Aortic Aneurysms

  • Nicole M. Bhave
  • Eric M. Isselbacher
  • Kim A. EagleEmail author
Part of the Contemporary Cardiology book series (CONCARD)


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 aneurysms, different types and classifications, their prevalence and associated mortality, and current medical and surgical management guidelines.


Abdominal aortic aneurysm Endovascular stent-graft therapy Matrix metalloproteinase Thoracic aortic aneurysm 


  1. 1.
    Isselbacher EM. Thoracic and abdominal aortic aneurysms. Circulation. 2005;111:816–28.CrossRefGoogle Scholar
  2. 2.
    Erbel R, Eggebrecht H. Aortic dimensions and the risk of dissection. Heart. 2006;92:137–42.CrossRefPubMedCentralGoogle Scholar
  3. 3.
    Isselbacher EM. Diseases of the aorta. In: Libby P, editor. Braunwald’s heart disease: a textbook of cardiovascular medicine. 8th ed. Philadelphia, PA: WB Saunders; 2008. p. 1457–67.Google Scholar
  4. 4.
    Anderson JL, Halperin JL, Albert N, Bozkurt B, Brindis RG, Curtis LH, et al. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations). J Am Coll Cardiol. 2013;61:1555–70.CrossRefGoogle Scholar
  5. 5.
    Nataf P, Lansac E. Dilation of the thoracic aorta: medical and surgical management. Heart. 2006;92:1345–52.CrossRefPubMedCentralGoogle Scholar
  6. 6.
    Frydman G, Walker PJ, Summers K, et al. The value of screening in siblings of patients with abdominal aortic aneurysm. Eur J Vasc Endovasc Surg. 2003;26:396–400.CrossRefGoogle Scholar
  7. 7.
    Michelena HI, Khanna AD, Mahoney D, Margaryan E, Topilsky Y, Suri RM, et al. Incidence of aortic complications in patients with bicuspid aortic valves. JAMA. 2011;306:2691–704.Google Scholar
  8. 8.
    Michelena HI, Desjardins VA, Avierinos JF, Russo A, Nkomo VT, Sundt TM, et al. Natural history of asymptomatic patients with normally functioning or minimally dysfunctional bicuspid aortic valve in the community. Circulation. 2008;117:2776–84.CrossRefPubMedCentralGoogle Scholar
  9. 9.
    Tzemos N, Therrien J, Yip J, Thanassoulis G, Tremblay S, Jamorski MT, et al. Outcomes in adults with bicuspid aortic valves. JAMA. 2008;300:1317–25.CrossRefGoogle Scholar
  10. 10.
    Kermani TA, Warrington KJ, Crowson CS, Ytterberg SR, Hunder GG, Gabriel SE, Matteson EL. Large-vessel involvement in giant cell arteritis: a population-based cohort study of the incidence-trends and prognosis. Ann Rheum Dis. 2013;72:1989–94.CrossRefGoogle Scholar
  11. 11.
    Guo DC, Papke CL, He R, Milewicz DM. Pathogenesis of thoracic and abdominal aortic aneurysms. Ann N Y Acad Sci. 2006;1085:339–52.CrossRefGoogle Scholar
  12. 12.
    The FBN1 mutations database. Accessed 5 July 2016.
  13. 13.
    Maleszewski JJ, Miller DV, Lu J, Dietz HC, Halushka MK. Histopathologic findings in ascending aortas from individuals with Loeys-Dietz syndrome (LDS). Am J Surg Pathol. 2009;33:194–201.CrossRefGoogle Scholar
  14. 14.
    Pressler V, McNamara JJ. Aneurysm of the thoracic aorta. Review of 260 cases. J Thorac Cardiovasc Surg. 1985;89:50–4.PubMedGoogle Scholar
  15. 15.
    von Kodolitsch Y, Nienaber CA, Dieckmann C, et al. Chest radiography for the diagnosis of acute aortic syndrome. Am J Med. 2004;116:73–7.CrossRefGoogle Scholar
  16. 16.
