What is the aorta?
It is the largest vein in our body, originating from the left ventricle of our heart and allowing blood to be distributed throughout our body. If we compare the vascular network in our body to a water network, the aorta is the main water pipe of this network. The outlet diameter is approximately 2.5 cm. After the aorta leaves the heart, it travels to the chest and abdominal cavity. During this progression, it gives branches to all our organs.
What is an aneurysm?
An aneurysm is the ballooning of any part of an artery, exceeding 1.5 times its normal diameter. Not every enlargement is an aneurysm. We define enlargements below this rate as "ectasia". A sufficiently enlarged aneurysm can rupture and cause fatal bleeding.
What is an aortic aneurysm?
What are the symptoms of aneurysm?
Chest pain, including the level of the aortic artery leaving the heart. These are aneurysms that develop in the parts of the cavity (thoracic aneurysms) or in the part of the abdominal cavity (abdominal aortic aneurysms).
What causes aneurysm?
It is caused by atherosclerosis, commonly known as arteriosclerosis. Loss of internal surface integrity and flexibility
. Continuous elevation of intravascular pressure due to uncontrolled hypertension
. Genetic predisposition (congenital looseness of tissues such as Marfan syndrome)
. Smoking (increases the risk of aneurysm by 8 times)
. Overweight – obesity
. Chest trauma (traffic accident, etc.)
. Rarely use of stimulant drugs such as cocaine
. Rarely, untreated infections (Syphilis, etc.) and inflammatory diseases (Behçet's disease, etc.)
Aortic Root Aneurysms and Ascending Aortic Aneurysms
Aneurysms that develop around the aortic valve and just above it are called sinus valsalva aneurysm or aorta. We call the aneurysms above this level, up to the aortic arch, the root aneurysm, and the aneurysms in the area above this level are called the ascending aortic aneurysm. Many of our patients have both conditions together. Aneurysm symptoms are often unclear and progress insidiously. This is a condition related to the slow development of the aneurysm. Aneurysm appears They vary depending on the area where they are located. An aneurysm occurring in the area where the aorta exits the heart can cause aortic valve insufficiency and shortness of breath if it puts pressure on the trachea. An abdominal aortic aneurysm in the abdominal area usually causes symptoms such as abdominal and back pain. However, most of our patients may present after having an aneurysm detected during health checks for any reason. Rarely, aneurysms are found to have ruptured in patients presenting to the emergency department. This condition is extremely fatal and requires urgent surgery.
What are the surgical options?
In aneurysms involving the aortic root, we replace the aorta starting from the aortic valve level. In this surgery, it is not enough to just replace the aorta, but also intervene in the aortic valve.
Aneurysm repair by replacing the aortic valve (Bentall Surgery)
In cases where the aortic valve is damaged beyond repair, an artificial tube is used with a valve placed at the end of the vessel (valved conduit). We replace both the aortic valve and aneurysmatic aortic walls. This surgery is called Bentall surgery. We can use both mechanical and biological valves in this surgery.
What is Aortic Dissection?
Aneurysm repair performed by preserving the aortic valve (Tirone David Surgery)
Our patient's aortic valve is structurally damaged. We protect the person's own cover if it is intact or repairable. We call this surgery, in which we replace the aortic root while preserving its own valve, Tirone David surgery. Tirone David surgery, which I personally enjoy performing, is a very complex surgery, but with its results, it is very advantageous for the patient as it saves the patient from using blood thinners.
How is aortic dissection treated?
The aorta consists of 3 main layers. Dissection is the tearing of the innermost layer, causing blood to pass into the middle layer and separating the layers from each other. The aorta is not ruptured in full thickness, but the layers are separated from each other like a dry tree bark peeling. Blood finds a new path. With each heartbeat, this new path progresses a little further. All vital organs such as heart, brain, kidneys are at risk. Usually in the elderly, uncontrolled hypertension patients, It occurs in people with previous aneurysms and loose tissue diseases such as Marfan Syndrome. Acute dissection is an extremely fatal condition. It requires emergency surgery. 50% of patients who are not operated on die in the first 48 hours. Afterwards, the risk of death increases by 1% for every hour.
