Dr Aidin Rawshani

Aortic rupture and aneurysm (diabetes)

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The figure illustrates the prevalence of the aorta in the body. The aorta starts from the left ventricle of the heart and then goes up into the chest and then turns down towards the abdominal organs and pelvis. In the pelvis, the aorta is divided into two smaller blood vessels that supply both legs with oxygen-rich blood.

Aneurysm (lat. aneurysms, “enlargement”) means that the vascular wall of a blood vessel is weakened and enlarged abnormally, which in the worst case can lead to rupture of the vessel and bleeding. An aneurysm is usually an acute life-threatening condition that needs to be addressed immediately, in some cases the condition is more stable and followed up by regular medical check-ups. Aneurysm of the large body artery, known as aortic aneurysm or aneurysm of the artery, arises as a result of several causes, but risk factors for cardiovascular disease such as old age, high blood pressure, high blood lipids, overweight/obesity, diabetes, heredity (genetics) and other factors contribute to the development of aortic aneurysm.

The aorta is the largest blood vessel in the body that originates from the left ventricle of the heart in the chest, the aorta bends in the chest and turns down towards the abdomen where it supplies the abdominal and pelvic organs with oxygen-rich blood; therefore, aortic aneurysm is divided into abdominal aortic aneurysm (abdominal aortic aneurysm, AAAA) or Aneurysm of the thoracic aorta (thoracic aortic aneurysm, TAA).

The aorta has thicker walls than other blood vessels in the body and can also withstand slightly higher blood pressure levels. However, some medical problems, genetic conditions and trauma can damage or weaken these walls. Blood pressure and pulse waves traveling through the aorta press against the weakened or damaged walls and can cause an aneurysm.

An aortic aneurysm may grow in size for several years but in some cases it passes very quickly with the risk of rupture of the blood vessel causing acute bleeding and oxygen deficiency (ischemia) in the tissue. Aortic aneurysms can grow up and in some cases become really large before they cause any symptoms. With the help of medicines and various procedures, doctors can slow the growth of an aortic aneurysm.

Different types of aortic aneurysm

Abdominal aortic aneurysm

There are two types of aortic aneurysm: thoracic aortic aneurysm and abdominal aortic aneurysm. Until recently, it was believed that thoracic aortic aneurysms and abdominal aortic aneurysms were due to the same cause. Now we know that the two types are separate diseases with different risk factors and causes

Abdominal aortic aneurysm

Abdominal Aortic Aneurysm — The most common site of an aneurysm is the part of the aorta that runs through the abdomen, called the abdominal aorta. The abdominal aorta provides oxygen-rich blood to the tissues and organs of the abdomen and lower limbs. The abdominal aorta begins at the diaphragm, approximately at the level of the twelfth thoracic vertebra. In the abdominal aorta, blood vessels supply the kidney, stomach, intestines, liver and several pelvic organs with oxygen-rich blood. The abdominal aorta then passes into two smaller blood vessels called left and right iliac arteries in medical language.

Thoracal aortic aneurysm

Thoracic aortic aneurysm

Thoracal aortic aneurysm — Breast aortic aneurysm is aneurysm that occurs in the thoracic part of the aorta, above the diaphragm, this variant does not occur as often as abdominal aortic aneurysm. The most part of the aorta located in the chest is the aortic arch (lat. arcus), which is a curved blood vessel. From the arch of the aorta, several blood vessels supply the brain, neck, neck and upper arms with oxygen-rich blood. The descending part of the thoracic aorta gives rise to the blood vessels supplying the chest, parts of the esophagus and lungs. The coronary arteries supplying the heart muscle with oxygen-rich blood emit right from the root of the aorta, very close to the heart and then spread around the left and right sides of the heart.

Aortic structure — The aorta is an elastic blood vessel consisting of a number of different cells. The aorta has three layers, just like most blood vessels, these are called tunica external, tunica media and tunica intimate. The aortic arch contains two types of specialized cells that record blood pressure and pH in the blood, these receptors are called baroreceptors and chemoreceptors. The information that these receptors record is sent to the brain and the autonomic nervous system.

Causes of aortic aneurysm

Aortic aneurysms are caused by a weakening of the aortic wall due to injury or age-related changes. Many health conditions and lifestyle habits can increase your risk of developing aortic wall damage, such as high blood pressure and smoking. A bulge can occur where the wall has been damaged and weakened. If left untreated, the aortic wall will continue to weaken, and the bulge will grow. If it becomes large enough, an aneurysm can crack and cause acute life-threatening bleeding. An aortic aneurysm that ruptures causes severe bleeding and it is not rare that patients leave as a result of internal bleeding before they get to hospital.