    Hartnell GG. Imaging of aortic aneurysms and dissection: CT and MRI. J Thorac Imaging. 2001;16:35–46.CrossRefGoogle Scholar
  17. 17.
    Tamborini G, Galli CA, Maltagliati A, et al. Comparison of feasibility and accuracy of transthoracic echocardiography versus computed tomography in patients with known ascending aortic aneurysm. Am J Cardiol. 2006;98:966–9.CrossRefGoogle Scholar
  18. 18.
    Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. J Am Coll Cardiol. 2010;55:1509–44.CrossRefGoogle Scholar
  19. 19.
    Griepp RB, Ergin MA, Galla JD, et al. Natural history of descending thoracic and thoracoabdominal aneurysms. Ann Thorac Surg. 1999;67:1927–30; discussion 53–58.CrossRefGoogle Scholar
  20. 20.
    Davies RR, Goldstein LJ, Coady MA, et al. Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. Ann Thorac Surg. 2002;73:17–27; discussion 8.CrossRefPubMedCentralGoogle Scholar
  21. 21.
    Elefteriades JA. Natural history of thoracic aortic aneurysms: indications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg. 2002;74:S1877–80; discussion S92–S98.CrossRefGoogle Scholar
  22. 22.
    Elefteriades JA. Thoracic aortic aneurysm: reading the enemy’s playbook. Curr Probl Cardiol. 2008;33:203–77.CrossRefGoogle Scholar
  23. 23.
    Williams JA, Loeys BL, Nwakanma LU, Dietz HC, Spevak PJ, Patel ND, et al. Early surgical experience with Loeys-Dietz: a new syndrome of aggressive thoracic aortic aneurysm disease. Ann Thorac Surg. 2007;83:S757–63.CrossRefGoogle Scholar
  24. 24.
    Hiratzka LF, Creager MA, Isselbacher EM, Svensson LG. Surgery for aortic dilatation in patients with bicuspid aortic valves: a statement of clarification from the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Circulation. 2016;133:680–6.CrossRefGoogle Scholar
  25. 25.
    Biancari F, Mariscalco G, Mariani S, Saari P, Satta J, Juvonen T. Endovascular treatment of degenerative aneurysms involving only the descending thoracic aorta: systematic review and meta-analysis. J Endovasc Ther. 2016;23:387–92.CrossRefGoogle Scholar
  26. 26.
    Hughes K, Guerrier J, Obirieze A, Ngwang D, Rose D, Tran D, et al. Open versus endovascular repair of thoracic aortic aneurysms: a nationwide inpatient sample study. Vasc Endovasc Surg. 2014;48:383–7.CrossRefGoogle Scholar
  27. 27.
    Poon SS, Theologou T, Harrington D, Kuduvalli M, Oo A, Field M. Hemiarch versus total aortic arch replacement in acute type A dissection: a systematic review and meta-analysis. Ann Cardiothorac Surg. 2016;5:156–73.CrossRefPubMedCentralGoogle Scholar
  28. 28.
    Bavaria JE, Appoo JJ, Makaroun MS, Verter J, Yu ZF, Mitchell RS. Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: a multicenter comparative trial. J Thorac Cardiovasc Surg. 2007;133:369–77.CrossRefGoogle Scholar
  29. 29.
    Abraha I, Romagnoli C, Montedori A, Cirocchi R. Thoracic stent graft versus surgery for thoracic aneurysm. Cochrane Database Syst Rev. 2016;6:CD006796.Google Scholar
  30. 30.
    Shores J, Berger KR, Murphy EA, Pyeritz RE. Progression of aortic dilatation and the benefit of long-term beta-adrenergic blockade in Marfan’s syndrome. N Engl J Med. 1994;330:1335–41.CrossRefGoogle Scholar
  31. 31.
    Yetman AT, Bornemeier RA, McCrindle BW. Usefulness of enalapril versus propranolol or atenolol for prevention of aortic dilation in patients with the Marfan syndrome. Am J Cardiol. 2005;95:1125–7.CrossRefGoogle Scholar
  32. 32.
