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The Dangerous Abnormal Bulge of the Aorta
Dr. Salim Lala explains aortic aneurysms, what causes them, associated medical complications, and suggested treatment plans.
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Learn more about Salim Lala, MD
Salim Lala, MD
Salim Lala, MD, is board certified in General Surgery and currently board eligible in Vascular Surgery. He is an assistant professor at The George Washington University School of Medicine & