Aortic Aneurysm

The aorta is the body's largest artery. It carries blood from your heart, down through your chest and abdomen, then splits low down into two branches (the iliac arteries) that supply each leg.

Anatomy - AortaAbdominale Aorta Aneurisme - KortAbdominal Aorta Aneurysm - Short

Abdominal aortic aneurysm

An abdominal aortic aneurysm (AAA) is a weak, bulging section of the aorta in your abdomen – a little like a balloon. A normal aorta is about 20 mm wide; it is called an aneurysm once it reaches 30 mm (3 cm) or more.

Small aneurysms are usually safe to watch. The larger one grows, the higher the chance it will burst (rupture) and cause dangerous internal bleeding. That is why repair is usually advised once it reaches about 55 mm in men or 50 mm in women, or if it grows quickly or causes symptoms.

An aneurysm can also shed small clots that block arteries further down, causing pain or, rarely, loss of a limb.

The good news: when an AAA is found early, it can usually be treated successfully, well before it becomes dangerous.

Symptoms

Most aneurysms cause no symptoms. When they do, you may notice:

A pulsing feeling in your abdomen, like a heartbeat near your belly button
Sudden, severe pain in your abdomen or lower back – this can mean the aneurysm is about to burst

If an aneurysm bursts you may feel sudden intense pain, weakness or dizziness, and may collapse. This is a life-threatening emergency – get medical help immediately.

Causes

The exact cause isn't fully understood. The aorta wall seems to weaken through inflammation, often linked to atherosclerosis (hardening of the arteries). Things that raise your risk include:

Age over 60
A close relative who has had an AAA
High blood pressure
Smoking
Being male – AAA is more common in men

Tests

An aneurysm can sometimes be felt during an examination, but is most often found by chance on a scan done for another reason. To find or measure an AAA, I may arrange:

Abdominal ultrasound
CT scan
MRI

Because an AAA usually causes no symptoms, the US Preventive Services Task Force recommends a one-time ultrasound screening for men aged 65 to 75 who have ever smoked, and suggests offering it selectively to men of that age who have never smoked. For women who have smoked, the evidence is not yet enough to recommend routine screening – ask your doctor, especially if a close relative has had an aneurysm.

Treatment Options

Watchful Waiting

If your aneurysm is too small to need repair, we simply keep an eye on it ("watchful waiting") with regular ultrasound or CT scans. How often depends on its size:

3.0 to 3.9 cm: every few years
4.0 to 4.9 cm: about once a year
5.0 to 5.4 cm: every three to six months

Stopping smoking is the single most important thing you can do to slow its growth. I may also prescribe medication to control your blood pressure and cholesterol.

Surgical Repair

Repair is advised if the aneurysm causes symptoms, is larger than 55 mm in men (50 mm in women), or is growing quickly. In an open repair, I make an incision in your abdomen and replace the weakened section of aorta with a fabric tube (a graft) that takes over the job of the artery. Expect about 5 to 7 days in hospital and 2 to 3 months to recover fully. It is a well-established operation with good long-term durability and seldom needs further procedures.

Risks: in planned surgery, about 3 to 5 in 100 people die within 30 days (about 4 in 100 in the EVAR-1 trial). Other risks include heart, lung and kidney complications, bleeding, reduced blood supply to the bowel or legs, an incisional hernia and, in men, problems with erection or ejaculation.

Endovascular Repair

A less invasive option is endovascular repair (EVAR). Instead of opening the abdomen, I make small cuts in the groin and thread a fabric-and-metal tube (a stent graft) up through the blood vessels, using x-ray guidance, to line the aneurysm from the inside. Recovery is quicker – usually only 2 to 3 days in hospital. The risk of dying within 30 days is lower than with open repair – about 2 in 100 in the EVAR-1 trial.

The trade-offs:
Endoleak – blood continues to leak into the aneurysm sac in up to a third of patients at some stage. Most are minor (type II) and settle on their own, but some need treatment.
Further procedures – roughly 1 in 5 to 1 in 3 patients need another procedure within ten years.
No long-term survival advantage – the early survival benefit is lost within a couple of years, and after about eight years survival in the EVAR-1 trial was lower after EVAR than after open repair, mainly because of late rupture of the aneurysm. Regular follow-up reduces this risk.
Lifelong follow-up scans are essential, and not everyone's anatomy is suitable, so open repair is sometimes the better choice.

References
European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg, 2024.
Society for Vascular Surgery (SVS) Practice Guidelines on the Care of Patients with an Abdominal Aortic Aneurysm. J Vasc Surg, 2018.
US Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: Recommendation Statement. JAMA 2019;322(22):2211–2218. doi:10.1001/jama.2019.18928
Patel R, Sweeting MJ, Powell JT, Greenhalgh RM; EVAR trial investigators. Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1). Lancet 2016;388(10058):2366–2374. doi:10.1016/S0140-6736(16)31135-7. PMID 27743617

Patient Roadmap for Endovascular Abdominal Aorta Aneurysm Repair (EVAR)Open Aorta Aneurysm Repair - Informed ConsentEndovascular Abdominal Aorta Aneurysm Repair - Informed ConsentEVAR: Endovascular Abdominal Aorta Aneurysm RepairEndovascular Aorta Aneurysm Repair - Discharge ProtocolEndovaskulêre Abdominale Aorta Aneurisme Herstel - Ontslagprotokol

Our Services

Open Arterial Procedures

Standard open surgical procedures to repair an aortic aneurysm and / or reconstruct blood flow to the legs.

Open aortic aneurysm repair
Aorto-bifemoral bypass
Iliofemoral bypass

Endovascular Procedures

Less invasive procedures performed from inside the blood vessels, through small punctures or incisions in the groin.

Endovascular abdominal aortic aneurysm repair (EVAR)
Endovascular thoracic aortic aneurysm repair (TEVAR)
Aortic and iliac artery angioplasty and stenting
Mesenteric, renal and subclavian artery angioplasty

Hybrid Procedures

Open and endovascular techniques combined in one operation – for example, a groin endarterectomy together with iliac artery stenting.

If you have any problems with any of these conditions, please contact your General Practitioner, or your Vascular Surgeon. If you live in Pretoria and have not seen a Vascular Surgeon before, you are more than welcome to contact our rooms for a formal consultation.