Aortic Aneuryms
An aneurysm is a bulging, weakened area in the wall of a blood vessel resulting in an abnormal widening or ballooning greater than 50 percent of the normal diameter (width). An aneurysm may be located in many areas of the body, such as the blood vessels of the brain, the aorta (the largest artery in the body), the intestines, the kidneys, the spleen, and the vessels in the legs. The most common location of an aneurysm is the aorta. The aorta extends upward from the top of the left ventricle of the heart in the chest area (ascending thoracic aorta), then curves like a candy cane (aortic arch) downward through the chest area (descending thoracic aorta) into the abdomen (abdominal aorta). The aorta delivers oxygenated blood pumped from the heart to the rest of the body. An aneurysm can be characterized by its location, shape, and cause. An ascending aortic aneurysm, which is located in the chest area, is involved the area of the aorta closest to the heart.
How are aneurysms diagnosed?
For most people, their aortic condition is discovered incidentally while being tested for other reasons. For patients suspected to have aortic disease, selection of a type of diagnostic examination is related to the location of the aneurysm. In addition to a complete medical history and physical examination, diagnostic procedures for an aneurysm may include any, or a combination, of the following:
- computed tomography scan (also called a CT or CAT scan): a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce cross-sectional images (often called slices). A CT scan shows detailed images of any part of the body, including the bones, muscles, fat and organs.
- magnetic resonance imaging (MRI): a diagnostic procedure that uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body.
- echocardiogram (also called echo): a procedure that evaluates the structure and function of the heart by using sound waves recorded on an electronic sensor that produce a moving picture of the heart and heart valves.
- arteriogram (angiogram): A dye (contrast) will be injected through a thin flexible tube placed in an artery. This dye will make the blood vessels visible on the X-ray.
- ultrasound: uses high-frequency sound waves and a computer to create images of blood vessels, tissues and organs. An ultrasound is used to view internal organs as they function, and to assess blood flow through various vessels.
How do I prevent an aortic dissection and/or further growth of my aneurysm?
Here are a few tips:
- Control your blood pressure. If you have high blood pressure, get a home blood pressure measuring device to help you monitor and keep your blood pressure well controlled.
- Don’t smoke. Or, if you do, take steps to stop.
- Maintain an ideal weight. Follow a low-salt diet, low fat, high fiber diet, and exercise regularly.
- Watch your cholesterol. Keep your cholesterol levels within a range that is recommended by your doctor.
- Continue low-impact exercise (eg brisk walking). If you have an aneurysm or are predisposed, avoid high-impact exercise that significantly increases your blood pressure (eg weight training)
- Wear a seat belt. This reduces the risk of traumatic injury to your chest area.
- Keep your doctor well-informed. If you have a family history of aortic dissection, let your doctor know.
Surgery is generally recommended when the proximal aorta is larger than 5 centimeters. However, depending on other factors, including other vascular conditions or the need for additional surgery (particularly heart surgery), this threshold varies with individual patients.
What are the possible treatment for aortic aneurysms?
Treatment options for an aortic aneurysm may include one or more of the following:
Controlling or modifying risk factors steps such as:
- quitting smoking,
- controlling blood sugar in those with diabetics,
- weight loss if those overweight or obese and
controlling dietary fat intake - Medication: to control factors such as: hyperlipidemia (elevated levels of fats in the blood) and high blood pressure
Surgery, typically the diseased area of the aorta is replaced with a fabric graft
Stent graft or endograft which is comprised of a layer of impermeable reinforcement material enclosed by a self-expanding metal support mesh and is placed across the aneurysm site
Specific treatment will be determined by your physician based on:
- age, overall health and medical history
size and extent of the disease
signs and symptoms - tolerance of specific medications, procedures or therapies
- expectations for the course of the disease
- patient preference
What are the symptoms of an aneurysm?
Aortic disease is often insidious. Most people with aortic aneurysms experience no symptoms, unless they are extremely large or an aortic dissection occurs. For most people, their aortic condition is discovered incidentally while being tested for other reasons.
When symptoms occur, they may include pain in the jaw, neck, chest and/or back; wheezing, coughing or shortness of breath; hoarseness or difficulty swallowing. The symptoms of an aneurysm may resemble other medical conditions or problems, including heart attacks, pneumonia, and digestive conditions. Always consult your physician for more information.
