Vascular Aneurysm Gregory Hills

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Aortic Dissection
Aortic Dissection
What is an aneurysm?
An aneurysm occurs when part of an artery enlarges or bulges because the wall of the artery is weak.
Untreated, an aneurysm can burst, causing severe and potentially fatal bleeding.
At AVC, your vascular surgeon typically handles all aneurysms of the body except those that occur in the heart or brain (cerebral aneurysms) which are the domain of cardiothoracic surgeons, neurosurgeons or neuro-interventional radiologists.

The common aneurysms we treat at AVC are Abdominal Aortic Aneurysm (AAA), Thoracic Aortic Aneurysm (TAA), peripheral arterial aneurysms and visceral aneurysms.

All arterial investigations scans are conducted on site at Gregory Hills and Wollongong, and all our arterial patients are entitled to bulk-billed vascular scans, if they hold a valid Medicare card.

These investigations can often be done on the same day as you see the surgeon and you will only be charged for the consult fee.

Our Canberra clinic performs mostly vein procedures – but call our main rooms number if you need a referral to an arterial vascular surgeon in Canberra.

We see urgent patients within 48 business hours with a call from a GP.

What is an Abdominal Aortic Aneurysm?
The most common type of aneurysm is the Abdominal Aortic Aneurysm or (AAA).

These occur in the lower part of the aorta, usually below the kidney arteries, just before the aorta splits to supply the legs with blood.

They occur more frequently in older adults and can be life threatening if they rupture.

Regular screening is vital for people with risk factors which include a family or previous personal history of aneurysm, a history of smoking or high blood pressure.

Quite often these aneurysms are asymptomatic, but some people may notice a pulsating feeling near the navel, or a throbbing sensation the abdomen and sometimes persistent back pain.

Symptoms of a ruptured AAA include sudden intense abdominal or back pain that feels like tearing or ripping – and is considered a medical emergency. A fast pulse, fainting and low blood pressure are other symptoms caused by internal bleeding.

What is a Thoracic Aortic Aneurysm (TAA)?

A Thoracic Aortic aneurysm is a bulge that occurs in the upper part of the aorta which connects to the heart.

These aneurysms often have no symptoms and are found incidentally on imaging tests for other conditions.

These can also be “silent” in terms of symptoms, but when symptoms are present, they include chest or back pain, shortness of breath, cough, or difficulty swallowing (due to pressure on nearby organs).

Sometimes there may be hoarseness due to pressure on the vocal cords, pain with swallowing, with some aneurysms pushing on the oesophagus – this is very rare (dysphagia lusoria).

Risk factors include high blood pressure, hardening of the arteries, genetic conditions such as Marfan Syndrome or Ehlers-Danlos Syndrome, a family history of aneurysms and smoking.

Ruptured aneurysm: If a TAA ruptures it can be life threatening and cause severe internal bleeding, or dissection where a tear in the aorta’s wall which can impede blood flow and damage organs.

What is a Peripheral Arterial Aneurysm?
A peripheral arterial aneurysm is an abnormal dilation or bulge in an artery wall, typically away from the heart and impacting arteries in the legs such as the popliteal artery located behind the knee, the femoral artery located at the thigh and the iliac artery located at the pelvis (and often found with abdominal concurrent aortic aneurysms).

They sometimes occur in the arms or neck; however, this type of aneurysm is less common.

Symptoms can be subtle or severe and include pain, swelling, a pulsating lump that you can feel, limb discoloration, coldness to the touch or numbness.

Complications of these aneurysms include rupture, which is rare compared to aortic aneurysms, but should it occur can cause extensive bleeding and be life-threatening. More frequently, peripheral aneurysms suddenly block (thrombose) causing the limb to suffer from lack of blood supply. This can lead to limb amputation.

What is a visceral aneurysm?
This type of aneurysm occurs when there is abnormal dilation or ballooning of and artery supplying blood to organs such as the liver and intestines (Mesenteric), kidney (renal artery) or spleen (splenic artery)

Symptoms a are often asymptomatic people often discover the issue during scanning for another issue.

When symptoms do occur, they include back pain, nausea, vomiting, intestinal bleeding and ruptures.

Although rupture is rare, when this occurs it is a medical emergency and can be life-threatening.

When is surgery needed?

Surgical intervention by your AVC vascular surgeon will be determined by the aneurysm’s size and bleeding risk of it bursting. Here are the general guidelines:

  • Abdominal Aortic Aneurysm (AAA): Surgery is usually considered when the aneurysm reaches 5.5 cm in men or 5.0 cm in women.
    Smaller aneurysms are monitored for growth, as the surgery’s risk may outweigh the risk of rupture unless the aneurysm is large.
  • Thoracic Aortic Aneurysm (TAA): Surgery is often considered if the aneurysm is larger than 6.0cms

What are the size criteria for surgical intervention?

The decision to intervene surgically is based on the size of the aneurysm and the risk of rupture.

Standard size criteria include:

Abdominal Aortic Aneurysm (AAA): Intervention is frequently undertaken when the aneurysm reaches 5.5 cm diameter in men and 5.0 cm in women.
Aneurysms smaller than this are monitored periodically for growth and not repaired until they are large enough, as the risk of surgery outweighs the risk of death from rupture

Thoracic Aortic Aneurysm (TAA): Surgery is often considered when the aneurysm exceeds 6.0 cm.
However, surgery may be performed at smaller diameters (around 4.5 cm) for patients with certain genetic conditions like Marfan syndrome.

Peripheral Aneurysms: Intervention is generally advised and your AVC surgeon will provide further guidance.