Risk factors for aortic aneurysm

  • Age
  • Heredity (genetics)
  • Lifestyle habits
  • Medical conditions and male sex are all risk factors for aortic aneurysm.

High age and risk of aortic aneurysm

The risk of contracting aortic aneurysm increases as you age. Various population studies show that the risk of abdominal aortic aneurysm rises significantly after 65 years of age. In addition, in old age, several age-related diseases develop which in turn contribute to an additional risk of aortic aneurysm, such as high blood pressure, high blood lipids, obesity/overweight, curved back (kyphosis) and diabetes.

Heredity (genetics)

Multiple genetic conditions increase the risk of breast aortic aneurysm (TAA), these include:

  • Ehler Danlos Syndrome
  • Loey’s Dietz Syndromes
  • Marfans Syndrome
  • Turner Syndrome
  • Familiar thoracic aortic aneurysm
  • Bicuspid aortic valve (BAV)

Also abdominal aortic aneurysms have a hereditary component. One in 10 people with abdominal aortic aneurysm has a family history of abdominal aortic aneurysms. The chance of developing an abdominal aortic aneurysm is 1 out of 5 for people who have a first-class relative with the condition.

Lifestyle habits contributing to aortic aneurysm

Some lifestyle habits increase the risk of contracting aortic aneurysm, these include:

  • Cigarette smoking increases the risk of aortic aneurysm, especially abdominal aortic aneurysm. If you are an active smoker, an existing abdominal aortic aneurysm may grow in size faster and be more prone to rupture.
  • Use of stimulants such as cocaine, and other drugs.
  • Lifting heavy weights, explosive training routines

The relationship between male sex and aortic aneurysm

Men are more likely than women to develop aortic aneurysms. However, an existing aneurysm is more likely to burst at a smaller size in women than in men. One possible explanation is that men have more cardiovascular risk factors such as obesity or overweight, high alcohol consumption, smoking, high blood pressure, diabetes, high blood lipids, low physical activity level and poor eating habits.

Screening and prevention of aortic aneurysm

If you have known risk factors for aortic aneurysm, your doctor may recommend screening. To exclude an aortic aneurysm, your doctor can order an X-ray examination to watch and measure the aorta. An aneurysm can develop and grow without any symptoms until it ruptures or dissects (innermost layer of the aorta ruptures), both events are considered life-threatening. If the aneurysm is detected early, treatment or surgery can slow growth and prevent rupture or dissection.

Screening tests for aortic aneurysm will show if the diameter of your aorta is larger than normal.

Computed tomography (computer tomography, CT), magnetic resonance examination (MRI) or ultrasound of the heart (echocardiography) can be used for screening of thoracic aortic aneurysm. The choice of the method of examination depends on your age and other medical conditions. The normal diameter of the thoracic aorta depends on where it is measured and whether you are male or female.

Ultrasound can be used to examine the abdominal aortic aneurysm and to monitor the aorta over time, CT and MRI are also used to examine the abdominal aorta, but then contrast agents are also required to map the aortic anatomy.

Who should be screened for aortic aneurysm?

People who should be screened for an aneurysm of the thoracic aorta. These include:

  • People who have Marfan, Loeys-Dietz, Ehlers-Danlos or Turner syndrome
  • First-grade relatives of people who have a thoracic aortic aneurysm or a bicuspid aortic valve (BAV)
  • Relatives of people with familial thoracic aortic aneurysms who also have specific genetic mutations

People who should be screened for an aneurysm of the abdominal aorta include:

  • Men and women 65 to 75 years who have ever smoked or who have a first-class relative who had an abdominal aortic aneurysm.
  • Men 65 to 75 years of age who have never smoked but have other risk factors, such as a family history or other cardiovascular risk factors
  • Men and women over 75 years of age who are in good health, who ever have smoked or having a first-class relative affected by an abdominal aortic aneurysm.
  • People who have bone artery disease (peripheral artery disease), regardless of age, sex, smoking history or family history

Factors preventing aortic aneurysm

If you have risk factors for aortic aneurysm, your doctor can recommend “cardio-healthy lifestyle changes” to prevent the condition, which include:

  • Various drugs, such as cocaine
  • A healthy diet
  • Learn tools to cope with stress, which can help lower blood pressure
  • Stop smoking, especially cigarette smoking, which is a leading risk factor for aortic aneurysm

Signs and symptoms of aortic aneurysm

Aortic aneurysm usually does not give rise to any signs or symptoms until the aneurysm ruptures or dissects. The symptoms that arise depend on the location of the aneurysm and whether it has become large enough to affect other parts of the body.

