You can treat aortic aneurysms naturally

Modern therapy of the aortic aneurysm - EVAR (Endovascular Abdominal Aortic Aneurysm Repair)

Albert Einstein, Charles de Gaulle and the top US diplomat Richard Holbrooke suffered the same fate: all three died of complications from an aneurysm of the abdominal aorta. Pathological enlargements of the main artery, d. H. when the diameter of the aorta is expanded to more than 3 cm, it is called an aortic aneurysm. The risk of this mostly asymptomatic disease lies in a sudden rupture of the aorta (rupture) and subsequent death from bleeding.

from MUDr./Univ. Bratislava Milan Lisy, PhD

Specialist in cardiovascular surgery, Clinic for Vascular Surgery and Angiology at the Northwest Hospital

etiology

Aortic aneurysms arise from a chronic inflammation of the aortic wall and are associated with atherosclerosis. Risk factors for developing an aneurysm include other vascular diseases, high blood pressure and smoking, and a family history of aortic aneurysms. Less common contributing factors are injury, vascular inflammation, syphilis, and connective tissue disease. The abdominal aorta is affected in 60 percent of all patients. While 95 percent of these aneurysms begin below the renal arteries, the renal arteries are included in only three percent and the visceral segment only in two percent of the cases.

Risk factors for the development of an aneurysm are other vascular diseases, high blood pressure and smoking, and a family history.

Epidemiology

The incidence of aortic aneurysms of the great vessels is 40 per 100,000 people. Men are six times more likely to be affected by this condition than women. The risk of rupture depends on the axial diameter of the aneurysm. With a diameter of 4.0 to 4.9 cm the risk is around three percent, with 5.0 to 5.9 cm ten percent, 6.0 to 6.9 cm 15 percent and more than 7 cm it is 60 percent. Another factor influencing the risk of rupture is the growth rate. With a growth of more than 0.5 cm in six months, this risk must be assessed as high. Therefore, asymptomatic aneurysms that grow more than 0.5 cm in six months or that are more than 5 to 5.5 cm in diameter should be electively eliminated. Symptomatic aneurysms should be treated within 24 hours and ruptured aneurysms are an emergency indication.

 

Diagnosis

All aneurysms are usually symptom-free unless they expand or rupture rapidly. Symptoms can sometimes be due to the pressure the aneurysm puts on the surrounding structures. An abdominal aortic aneurysm can lead to back pain and abdominal pain, which is often long-lasting. Sometimes blood flow problems in the feet occur because small blood clots separate from the aneurysm and are carried along in the blood to the lower extremities. An abdominal aortic aneurysm may be discovered by chance as a pulsating lump in the abdomen. A rapidly growing aneurysm can cause abdominal pain.

An aneurysm in the aorta in the chest can cause chest pain or symptoms caused by pressure on the esophagus, vocal cord nerve, or large vena cava. As a result, you may experience a bloody cough from compressed airways or bronchi. Hoarseness can also be caused by pressure on the left side of the vocal cord nerve. An aneurysm in the thoracic part of the aorta is usually an incidental finding during a radiological diagnosis of the chest.

An ultrasound exam can show the size and extent of the aneurysm. Abdominal aortic aneurysms in particular can be clearly seen on ultrasound. Over 80 percent of all abdominal aortic aneurysms are clinically asymptomatic and are discovered by chance during an ultrasound examination of the abdomen. The examination also serves to check whether there has been an increase. With a computed tomography (CT) a precise measurement is possible. It shows the exact anatomical conditions and is therefore a possible alternative to ultrasound examination. A CT angiography of the aorta with a contrast medium is recommended before a possible operation.

therapy

Conventional open surgery still has a high mortality and morbidity rate, despite advances in perioperative management, additional intraoperative measures and improved postoperative treatment. After it was first introduced in 1991, endovascular repair (EVAR) of abdominal aortic aortic aurysms (AAA) has become the standard procedure in many centers. A direct comparison with open surgery is unrealistic, however, because on the one hand most endovascularly treated patients were assessed as unsuitable for open surgery and on the other hand it must be taken into account that anatomical suitability for endovascular repair also means a selection of the cases.


