Aneurysm disease

An aneurysm is a weakness in a blood vessel that causes the vessel to dilate to a size larger than normal. This looks like a balloon-like bulge, and it can happen to any artery in the body. They can be either tube-shaped or round. Our multidisciplinary team at Sunnybrook has expertise in treating these aneurysms, through both open and minimally-invasive approaches.

These can occur in the aorta, a large blood vessel arising from the heart, and can occur in any part of the aorta, whether it be in the chest, called a ‘thoracic aortic aneurysm’, or the abdomen, called an ‘abdominal aortic aneurysm’. They can also occur in the blood vessels leading to the arms, legs, head, and to the vital organs in the abdomen.

In addition to those listed above, some common aneurysms are:

• Cerebral aneurysm – aneurysm occurring in an artery in the brain
• Popliteal artery aneurysm – aneurysm occurring in the artery behind the knee
• Iliac Artery Aneurysm – aneurysm that occurs in the artery leading from your pelvis to your leg
• Mesenteric Artery Aneurysm – aneurysm that occurs in the arteries supplying blood to the intestines

Anuerysms often grow very slowly, and typically grow without causing any symptoms. Often, they are found in patients who are being investigated for other tests.

There are a number of risk factors that can increase your risk of developing an aneurysm over time. Aneurysms can affect people of any age, and it depends on your unique set of risk factors that will identify why you may develop, or have developed, an aneurysm.

These risk factors include:

• Age – typically, aneurysms occur in people over 60-65 years of age
• Gender – aneurysms occur more commonly in men
• Smoking – this is one of the strongest risk factors for developing aneurysms
• High blood pressure – this can weaken or damage the walls of blood vessels
• High cholesterol
• Genetic conditions and connective tissue disorders – some common genetic disorders associated with aneurysms include Marfan Syndrome, Loeys-Dietz Syndrome, Ehlers-Danlos Syndrome, Familial Aortopathy Syndromes, Turner Syndrome.
• Having a bicuspid aortic
• Inflammatory disorders – some examples include Takayasu Arteritis, Giant Cell Arteritis, Systemic Lupus Erythematosus. These cause the blood vessels to become inflamed.
• Infectious disorders – some examples include syphilis, fungal infections, bacterial infection
• Traumatic injury

If you have an aneurysm, it is often treatable. If someone in your immediate family has an aneurysm, ask your health practitioner to find out if you should be screened for an aneurysm.

Each blood vessel is made up of three layers. As aneurysms grow, these layers becomes progressively weaker. With continued growth, they can become weak enough that one of two things can happen:

• Rupture: a sudden tear through all the layers of the blood vessel, causing bleeding inside the body.
• Dissection: a sudden tear in the innermost layer of the blood vessel, causing the layers to separate as blood tracks in between the layers.

Both of these situations are surgical emergencies, and require urgent surgery to fix. Depending on where your aneurysm is, this can be treated with either open surgery or minimally invasive surgery. By increasing awareness about aneurysms, we hope to reduce the number of people who have these complications of aneurysms, so that these aneurysms can be fixed in a non-emergent fashion.

As aneurysms grow, they usually do not cause any symptoms. However, once they reach a large enough size, if they expand too quickly, or once there is a complication from an aneurysm, they can cause symptoms. These symptoms typically depend on where in the body the aneurysm is located.

Some examples include:

• Aneurysm in the brain: headache, vision changes, dizziness, confusion
• Aneurysm in the chest: chest pain, back pain, hoarseness, difficulty swallowing
• Aneurysm in the abdomen: abdominal pain, nausea, vomiting, pulsatile abdominal mass
• Aneurysm in the extremities: localized pulsatile bulge or swelling
• Aneurysm complication: sudden intense pain, fast pulse, low blood pressure

This usually depends on the size of the aneurysm, and where the aneurysm is located. In all cases, we balance the risks of surgically repairing your aneurysm with the risks of living with the aneurysm. Many studies have been conducted to help create guidelines in making these decisions.

In some cases, we may want to proceed with fixing your aneurysm. However, in others, we may continue to watch the aneurysm with routine imaging surveillance. Just because you have an aneurysm doesn’t necessarily mean you need surgery. Some aneurysms will stay small, others grow slowly, and others will grow rapidly. You and your provider team will identify the optimal time for intervention, if necessary.

Aneurysms can be treated with both open surgical procedures and minimally invasive surgical procedures. The multidisciplinary team within the Sunnybrook Center for Aneurysmal and Aortic Disease has experience treating aneurysms using both strategies. However, your health care providers will discuss a plan with you depending on your anatomy and your diagnosis, to offer the best possible treatment option tailored to you.

Minimally invasive, aka ‘endovascular’ surgery

This approach uses wires and catheters to treat your aneurysm. Often, access to the body’s arterial system is gained through a peripheral blood vessel, either in your arms or legs. This is often performed with a small incision to gain access to the artery, but sometimes can be through the skin without an incision. A wire is then placed across the aneurysm. A device called a ‘stent graft’ is then loaded onto the wire, and delivered across the aneurysm, to divert blood flow away from the aneurysm sac.

Open surgery

This approach is more invasive, but depending on your anatomy, may be the only option available. In this situation, the aneurysm is exposed and is removed. A synthetic tube graft is then sewn in to reconnect the two ends of the artery that had the aneurysm.

Hybrid surgery

Sometimes, your aneurysm can be treated with a hybrid approach. This uses a combination of both open surgical techniques and minimally invasive, ‘endovascular’, techniques. Your healthcare providers will be able to discuss if you are a candidate for this type of procedure.

Here at Sunnybrook, we have created a hybrid OR to facilitate these procedures.

How can I avoid getting an aneurysm?

To reduce the likelihood of developing an aneurysm, or to help prevent its rate of growth, you can try the following:

1. Don’t smoke or use tobacco products. Smoking is one of the most significant risk factors for developing an aneurysm, and is highly ‘modifiable’, which means we have control over it. If you are a current smoker or use tobacco products, we would advise you quit. If you need help quitting, reach out to your doctor to learn about medication and therapies that can help.
2. Get regular exercise. If you are not active, start to slowly build up your exercise tolerance. Start with 5-10 minutes per day, and try to work up to 30 minutes per day, or 150 minutes per week. Talk to your health care provider about what activities might be best for you.
3. Eat a healthy diet. Consume a variety of fruits, vegetables, whole grains, low-fat dairy, poultry, and fish. Try to avoid processed food, foods high in salt, and foods with a high content of saturated fat. Speak to your health care provider about connecting with a dietician to help reach your goals.
4. Monitor your blood pressure. Blood pressure control is another ‘modifiable’ risk factor for developing aneurysms. Ideally, the blood pressure is maintained under 130 mmHg systolic (the top number). Take your medications as prescribed, and speak to your healthcare provider about whether your medications should be adjusted if your blood pressure is too high.

• Genetic Aortic Disorders Association Canada
• Society for Vascular Surgery
• American Association for Thoracic Surgery
• Canadian Cardiology Society
• Society of Thoracic Surgeons
• Heart.org: What is an aneurysm