How is the diagnosis made in Abdominal Aortic Aneurysms?
The treatment of aortic dissection is surgery. We remove all of the dissected aortic tissue and replace it with an artificial vessel. During this surgery, a heart-lung machine is used, when necessary, we cool the patient to 16 - 18 degrees and stop the circulation completely.
The easiest diagnostic method is a good physical examination and ultrasonography. Nowadays, computed tomography is an indispensable examination for a more detailed diagnosis, follow-up and surgery scheduling.
Abdominal Aortic Aneurysms
It is the most common type of aortic aneurysm we encounter. It occurs 5-10 times more in men than in women. The risk of occurrence increases with age. It occurs most frequently in people between the ages of 60 and 80. While 75% of the patients do not show any symptoms, some of our patients notice a mass in their abdomen that pulsates in harmony with the heartbeat (this may also be a normal finding in underweight patients). Or it may be detected incidentally during a health check. There is a risk of explosion when they are not under control.
Why is early diagnosis important?
Surgical Options in Abdominal Aortic Aneurysm (AAA)
Today, we can apply two types of surgical options in AAA. The first one, which we call the classical method, is the process of surgically opening the abdomen and removing the aneurysmatic aortic section and replacing it with artificial vessels known as Dacron or Gorotex. The second option is the endovascular aneurysm repair (EVAR) technique, which is the process of inserting a new vessel into the aneurysmatic aortic vessel by entering through the groin artery without opening the abdomen, which we have preferred more in recent years. Although the EVAR technique can be applied to almost all abdominal aortic aneurysms, we always have the chance to perform classical surgery in patients who are not suitable for this technique.
In a patient whose aneurysm is detected before its diameter increases, the progression of the aneurysm can be slowed down and even almost stopped in some patients. This figure There are patients in the province who survive to the end. Another importance of early diagnosis is that aneurysms with increased diameter can be operated on before they burst. If the aneurysm diameter is less than 3 cm, follow-up every 5 years is usually sufficient. For aneurysms between 3 and 4 cm, patients must come to the doctor for an ultrasound once a year. Aneurysms with a diameter of 4 – 4.5 cm should be checked every 6 months. If the aortic diameter is 5 cm or more or if it enlarges more than 1 cm per year, surgery is required as soon as possible.
What are the advantages of the EVAR method?
The first is the repair of the aneurysm without opening the abdomen. Since it is less traumatic, it is a more suitable treatment method than open surgery, especially for elderly patients or patients in poor general condition. Our patients return to their daily lives more quickly. As with all surgeries performed with small incisions, there is less pain, the need for blood transfusion and the risk of infection. It is more aesthetic than surgery performed with a classical incision.
Endovascular Aneurysm Repair (EVAR)
What are the disadvantages and possible complications of the EVAR method?
In this method, which we apply without opening the abdomen in abdominal aortic aneurysms, the groin is removed. We place a self-stented artificial vessel, which we call a stentgraft, from the artery into the aneurysmatic area. In this way, the aneurysm is repaired from the inside. Blood now flows through the new artificial vessel without filling the aneurysm sac. The stents on it allow the artificial vessel to hold tightly to both ends of the aneurysmatic segment and not collapse inside. Since the blood flow passing through the vein exerts pressure in the same direction, the artificial vein remains more solid. Since the opaque substance used to visualize the veins is eliminated from the body through the kidneys during the procedure, its use is limited in patients with kidney failure. The most important complication is blood leakage between the stent and the aneurysm from the edges of the artificial vessel or from a vessel opened into the aneurysm sac. This condition is called endoleak. If the endoleak is not corrected, it may cause the aneurysm to grow and even burst. A possible endoleak is treated with the same method. Very rarely, it is corrected by open surgery.
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