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NATURAL HISTORY OF AORTIC ANEURYSMS

Luis A López Galarza MD, FACS

10 Th VASCULAR SYMPOSIUM

(2)

Early History of Aortic Surgery

Studies of Egyptian mummies have revealed that

atherosclerosis and arterial calcification were relatively common 3500 years ago [1] .The Ebers Papyrus is among the earliest medical writings and is thought to have

been prepared around 2000 bc. The writer clearly identified arterial aneurysms, probably peripheral aneurysms, and recommended the following

treatment: “Treat it with a knife and burn it with a fire

so that it bleeds not too much.” [2]

(3)

Early History of Aortic Surgery

Prominent individuals who have suffered from or have been treated for aortic disease are interesting to note.

Albert Einstein had an abdominal aortic aneurysm that was wrapped with cellophane in 1949. The aneurysm ruptured 6 years later, on April 13, 1955. Surgical

treatment was recommended, but Einstein rejected the surgery and remarked, “I want to go when I want. It is

tasteless to prolong life artificially. I have done my share.

It is time to go. I will do it elegantly.” On April 18, he died

at Princeton, NJ, at the age of 76.By contrast, the Duke of

Windsor traveled to Houston and had his aortic aneurysm

repaired electively by Dr. DeBakey, in 1965, with a very

(4)

Anatomy

 Every year approximately 200,000 AAA are diagnosed in the United States. Of

these, approximately 45,000 undergo open or endovascular surgery.

 In 2018, in the United States, AAA-related complications were responsible for 4,903

deaths with a crude rate of 1.5 deaths per 100,000 [3,4] .

Natural History of Aortic

Aneurysms

(5)

 Is a focal dilatation more than 50 percent greater

than the normal diameter of the Aorta, is a common but potencial lethal condition.

 The abdominal Aorta is the most common site of true arterial aneurysm, affecting predominantly the segment of the Aorta below the renal arteries .

AORTIC ANEURYSM

(6)

Layers of the Aorta

(7)

1996

Degenerative aortic aneurysms are the most common

type of aneurysms. They occur when the connective tissue and muscular layer of the aorta weakens and gets thinner, which increases the chances that it will break (called

rupture) or that the layers of tissue will tear (called dissection).

Aneurysmal Degeneration of the

Abdominal Aorta

(8)

 Is a multifactorial systemic process due to alteration in vascular wall biology.

 AAA are characterized by transmural inflammatory changes.

 Abnormal collagen remodeling and cross-linking , reactive oxygen species, and loss of elastin and smooth muscle cells, which result in progressive thinning and weakening of the Aortic Wall and enlargement of the aortic diameter.

LG, MD

Aneurysmal Degeneration of the

Abdominal Aorta

(9)

 Older age*

 Male sex*

 Cigarette smoking*

 Positive family history of AAA*

 Being from a white population.

 Other large artery aneurysms ( CFA 85%, popliteal 60%)

 Hypertension

 Atherosclerotic risk factors

although Diabetes Mellitus is a strong factor for atherosclerosis, it is negatively associated with the development of Abdominal Aortic Aneurysm.

Main Risk Factors for

Developing AAA

(10)

 Is one of progressive expansion, the rate of which is variable.

 AAAs expand on average, at rate of 0.3-0.4cm per year [5-9] (expansion tends to be more rapid in

smokers and less rapid in patients with Diabetes Mellitus or Peripheral Artery Disease [7] .

 Some aneurysms, for unclear reasons, remain

relatively fixed in size for a period of time but then undergo rapid expansion.

 The likelihood that an aneurysm will rupture is

increased for those with aneurysm diameter >5.5cm

Natural History of AAA

(11)

 The most important of which are:

‐ Aortic Diameter (rapid expansion)

‐ Smoking

 Other factors:

‐ Hypertension, Elevated Peak Wall stress, Hx of Cardiac or Renal Transplant and Decreased FEV

 Small and medium sized AAAs (< 5.5cm) expand at an average rate of 2 to 3 mm/year.

 AAAs that exhibit rapid diameter or > 10mm over one year of follow-up have an increased risk for rupture.

 The 1-year incidence of probable rupture by initial AAA diameter was 9.4% for AAA of 5.5 to 5.9 cm, 10.2% for AAA of 6.0 to 6.9 cm (19.1% for the subgroup of 6.5-6.9 cm), and 32.5% for AAA of 7.0 cm or more.

Source: Rupture Rate of Large Abdominal Aortic Aneurysms in ...https://jamanetwork.com › journals › jama › fullarticle

Multiple Factors Influence Aortic

Expansion and the Risk of Rupture

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 Is the modifiable risk factor most strongly associated with the development of AAA

 90 % of all AAA have a history of tobacco use [2]

 Only lung cancer has stronger epidemiology association with. Tobacco

[10]

.