    Habashi JP, Judge DP, Holm TM, et al. Losartan, an AT1 antagonist, prevents aortic aneurysm in a mouse model of Marfan syndrome. Science. 2006;312:117–21.CrossRefPubMedCentralGoogle Scholar
  33. 33.
    Lacro RV, Dietz HC, Sleeper LA, Yetman AT, Bradley TJ, Colan SD, et al. Atenolol versus losartan in children and young adults with Marfan’s syndrome. N Engl J Med. 2014;371:2061–71.CrossRefPubMedCentralGoogle Scholar
  34. 34.
    Milleron O, Arnoult F, Ropers J, Aegerter P, Detaint D, Delorme G, et al. Marfan Sartan: a randomized, placebo-blind, placebo-controlled trial. Eur Heart J. 2015;36:2160–6.CrossRefGoogle Scholar
  35. 35.
    Groenink M, den Hartog AW, Franken R, Radonic T, de Waard V, Timmermans J, et al. Losartan reduces aortic dilatation rate in adults with Marfan syndrome: a randomized controlled trial. Eur Heart J. 2013;34:3491–500.CrossRefGoogle Scholar
  36. 36.
    Ejiri J, Inoue N, Tsukube T, et al. Oxidative stress in the pathogenesis of thoracic aortic aneurysm: protective role of statin and angiotensin II type 1 receptor blocker. Cardiovasc Res. 2003;59:988–96.CrossRefGoogle Scholar
  37. 37.
    Diehm N, Becker G, Katzen B, Benenati J, Kovacs M, Dick F. Statins are associated with decreased mortality in abdominal, but not in thoracic aortic aneurysm patients undergoing endovascular repair: propensity score-adjusted analysis. Vasa. 2008;37:241–9.CrossRefGoogle Scholar
  38. 38.
    Stein LH, Berger J, Tranquili M, Elefteraides JA. Effect of statin drugs on thoracic aortic aneurysms. Am J Cardiol. 2013;112:1240–5.CrossRefGoogle Scholar
  39. 39.
    Weinsaft JW, Devereux RB, Preiss LR, Feher A, Roman MJ, Basson CT, et al. Aortic dissection in patients with genetically mediated aneurysms: incidence and predictors in the GenTAC Registry. J Am Coll Cardiol. 2016;67:2744–54.CrossRefPubMedCentralGoogle Scholar
  40. 40.
    Patel HJ, Deeb GM. Ascending and arch aorta: pathology, natural history, and treatment. Circulation. 2008;118:188–95.CrossRefGoogle Scholar
  41. 41.
    Kaewlai R, Abujudeh H. Nephrogenic systemic fibrosis. AJR Am J Roentgenol. 2012;199:W17–23.CrossRefGoogle Scholar
  42. 42.
    Almahameed A, Latif AA, Graham LM. Managing abdominal aortic aneurysms: treat the aneurysm and the risk factors. Cleve Clin J Med. 2005;72:877–88.CrossRefGoogle Scholar
  43. 43.
    Lederle FA, Johnson GR, Wilson SE, et al. Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group. Ann Intern Med. 1997;126:441–9.CrossRefGoogle Scholar
  44. 44.
    Lederle FA, Johnson GR, Wilson SE, et al. The aneurysm detection and management study screening program: validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators. Arch Intern Med. 2000;160:1425–30.CrossRefGoogle Scholar
  45. 45.
    Fink HA, Lederle FA, Roth CS, Bowles CA, Nelson DB, Haas MA. The accuracy of physical examination to detect abdominal aortic aneurysm. Arch Intern Med. 2000;160:833–6.CrossRefGoogle Scholar
  46. 46.
    Rubin GD, Armerding MD, Dake MD, Napel S. Cost identification of abdominal aortic aneurysm imaging by using time and motion analyses. Radiology. 2000;215:63–70.CrossRefGoogle Scholar
  47. 47.