Signs and symptoms of aortic aneurysm include the following:

  • Difficulty or painful to swallow if the aneurysm presses on the esophagus
  • Breathing difficulties if it presses trachea satiety feeling even though you have not eaten much
  • Severe pain in the neck, jaw, back, chest, abdomen or shoulder, depending on where the aneurysm is located.
  • Pulsating or throbbing sensation in the abdomen
  • Shortness of breath if the aneurysm presses your lung
  • Swelling in the face, neck or arms if the aneurysm presses on the large vein of the body (vena cava).

If you know that you have an aortic aneurysm, it is important to know the signs and symptoms of rupture, since timely treatment can be life-saving.

Signs and symptoms of aortic upture include the following

  • Rapid heart rate
  • Sudden, severe pain in the abdomen, chest or back
  • Shortness of breath

Complications from aortic aneurysm

Aortic dissection

Aortic dissection is like a rupture of the inner layer of the aortic wall, remember that the aorta consists of three different layers called the tunica external, the tunica media and the tunica intima. The innermost layer called the tunica intimate is torn off, as a result of which blood accumulates between the inner and middle layers of the aortic wall. This can lead to rupture of the aorta or insufficient blood flow to your organs.

Epidemiological studies investigating the relationship between diabetes and aortic aneurysm show a paradoxical finding, namely that diabetes may protect against aortic aneurysm and aortic rupture. This is considered a paradoxical finding because diabetes is considered a classic cardiovascular risk factor contributing to cardiovascular diseases. However, it seems that diabetes may not contribute to aneurysm and rupture.

Scientists believe that the lower risk of aortic rupture in individuals with diabetes is due to the fact that high blood sugar levels “arm” the vascular wall of the aorta. High blood sugar levels contribute to atherosclerosis of the blood vessels, as a result of which the blood vessels become hard and stiff. The same mechanism seems to help increase the innermost vascular wall (tunica intima) by the high sugar levels. However, this does not mean that diabetes is positive for aortic aneurysm and its complications. Atherosclerosis is a central component in aortic aneurysm and diabetes, after all, contributes to atherosclerosis at least as much as the other cardiovascular risk factors.

Aortic regurgitation

Aortic regurgitation

Aortic insufficiency or aortic regurgitation, both of which occur when the aortic valve is not closed properly because a nearby part of the aorta is enlarged. This allows a little backward flow of blood back into the heart. As a result, your heart will have to work harder, which can lead to heart failure.

Other complications of aortic aneurysm

  • Aortic rupture (aortic rupture leading to severe bleeding in the body)
  • Cardiac tamponade
  • Renal failure

How to put the diagnosis of aortic aneurysm?

To diagnose aortic aneurysm, your doctor will conduct a physical medical examination and order an X-ray examination. When your abdominal aorta is three centimeters or larger in diameter, it is defined as aortic aneurysm. The normal diameter of the thoracic aorta depends on your age, sex and what part of the chest is measured.

During a physical examination, your doctor can do the following:

  • Examine your abdomen to see if abdominal aortic aneurysm can be identified with your hands (palpation)
  • Listen to your heart after heart murmur, quieter heart sounds or other deviant heart sounds may be a sign of an aneurysm
  • Check your heart rate in your arms and legs to see if they feel weaker than normal
  • Look for signs and symptoms of medical conditions that are risk factors for aortic aneurysms, such as Marfan or Ehlers-Danlos syndrome. This may include looking at the skin, muscles and bones, eyes, head and face, and heart.

Diagnostic tests

Various types of X-ray examinations can be used to diagnose aortic aneurysm. Discuss the options with your doctor. Your doctor may order some of the following X-ray examinations to confirm or diagnose aortic aneurysm.