The use of stent prostheses enables abdominal (AAA) and thoracoabdominal (TAAA) aortic aneurysms to be treated in a minimally invasive manner. Nowadays everyone, not just the patients who have been denied open surgery because of their comorbidity or their age, can now be treated with EVAR at a lower risk. In open aortic surgery, the aorta must be clamped ("cross-clamping") during the reconstruction. Cross-clamping increases cardiac afterload and is the main reason for cardiac ischemia or cardiac decompensation during surgery or in the early postoperative course. This cardiac stress is not required during EVAR.

The main limitation of EVAR, however, is the need for a suitable normal infrarenal aortic segment (i.e., proximal neck) as the landing zone for the stent graft. Severe kinking, stenoses, larger thrombi or extensive calcifications of the aorta or iliac arteries can be contraindications. The solution of the suitable landing zone in the peri- or suprarenal area as well as in the area of ​​the left subclavian artery was the introduction of custom-made fenestrated and branched prostheses with side arms to connect the vital visceral / supra-aortic arteries. The advances this has made in fenestrated endovascular technology (F-EVAR) have paved the way for the treatment of juxtarenal and short neck aneurysms over the past decade. F-EVAR is now established with over 2,500 cases worldwide. Further development in endovascular technology, particularly of branched prostheses (B-EVAR, i.e. prostheses with directed side branches), led to the first attempts to treat TAAA and the aneurysm of the aortic arch as well.

The different types of prostheses available on the market have different configurations, so that the user can select the most suitable prosthesis for the patient taking into account the anatomical requirements. The manufacturers specify application restrictions and limitations for their stent prostheses. The use of stent prostheses outside of these standards (off-label use) is practiced worldwide in everyday clinical practice. Such off-label use of the prosthesis is recognized as one of the independent significant risk factors for enlargement of the aneurysm sac after EVAR.

Growth of the aortic aneurysm after EVAR
If the aneurysm has been eliminated by the stent prosthesis, a size reduction in the aneurysm sac can be observed over time. In cases where expansion of the aneurysm can be observed after implantation, there is a potential risk of rupture. The cause for this is usually an endoleak, which must be viewed as a therapy failure. Obviously, this is consistently a problem that can occur over the long term.

Follow-up care after EVAR
The mortality of the rupture after EVAR is high (> 60 percent). However, the complications after EVAR that lead to secondary aneurysm rupture can be identified with appropriate imaging, with very rare exceptions. The following parameters are assessed as part of the controls:
Dynamics of the aneurysm sac (shrinkage, expansion)
Endoleakages (yes / no, type)
Position of the individual stent graft components (migration, dislocation)

CT angiography is currently the gold standard for progress diagnosis. In addition to the advantage of a very short examination time, this method provides detailed information on all of the above points. The disadvantage of this method is the cumulative radiation exposure and the iodine-containing nephrotoxic contrast agent. In order to reduce the burden of CT angiographies in EVAR patients, contrast-enhanced ultrasound examinations can alternatively be carried out for annual follow-up. This allows the size of the aneurysm sac and endoleakage to be assessed. Another alternative to reducing the cumulative radiation dose after EVAR is magnetic resonance angiography (MRA).

Summary

With the establishment of the endovascular technique, a further reduction in the perioperative mortality rate in open surgery could be achieved. The introduction of the stent prosthesis also appears to reduce the risk of dying from an aneurysm rupture. The further development since the beginning of endovascular technology and the use of the resulting modern third-generation prostheses enables an increasingly broader application. As a result, doctors are increasingly faced with the decision to advise patients about a particular procedure. In a patient with a low operative risk profile whose aortic aneurysm to be treated meets the morphological requirements for EVAR, the two methods, EVAR and open surgery, compete.

 

EVAR can be performed with a low complication rate.

 

The indication for an open or endovascular replacement of the aorta is clearly defined and the operations can be performed in vascular surgery centers with proven expertise and extensive experience with a low complication rate. In the long term, however, some complications could arise with the endovascular aortic prosthesis. Therefore, regular checks are currently recommended after EVAR.

Endovascular therapy of aortic aneurysms in the Northwest Hospital
Two years ago, a modern “hybrid operating room” with a biplanar X-ray system was built in the Northwest Hospital to perform interventional vascular therapy and thus endovascular aortic surgery. The Clinic for Vascular Surgery and Vascular Medicine under the direction of Prof. Dr. med. M. Zegelman, as a central component of the interdisciplinary vascular center, carries out modern, highly complex aortic surgery.

MUDr./Uni Bratislava Milan Lisy, PhD

Specialist in cardiovascular surgery