 The number pack –year is positively associated with increased odds of AAA.

Males who smoke over one pack per day have 15-fold increased risk of AAA compared with age-matches males who do not smoke.

 Meta analysis have shown that current smokers have nearly five-fold increase in the risk development an AAA

[4]

.

 Smoking cessation decreases the subsequent odds of AAA; identified on screening, with the greatest benefit among those who have quit for more than 10 years.

 The risk of AAA after smoking cessation approaches that of never-smokers after 25 years of smoking cessation

[11]

.

 Unfortunately, the odds never return to the baseline of non smokers, indicating that some degree of arterial damage inflicted by tobacco use is permanent.

LG, MD

Tobacco Use

(13)

 The effectiveness of population-based screening for AAAs with abdominal ultrasonography have been evaluated in large randomized trials and systemic reviews [13-20] .

 In a screening study that include 81,500 men the overall prevalence of screen-detected AAA (>3.0 cm) was 3.4%

decreasing from 5.0 percent in 1991 to 1.3 percent in 2015 [21]

‐ AAA expansion rate were unchanged.

‐ Males with sub aneurysmal aorta (2.6 -2.9cm)

o 57.6 percent were estimate to developed AAA > 3.0 cm within 5 years of initial Scan.

o 28 percent to developed a large AAA (5.5cm) within 15 years

The Incidence of AAA

(14)

 The prevalence of AAA is 4 to 8 percent (are generally small aneurysm).

 Those measuring >5.5cm or greater are found in only 0.4 to 0.6 percent of those screened [22] .

 The incident of AAA rises sharply in individuals over 60 year age [4] .

 Age significant impacts the incidence:

‐ males aged 65 to 74 years the incidence was 55 per 100,000

‐ males aged 75 to 85 years the incidence was 112 per 100,000

‐ males aged > 85 years increased to 298 per 100,000

person-years [23] . LG, MD

Development of AAA Epidemiology

(15)

 AAA presents clinically in a variety of ways. Most individuals with AAA have no symptoms. When symptoms do occur, pain is the most common complaint.

 Ultrasound screening studies have found that 4 to 8 percent of older males have on occult AAA.

 The prevalence of AAA is 4-6 times lower for females , but females present with rupture more often than males.

 Only 20-30% of patients who present to an emergency

department with rupture have known history of AAA [24-25] . Clinical Presentation

Aortic Aneurysm

(16)

 Asymptomatic: a previously unknown AAA may also become apparent as a result of screening or be

discovered incidentally on routine physical examination, on imaging studies performed for other indications, or in the course of evaluating other unrelated conditions.

 Symptomatic but not ruptured: refers to any of a number of symptoms that can be attributed to the aneurysm.

 Symptomatic and ruptured: the clinical presentation of ruptured AAA is variable but, the classic presentation of severe pain, hypotension, and a pulsatile abdominal

mass occurs in approximately 50% of patients. LG, MD

Patients with intact AAA may present with or without symptoms

Clinical Presentation

(17)

 AAA are managed according to their diameter and the presence or absence of symptoms. Under most

circumstances, patients with symptoms that cannot be definitively attributed to another etiology should be

admitted for observation and further vascular evaluation.

Asymptomatic aneurysms are evaluated on an outpatient basis, unless they are very large.

 Surgery:

‐ Open surgical aneurysm repair

‐ Endo Vascular aneurysm repair

 Medical management:

‐ Blood pressure control

‐ Encourage to stop cigarette smoke

Management

(18)

Natural History of Aortic

Aneurysms

(19)

 Conservative treatment of a small or sub

aneurysmatic aneurysms sometimes produce psychological stress in the patient. This is why I recommend referring all patients that are

diagnosed with aortic aneurysm, regardless of the aneurysms size, to the vascular

Recommendation

(20)

[1] G. SlaneyA history of aneurysm surgery. RM Greenhalgh, JA Mannick, JT Powell (Eds.), The cause and management of aneurysms., WB Saunders, London (1990), pp. 1-18

[2] WF. Barker. Clio: the arteries. RG Landers, Austin (TX) (1992), pp. 2-502

[3] Centers for Disease Control and Prevention. Underlying Cause of Death 1999-2019 on CDC WONDER Online Database, released 2020. Data are from the Multiple Cause of Death Files, 1999-2019, as compiled from data provided by the 57 vital statistics jurisdict ions through the Vital Statistics Cooperative Program. https://wonder.cdc.gov/ucd-icd10.html (Accessed on December 17, 2020).