Popliteal aneurysms: Intervention generally occurs when they exceed 2.0 cm, or if they are causing issues with blockages below the popliteal aneurysm

Femoral aneurysms: Your AVC vascular specialist will generally operate when these are approximately 3.0 cm or are symptomatic.

Iliac aneurysms: Intervention generally occurs at the 3.5-4.0cm mark.

What symptoms can aneurysms cause?

Aneurysms are often asymptomatic until they grow large or rupture, but when symptoms do occur, they vary depending on the aneurysm’s location:

What are the symptoms of aneurysms?
  • Abdominal Aortic Aneurysm (AAA)
    A pulsating feeling near the navel; deep, constant pain in the abdomen or back
    Sudden, severe pain indicates rupture, which can lead to rapid death if not treated immediately.
  • Thoracic Aortic Aneurysm (TAA)
    Chest or back pain, shortness of breath, cough, or difficulty swallowing (due to pressure on nearby organs)
    Hoarseness, pain with swallowing, with some aneurysms pushing on the oesophagus – this is very rare (dysphagia lusoria)
  • Peripheral aneurysms
    Swelling, a pulsating lump that you can feel, limb discoloration, coldness to the touch or numbness.
  • Popliteal or femoral aneurysms
    A pulsatile mass behind the knee or in the groin, leg pain, or symptoms of reduced blood flow (such as coldness or numbness), sudden onset of pain from the aneurysm blocking blood supply due to clot formation
  • Iliac artery aneurysm
    Lower back pain or a pulsatile mass in the pelvis. Rupture may cause severe abdominal pain.
  • Splenic artery aneurysm:
    Often asymptomatic but can cause left upper abdominal pain. Rupture leads to sharp pain and internal bleeding
What is the diagnosis for aneurysms?
Depending on the locations your first consult will include a thorough clinical evaluation, and you can often have a bulk-billed arterial scan on the same day.

Imaging tests for aneurysms include ultrasound, especially for abadominal, CT scan, particularly useful for abdominal and thoracic aneurysms, and MRI often used for brain aneurysms or when detailed soft tissue images are required. Other tests your AVC vascular surgeon may order could include an echocardiogram for aneurysms near the heart, or a transthoracic or transesophageal echocardiogram. Blood tests will also be taken to assess overall general health conditions.

What is the treatment for an aneurysm?
Treatment options vary depending on the size, location, and growth rate of the aneurysm and can include:

Monitoring for aneurysm
Keeping an eye on the size of an aneurysm is essential. All aneurysms will grow, but some may not become large enough to be a problem.
Ongoing annual check-ups or more often if your doctor suggests to one to monitor size and growth trajectory.
Medicine can help modify risk factors for aneurysm progression.

Surgical Interventions

Open surgical repair
This involves removing the weakened section of the artery and replacing it with a graft (fabric) and is the go-to treatment for large, symptomatic aneurysms.
Endovascular repair (EVAR or TEVAR)
Inserting a stent graft through the arteries to reinforce the weakened area is a less invasive approach commonly used for AAA and TAA – but may also be used for other peripheral aneurysms, depending on location and anatomy.

Coiling or embolization
This technique blocks blood flow towards or within an aneurysm, removing the pressurise within the wall and eliminating rupture risks.
Not all aneurysms can be blocked though as this may lead to organ or limb ischaemia (reduced blood flow).
Coiling is reserved for specific aneurysm locations, such as splenic artery aneurysms and some mesenteric aneurysms.

What are the pros and cons of open repair for vascular aneurysm v minimally invasive endovascular repair for aneurysms?

The choice between open and endovascular repair depends on the patient’s health, the aneurysm’s location and size, and the risks associated with surgery.

The biggest consideration is deciding whether an abdominal aortic aneurysm should be fixed with open surgery (big cut) or minimally invasive stent grafting (keyhole surgery).

Pros for minimally invasive

  • Lower risk of death and major complications in the short-term
  • Faster recovery, with minimal pain and suffering

Cons for minimally invasive

  • The repair is not as durable. It may begin to leak around the stent graft fabric, or other small vessels that attach to the aorta can deliver blood under low pressure into the aneurysm. Growth in the following 5-10 years may eventually need further minimally invasive surgeries to resolve the leak.
  • Because of the risk of a leak in the years to come, it needs a lifetime of ongoing surveillance with ultrasound, usually once yearly

Pros for open surgical repair

  • The repair is likely to last > 20 years, and unlikely to cause further issues after initial surgery
  • Requires minimal follow-up surveillance in the years following surgery

Cons of open surgical repair

  • Much higher risk of complications, including kidney failures, bowel resection, death, stoma formation, respiratory failure, heart attack, impotence, and return to the operating theatre for emergent surgery.
  • Requires one week in the hospital and six months until energy levels return to normal
What’s new in aneurysm surgery?
In October 2024, US surgeons performed the first FDA approved Thoracoabdominal Branch Endoprosthesis (TAMBE) – a device to treat aortic aneurysms.

“This is exciting because it will be the first off-the-shelf treatment for a complex disease of aortic aneurysm,” says Dr Jason Toniolo, AVC Vascular Surgeon.

“TAMBE has shorter recovery times than the more invasive surgery to treat aortic aneurysms, which untreated can be lethal.”

He says a ruptured AAA has a death rate above 75%*4, while treated AAAs have a mortality rate during surgery of 1-5%, so the TAMBE procedure brings these statistics down further.”

TAMBE has four built-in, pre-cannulated internal portals to facilitate placement of bridging stent grafts into the visceral arteries perfusing the internal organs within the abdomen, using minimally invasive surgical techniques.

Dr Toniolo assisted in Wollongong’s first TAMBE procedure in 2024, and believes the procedure will become increasingly available in the next few years.