Most people with aortic aneurysms experience no symptoms. Most often, their aortic condition is discovered incidentally while being tested for other reasons.
What are the causes of aortic aneurysms?
Thoracic aortic aneurysms may be caused by different disease processes, especially in respect to their location. Ascending thoracic aneurysms may be caused by
- The break down of the tissue of the aortic wall, called cystic medial degeneration (necrosis). This is the most common cause of this type of thoracic aortic aneurysm.
- Family history of thoracic aortic aneurysm
- Genetic disorders which affect the connective tissue, such as Marfan’s syndrome and Ehlers
- Danlos syndromes
- Hardening of the arteries caused by a build-up of plaque in the inner lining of an artery, called atherosclerosis.
- Infection
If my aneurysm is not causing symptoms, why do I need surgery?
The objective of surgical repair of an aneurysm is to prevent potential complications related to the aneurysm. These include:
- heart attack (myocardial infarction)
a leaking aortic valve aortic valve regurgitation
heart failure - hoarseness due to left vagus or left recurrent laryngeal nerve compression
diaphragmatic paralysis due to (phrenic) nerve compression - difficulty breathing due to airway compression
difficulty swallowing due esophageal compression - swelling of the head or arm due compressoin of veins (superior vena cava syndrome)
- blood clots
- aortic dissection
- rupture of the aorta
- In addition, the risk of aortic catastrophe, including dissection and rupture, increases dramatically after the aneurysm reaches 5 centimeters.
When is surgery recommended?
Surgery is generally recommended when the proximal aorta is larger than 5 centimeters. However, depending on other factors, including other vascular conditions or the need for additional surgery (particularly heart surgery), this threshold varies with individual patients.
Surgery is recommended in order to prevent an aortic catastrophe, including aortic rupture or aortic dissection. An aortic rupture is typically a fatal event. An aortic dissection is associated with a high rate of death as well as other serious complications including heart attack, stroke, and paralysis.
The risk of aortic catastrophe increases with aortic size:
- For aneurysms less than 5 cm, the risk of is approx 4-6% per year
- At 5 – 6 cm, the risk increases to as much as 12% per year
- At 7 cm, it exceeds 25% per year.
Given these risks, surgery is usually recommended for patients with aneurysms 5.0 – 5.5 cm in diameter. However, this threshold may vary depending on other patients factors.
Surgery is recommended for patients with smaller aneurysms if they have:
- symptoms related to the aneurysm,
other heart disease requiring surgery, - a bicuspid aortic valve,
strong family history, and/or - connective tissue disease such as Marfan’s or Lowy Dietz.
How do I prevent an aortic dissection and/or further growth of my aneurysm?
Here are a few tips:
- Control your blood pressure. If you have high blood pressure, get a home blood pressure measuring device to help you monitor and keep your blood pressure well controlled.
- Don’t smoke. Or, if you do, take steps to stop.
- Maintain an ideal weight. Follow a low-salt diet, low fat, high fiber diet, and exercise regularly.
Watch your cholesterol. Keep your cholesterol levels within a range that is recommended by your doctor. - Continue low-impact exercise (eg brisk walking). If you have an aneurysm or are predisposed, avoid high-impact exercise that significantly increases your blood pressure (eg weight training)
- Wear a seat belt. This reduces the risk of traumatic injury to your chest area.
- Keep your doctor well-informed. If you have a family history of aortic dissection, let your doctor know.
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Commonly Performed Procedures
Minimally invasive valve surgery is a specialized approach to treating heart valve disease that avoids the need to “crack the chest.” This method uses sophisticated instruments to perform the surgery through a smaller incision at the side of the chest and offers the patients less pain and faster recovery. We perform nearly all of our isolated valve surgeries minimally invasively.
An aortic aneurysm is a bulging, weakened area in the wall of main blood vessel in the body. The risk of aortic catastrophe, including dissection and rupture, increases dramatically with an aneurysm. Surgery may be recommended when the aorta is larger than 4.5-6 cms. Factors including family history, lifestyle, and need for other heart surgery guide decisions about surgery.