    Thompson SG, Ashton HA, Gao L, Buxton MJ, Scott RAP. Final follow-up of the Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal aortic aneurysm screening. Br J Surg. 2012;99:1649–56.CrossRefPubMedCentralGoogle Scholar
  48. 48.
    Crow P, Shaw E, Earnshaw JJ, Poskitt KR, Whyman MR, Heather BP. A single normal ultrasonographic scan at age 65 years rules out significant aneurysm disease for life in men. Br J Surg. 2001;88:941–4.CrossRefGoogle Scholar
  49. 49.
    Guirguis-Blake JM, Beil TL, Senger CA, Whitlock EP. Ultrasonography screening for abdominal aortic aneurysms: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Int Med. 2014;160:321–9.CrossRefGoogle Scholar
  50. 50.
    Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg. 2009;50:2S–49S.CrossRefGoogle Scholar
  51. 51.
    Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. UK Small Aneurysm Trial Participants. Ann Surg. 1999;230:289–96; discussion 96–97.CrossRefPubMedCentralGoogle Scholar
  52. 52.
    Szilagyi DE, Smith RF, DeRusso FJ, Elliott JP, Sherrin FW. Contribution of abdominal aortic aneurysmectomy to prolongation of life. Ann Surg. 1966;164:678–99.CrossRefPubMedCentralGoogle Scholar
  53. 53.
    Powell JT, Greenhalgh RM. Clinical practice. Small abdominal aortic aneurysms. N Engl J Med. 2003;348:1895–901.CrossRefGoogle Scholar
  54. 54.
    Gadowski GR, Pilcher DB, Ricci MA. Abdominal aortic aneurysm expansion rate: effect of size and beta–adrenergic blockade. J Vasc Surg. 1994;19:727–31.CrossRefGoogle Scholar
  55. 55.
    The United Kingdom EVAR Trial Investigators. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1863–71.CrossRefGoogle Scholar
  56. 56.
    Lederle FA, Freischlag JA, Kyriakides TC, Matsumura JS, Padberg FT, Kohler TR, et al. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. N Engl J Med. 2012;367:1988–97.CrossRefGoogle Scholar
  57. 57.
    DeBruin JL, Baas AF, Buth J, Prinssen M, Verhoeven ELG, Cuypers PWM, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1881–9.CrossRefGoogle Scholar
  58. 58.
    McFalls EO, Ward HB, Moritz TE, et al. Coronary artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351:2795–804.CrossRefGoogle Scholar
  59. 59.
    Poldermans D, Schouten O, Vidakovic R, et al. A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: the DECREASE–V Pilot Study. J Am Coll Cardiol. 2007;49:1763–9.CrossRefGoogle Scholar
  60. 60.
    Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64:e77–137.CrossRefPubMedCentralGoogle Scholar
  61. 61.
    Brophy C, Tilson JE, Tilson MD. Propranolol delays the formation of aneurysms in the male blotchy mouse. J Surg Res. 1988;44:687–9.CrossRefPubMedCentralGoogle Scholar
  62. 62.
    Slaiby JM, Ricci MA, Gadowski GR, Hendley ED, Pilcher DB. Expansion of aortic aneurysms is reduced by propranolol in a hypertensive rat model. J Vasc Surg. 1994;20:178–83.CrossRefPubMedCentralGoogle Scholar
  63. 63.
    Propanolol Aneurysm Trial Investigators. Propranolol for small abdominal aortic aneurysms: results of a randomized trial. J Vasc Surg. 2002;35:72–9.CrossRefGoogle Scholar
  64. 64.
    Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2889–934.CrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Nicole M. Bhave
    • 1
  • Eric M. Isselbacher
    • 2
  • Kim A. Eagle
    • 3
    Email author
  1. 1.Division of Cardiovascular MedicineUniversity of Michigan Medical SchoolAnn ArborUSA
  2. 2.Cardiology Division and Department of MedicineMassachusetts General HospitalBostonUSA
  3. 3.Division of Cardiovascular Medicine, Cardiovascular CenterUniversity of Michigan Medical SchoolAnn ArborUSA

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