A minority of patients experience symptoms, and in rare instances acute aneurysm expansion, rupture, or dissection constitutes the initial presentation.

• Emergent surgery for thoracic aortic aneurysm is associated with substantial morbidity and mortality. The goal is to operate electively aorta reaches the critical size which increases the risk of rupture, i.e., 5.5 cm for the ascending aorta and 6 cm for the descending aorta.

• Surgical repair is the standard of care for symptomatic, large high risk or unstable aortic aneurysms. Asymptomatic patients are usually managed medically with aggressive blood pressure reduction, with beta-blocking agents, angiotensin receptor blockers (or angiotensin-converting enzyme inhibitors), reduction of cardiovascular risk factors, follow-up surveillance, and patient education.

Abdominal Aortic Aneurysms

• Smoking is the strongest independent risk factor for abdominal aortic aneurysm, followed by male gender, age, hypertension, hyperlipidemia, and atherosclerosis.

• The triad of abdominal pain, pulsatile epigastric mass, and hypotension, although uncommon, suggests a leaking or ruptured AAA. Palpation of asymptomatic AAAs is safe and does not precipitate rupture.

• Ultrasound scanning is the preferred method for detecting and following AAAs; however, CTA and MRA are the “gold standards” in the preoperative and postoperative evaluation of AAAs.

• Currently, ultrasound screening for AAA is recommended in men 60 years of age or older who have a family history of AAA or men who are 65–75 years of age who have ever smoked (former or current). Screening of women is reserved for those who have a family history, a suggestive physical exam, and possibly those with established atherosclerosis beyond age 75 years.

• Baseline aortic aneurysm size and annual expansion rate are the most important predictors of aneurysm rupture, followed by smoking, hypertension, family history, and gender.

• Current guidelines recommended surgical repair of abdominal aortic aneurysms ≥5.5 cm in diameter in asymptomatic patients. AAAs measuring 4.0–5.4 cm in diameter should be monitored by ultrasound or CT scans every 6–12 months to detect expansion.

• Endovascular stent-graft therapy is a less invasive alternative to open repair with potentially fewer postoperative complications and lower morbidity.

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Author information

Authors and Affiliations

  1. Division of Cardiovascular Medicine and Michigan Cardiovascular Research and Reporting Program, University of Michigan Medical School, Ann Arbor, MI, USA

    Irfan Hameed MD

  2. Cardiac Unit Associates and Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

    Eric M. Isselbacher MD

  3. Division of Cardiovascular Medicine, Cardiovascular Center, University of Michigan Medical School, Ann Arbor, MI, USA

    Kim A. Eagle MD

Authors
  1. Irfan Hameed MD
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  2. Eric M. Isselbacher MD
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  3. Kim A. Eagle MD
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Editors and Affiliations

  1. Sterling Rock Falls Clinic, 101 E. Miller Road, Sterling, 61081, USA

    Peter P. Toth

  2. Brigham & Women's Hospital, Cardiovascular Division, Harvard Medical School, Longwood Ave. 350, Boston, 02115, USA

    Christopher P. Cannon

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Hameed, I., Isselbacher, E.M., Eagle, K.A. (2011). Aortic Aneurysms. In: Toth, P., Cannon, C. (eds) Comprehensive Cardiovascular Medicine in the Primary Care Setting. Contemporary Cardiology. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-60327-963-5_20

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  • DOI: https://doi.org/10.1007/978-1-60327-963-5_20

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  • Online ISBN: 978-1-60327-963-5

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