Should I have a screening test for aortic disease?
Because large AAAs are rare in women, the US Preventative Services Task Force does not recommended that a woman receive routine screenings for aortic aneurysms, unless she has a family history of AAA. Medicare covers a one-time screening for women with a family history of AAA as part of the Welcome to Medicare exam. If you are concerned about your AAA risk (even if you do not have a family history) talk to your doctor about the risks and benefits of screening.
How is aortic disease diagnosed?
Most aortic aneurysms have no symptoms, and are often discovered on an imaging test such as a chest x-ray or CT scan that is being used to investigate an unrelated condition, such as lung disease. Occasionally they may be found when your doctor notices a large pulsing mass in your abdomen during a physical examination.
Sometimes an aneurysm is discovered only when it has grown large enough to cause symptoms by pressing against other organs. If your doctor suspects an aortic aneurysm, you will need to undergo imaging tests to confirm it and determine the best treatment:
- Abdominal Ultrasound : this fast, simple test uses sound waves (like those used to view the fetus during pregnancy) to produce images of the aorta and determine the location and size of an aneurysm
- Echocardiogram : an ultrasound of the heart; this test looks at the heart’s valves and the upper part of the thoracic aorta
- CT scan / CT Angiogram : a test that uses x-rays to produce images of the aorta and monitor the growth of the aneurysm; more detailed than an ultrasound. A dye is injected through a vein in your arm to highlight the aorta on the images.
- MRI / MR Angiogram : a test that uses a large magnet and radio waves to produce a detailed image of the aorta, and can find the exact size and location of an aneurysm. An MR angiogram uses an injected dye to produce images of blood flow.
- Contrast Angiogram : an invasive test that uses a catheter (a long, thin tube inserted into an artery in your leg or arm) that is guided to the aorta and injects a radioactive dye to trace blood flow. The test produces an x-ray movie of blood flow through the aorta, and can determine the location and size of an aneurysm, whether the vessels are narrowed by atherosclerosis, and if there are blood clots or tears (dissections) in the blood vessel wall. This test is not usually used for diagnosis, and is instead used if you are undergoing a procedure to treat aneurysms.
How is aortic disease treated?
Not all aortic aneurysms require immediate treatment. Small, slow-growing aneurysms are unlikely to rupture, and your doctor may recommend monitoring it closely with periodic imaging tests (usually every 6 to 12 months) to see how the aneurysm is growing. This is often done if your aneurysm is smaller than 4.5 cm/1.8 inches in diameter in women (5 cm/2 inches in men). Because large aneurysms tend to grow faster than smaller ones, the larger your aneurysm is the more closely you will need to be monitored. An aneurysm will not go away on its own, and may continue to grow and can rupture if it goes untreated, so it is important that you keep all follow-up appointments.
In the meantime, you will need to make healthy lifestyle changes and take medications to control your risk factors and slow the growth of the aneurysm. You may need medication to control high blood pressure and reduce pressure on the artery walls (such as beta blockers), and you should stop smoking.
If your aneurysm is causing symptoms, or if it is larger than 5.5 cm (2.2 inches) or expanding more than 1 cm (0.4 inches) a year, you will need a procedure to repair the aneurysm and prevent it from bursting.1 Because women tend to have smaller aortas than men, a procedure may also be considered in women with aneurysms 4.5 cm (1.8 inches) or larger. These procedures can also be performed in an emergency in someone whose aneurysm has already burst.
Surgical Aneurysm Repair
Also called “open” aneurysm repair, surgical aneurysm repair has long been the standard treatment to prevent aneurysms from bursting. During the procedure, an incision is made in your abdomen to reach the aneurysm. The surgeon will put a clamp above the aneurysm to stop blood flow, then open the aneurysm and remove any blood clots and fatty deposits. The diseased part of the aorta is then removed and replaced with an artificial graft that is the same size and shape as your healthy artery. Alternatively, fabric patches may be used to strengthen the artery wall.
Surgical aneurysm repair may be preferred in younger women who have a low risk of complications from surgery, or who have aneurysms that cannot be treated with less-invasive procedures. Approximately 50,000 aneurysm repair surgeries are performed each year in the United States (20% to 25% of them in women)8 with death rates as low as 2% in some centers.
Reprinted with permission from JAMA 302(18):2019. Copyright © 2009 American Medical Association. All rights reserved.
Endovascular Aneurysm Repair
A newer alternative to surgical repair, endovascular aneurysm repair is a less-invasive procedure that does not remove the aneurysm, but instead uses a stent graft to strengthen the artery wall from the inside. The stent graft is a fabric tube with a wire mesh skeleton that is placed in the aorta and seals to the walls above and below the aneurysm. As blood flows through the aorta, the pressure is absorbed by the stent graft, instead of pressing on the aneurysm and causing it to enlarge or burst. Over time, the aneurysm usually shrinks.
Because the procedure is endovascular (“through the blood vessels”), it does not require opening the body. Instead, the stent graft is carried on a long thin tube called a catheter that is inserted into an artery in your groin and guided up to the aorta. The graft is guided into a position and then opened into place, and the catheter is removed.
Placement of a stent graft in an abdominal aortic aneurysm.
A: a catheter is inserted into an artery in the groin and guided to the abdominal aorta, and the stent graft is released.
B: the stent reinforces the artery walls and allows blood to flow through the aneurysm, preventing it from rupturing.
Endovascular procedures allow you to leave the hospital and recover more quickly because large incisions are not required. However, the size or location of some aneurysms may mean that endovascular repair is not possible. Although the majority of these procedures are performed in men, women who undergo endovascular aneurysm repair have a 50% higher risk of dying or having complications, causing them to have longer hospital stays than men.10
Prognosis after Aneurysm Repair
Aneurysm repair procedures are becoming safer each year and are an important tool to prevent a deadly rupture in women and men with large aneurysms. In one study of 8,663 patients (17% were women) who underwent non-emergency AAA repairs (surgical or endovascular), 69% survived for 5 years. The risk of complications is highest just after the procedure: 90% of those who survive the first few months live for at least 5 years.
A vascular specialist can help you decide whether surgical or endovascular repair is best for you. For more on procedures to treat aortic aneurysms, see Aortic Disease Treatment (coming soon).
Can I prevent aortic disease?
There are no medications you can take specifically to prevent an aortic aneurysm. However, because many aneurysms are caused by atherosclerosis, making heart-healthy lifestyle changes and controlling your risk factors will improve the health of your arteries and reduce your chances of developing heart and blood vessel disease, including aortic disease.
Some steps you can take:
- Eat a heart healthy diet low in saturated fat and cholesterol
- Get regular exercise – 30 minutes a day at least 5 days a week. If you already have heart disease or an aneurysm, talk to your doctor about how much physical activity is safe for you.
- If you smoke, get the help you need to quit. Avoid exposure to second-hand smoke.
- Maintain a healthy weight, and lose weight if you are overweight or obese
If you have risk factors for aortic aneurysm, talk to your doctor. In addition to lifestyle changes, she or he may be able to prescribe medications to get high blood pressure and high cholesterol under control.