[4] Deaths, percent of total deaths, and death rates for the 15 leading causes of death in 5-year age groups, by race, and sex: Unite d States, 2013. https://www.cdc.gov/nchs/data/dvs/lcwk1_2015.pdf (Accessed on February 19, 2018).

[5] Rogers IS, Massaro JM, Truong QA, et al. Distribution, determinants, and normal reference values of thoracic and abdominal ao rtic diameters by computed tomography (from the Framingham Heart Study). Am J Cardiol 2013; 111:1510.

[6] Salem MK, Rayt HS, Hussey G, et al. Should Asian men be included in abdominal aortic aneurysm screening programmes? Eur J Vasc Endovasc Surg 2009; 38:748.

[7] Lederle FA, Johnson GR, Wilson SE, et al. The aneurysm detection and management study screening program: validation cohor t and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators. Arch Intern Med 2000;

160:1425.

[8] Kent KC, Zwolak RM, Egorova NN, et al. Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 millio n individuals. J Vasc Surg 2010; 52:539.

[9] Clifton MA. Familial abdominal aortic aneurysms. Br J Surg 1977; 64:765.

[10] Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with a n abdominal aortic aneurysm. J Vasc Surg 2018; 67:2.[11] Aune D, Schlesinger S, Norat T, Riboli E. Tobacco smoking and the risk of abdominal aortic aneurysm: a systematic review and meta-analysis of prospective studies. Sci Rep 2018; 8:14786.

[11] Aune D, Schlesinger S, Norat T, Riboli E. Tobacco smoking and the risk of abdominal aortic aneurysm: a systematic review and meta-analysis of prospective studies. Sci Rep 2018; 8:14786.

[12] Pinard A, Jones GT, Milewicz DM. Genetics of Thoracic and Abdominal Aortic Diseases. Circ Res 2019; 124:588.

[13] Salo JA, Soisalon-Soininen S, Bondestam S, Mattila PS. Familial occurrence of abdominal aortic aneurysm. Ann Intern Med 199 9; 130:637.

References

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[14] Shibamura H, Olson JM, van Vlijmen-Van Keulen C, et al. Genome scan for familial abdominal aortic aneurysm using sex and family history as covariates suggests genetic heterogeneity and identifies linkage to chromosome 19q13. Circulation 2004; 109:2103.

[15] Bertoli-Avella AM, Gillis E, Morisaki H, et al. Mutations in a TGF-β ligand, TGFB3, cause syndromic aortic aneurysms and dissections. J Am C oll Cardiol 2015; 65:1324.

[16] Kuivaniemi H, Elmore JR. Opportunities in abdominal aortic aneurysm research: epidemiology, genetics, and pathophysiology. Ann Vasc Su rg 2012; 26:862.

[17] Pinard A, Jones GT, Milewicz DM. Genetics of Thoracic and Abdominal Aortic Diseases. Circ Res 2019; 124:588.

[18] Kuivaniemi H, Ryer EJ, Elmore JR, Tromp G. Understanding the pathogenesis of abdominal aortic aneurysms. Expert Rev Cardiovasc Ther 2 015; 13:975.

[19] Lederle FA, Nelson DB, Joseph AM. Smokers' relative risk for aortic aneurysm compared with other smoking-related diseases: a systematic review. J Vasc Surg 2003; 38:329.

[20] Wong DR, Willett WC, Rimm EB. Smoking, hypertension, alcohol consumption, and risk of abdominal aortic aneurysm in men. Am J Epide miol 2007; 165:838.

[21] Forsdahl SH, Singh K, Solberg S, Jacobsen BK. Risk factors for abdominal aortic aneurysms: a 7-year prospective study: the Tromsø Study, 1 994-2001. Circulation 2009; 119:2202.

[22] Von Allmen RS, Powell JT. The management of ruptured abdominal aortic aneurysms: screening for abdominal aortic aneurysm and inciden ce of rupture. J Cardiovasc Surg (Torino) 2012; 53:69.

[23] Howard DP, Banerjee A, Fairhead JF, et al. Population-Based Study of Incidence of Acute Abdominal Aortic Aneurysms With Projected Imp act of Screening Strategy. J Am Heart Assoc 2015; 4:e001926.

[24] Ramella M, Bernardi P, Fusaro L, et al. Relevance of inflammation and matrix remodeling in abdominal aortic aneurysm (AAA) and popliteal artery aneurysm (PAA) progression. Am J Transl Res 2018; 10:3265.

[25] Whitehouse WM Jr, Wakefield TW, Graham LM, et al. Limb-threatening potential of arteriosclerotic popliteal artery aneurysms. Surgery 19 83; 93:694.

Thompson JE. Early history of aortic surgery. J Vasc Surg 1998;28:746-52.

References

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