Computed tomography (CT) to provide information about the location, size and shape of an aneurysm. This may be the first test you get if you develop sudden back or abdominal pain, if you already know that you have an aortic aneurysm, or if your doctor feels a pulsating bump in the abdomen while you are examining yourself. CT can provide information about the entire aorta, but for routine screening, other diagnostic tests such as echocardiography or ultrasound can be done first.Heart ultrasound (echocardiography) to provide information about the size of the aortic aneurysm and thoracic aorta.

Some parts of the thoracic aorta are better seen with other examinations such as computed tomography or magnetic resonance imaging (MRI). MRI is the primary examination and provides the best resolution and information on the size, shape and location of the aneurysm. Ultrasound is used to examine the aneurysm of the abdominal aorta. When aortic aneurysm is seen or suspected on ultrasound, you may need to undergo a computer tomography or an MRI to provide more information about the shape or location of the aneurysm.

Treatment of aortic aneurysm

Treatment of aortic aneurysm depends on the cause, size and localization. Small aortic aneurysms can be handled with healthy lifestyle changes or medication. The goal is to slow the growth of the aneurysm and reduce the risk of rupture or dissection. Your doctor may treat other medical conditions that increase the risk of rupture or dissection, such as high blood pressure, coronary heart disease, chronic kidney disease and high blood cholesterol. Surgery or minimally invasive catheter can be recommended to repair large aneurysms.

Healthy lifestyle changes

Your doctor may recommend the following lifestyle changes:

Quit smoking to slow the growth of aneurysms Healthy diet to help you lower high blood pressure or high cholesterol levels in the blood. Handle stress is important because they can help you control high blood pressure, especially for aneurysms of the thoracic aorta. Your doctor may also suggest that you avoid weightlifting and drugs such as cocaine.

Drug treatment of aortic aneurysm

Your doctor may recommend the following drugs for the treatment of aortic aneurysm:

  • Thrombyl (aspirin), especially if you have other cardiovascular risk factors
  • Blood pressure medications to lower blood pressure, slow the growth of aneurysms and reduce the risk of rupture. These drugs include beta-blockers, ACE inhibitors and angiotensin receptor blockers (ARBs).
  • Treatment with statins to control cholesterol levels and stop or slow the growth of aortic aneurysm

Surgery (surgery) for aortic aneurysm

Depending on the cause or size of an aortic aneurysm or how quickly it grows, your doctor may recommend surgery to repair it. Rupture or dissection of an aneurysm may require immediate surgical repair.

Open surgical repair is the most common type of operation. You will be anesthetized during the procedure. Your surgical team first makes a large incision, or cuts, in the abdomen or chest, depending on the location of the aneurysm, then removes the aneurysm and sews a graft in its place. This graft is typically a tube made of leak-proof polyester. Recovery time for open surgical repair is about a month.

Endovascular aneurysm repair (EVARS) is less invasive than open surgical repair. This is due to the fact that the surgical incision is smaller, and you usually need less recovery time. EVARS is used to repair abdominal aortic aneurysms more often than to repair thoracic aortic aneurysms. During the procedure, your surgical team makes a small incision, usually in the groin, then they guide a stent graft (a tube covered with cloth) through your blood vessels up to the aorta. The stent then expands and attaches to the aortic walls. A closure is formed between the stent graft and the vessel wall to prevent blood from entering the aortic aneurysm.

Possible surgical complications in case of aortic aneurysm

  • Bleeding and blood loss
  • Blood clots in blood vessels leading to bowel, kidneys or bone D
  • amage to blood vessels or walls of the aorta when placing the stent graft. The stent graft can also move after it is placed.
  • Endoleak, which is a blood leakage around the stent graft in the aneurysm. Endoleak can cause rupture of the aneurysm if not treated.
  • Gastrointestinal bleeding. Blood can appear in the feces.
  • Cardiac complications such as myocardial infarction or rhythm disturbances (arrhythmia).
  • Reduced blood flow to the intestines, legs, kidneys or other organs during surgery. This can lead to damage to these organs.
  • Infection in the surgical section or graft
  • Kidney injury
  • Spinal cord injury that can cause paralysis
  • Stroke

Living with aortic aneurysm

If you have an aortic aneurysm, it is important to follow your treatment plan. Your doctor may recommend measures to prevent complications such as rupture or dissection.

When aneurysms increase in size, they expand faster and are more prone to rupture. Your doctor may recommend regular X-ray examinations, such as computed tomography, MRI or ultrasound, to see how quickly your aortic aneurysm grows and whether you need surgery.

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