An aortic aneurysm is a bulging, weakened area in the wall of main blood vessel in the body. The risk of aortic catastrophe, including dissection and rupture, increases dramatically with an aneurysm. Surgery may be recommended when the aorta is larger than 4.5-6 cms. Factors including family history, lifestyle, and need for other heart surgery guide decisions about surgery.
A “bypass” or “cabg” surgery is the most commonly performed heart surgery. It is necessary when the coronary arteries, which provide blood to the heart become narrow preventing sufficient blood from passing through, and thus depriving the heart of oxygen and nutrients. RWJUH has CABG outcomes that exceed national benchmarks.
When other treatments are insufficient, a heart transplant is a surgical procedure offered to patients with the most severe damage to the heart. RWJUH is one of a limited number of centers in the US that offer advance heart failure surgery, including heart transplant. Dr. Russo has participated in 500+ successful transplant surgeries.
When other treatments are insufficient, a heart transplant is a surgical procedure offered to patients with the most severe damage to the heart. RWJUH is one of a limited number of centers in the US that offer advance heart failure surgery, including heart transplant. Dr. Russo has participated in 500+ successful transplant surgeries.
Clinical Trials at RWJUH
Transcatheter aortic valve replacement vs OMM (randomized) for asymptomatic severe AS The EARLY TAVR trial (Edwards) looks at transcatheter aortic valve replacement (TAVR) as an effective treatment for patients with asymptomatic aortic stenosis. Patients are randomized to either treatment with TAVR or clinical surveillance until the develop symptoms, at which point they are eligible to be treated with TAVR. Read More
This study objective is to establish the safety and effectiveness of the Edwards SAPIEN 3/ SAPIEN 3 Ultra Transcatheter Heart Valve in subjects with moderate, calcific aortic stenosis. Patients are randomized to S3 TAVR device or medical management. Read More
ALIGN-AR evaluates the safety and probable benefit of the transfemoral JenaValve Pericardial TAVR System in patients with symptomatic severe aortic regurgitation. Patients who are high risk for open surgical aortic valve replacement/repair are eligible. RWJUH is one of only 15 centers in the U.S. that can offer this therapy that has been granted a “Breakthrough Device Designation” by the US Food and Drug Administration. This designation is reserved for investigative therapies designed to treat a serious or life-threatening disease or condition and where preliminary clinical evidence indicates that the therapy may demonstrate substantial improvement over existing therapies on one or more clinically significant endpoints, such as substantial treatment effects observed early in clinical development.
Transcatheter aortic valve replacement for severe AS with a novel deviceEvaluates the safety and efficacy of Acurate (Boston Scientific) valve for transcatheter aortic valve replacement. For patients with severe aortic stenosis who are at intermediate or greater risk for SAVR. Patients are randomized to Acurate or commerical TAVR device. Read More
The study is a prospective, multi-center, randomized controlled pivotal clinical trial to evaluate the safety and effectiveness of the EVOQUE System with optimal medical therapy (OMT) compared to OMT alone in the treatment of patients with at least severe tricuspid regurgitation. Subjects will be followed at discharge, 30 days, 3 months, 6 months and annually through 5 years.
This study will establish the safety and effectiveness of the SAPIEN M3 System in subjects with symptomatic, at least 3+ mitral regurgitation (MR) for whom commercially available surgical or transcatheter treatment options are deemed unsuitable.
The SUMMIT-Tendyne trial (Abbott) evaluates the safety and effectiveness of using the Tendyne Mitral Valve System for the treatment of symptomatic mitral regurgitation or mitral annular calcification in patients who are not appropriate for conventional mitral valve surgery. In the randomized arm, patients are treated with either the Tendyne device or MitraClip, while patients in the non-randomized and MAC arms receive the Tendyne device.
https://clinicaltrials.gov/ct2/show/NCT03433274
CLASP IID/F is a prospective, multicenter, randomized, controlled pivotal trial to evaluate the safety and effectiveness of transcatheter mitral valve repair in patients with degenerative/functional mitral regurgitation with the Edwards PASCAL Transcatheter Valve Repair System compared with the commercially available device (Abbott MitraClip).
RESTORE is a prospective, multicenter, non-randomized trial designed to evaluate the safety and effectiveness of the HARPOON™ Beating Heart Mitral Valve Repair System in patients with severe degenerative mitral regurgitation (DMR).
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Newest heart valve options
Miracle transplant at RWJUH
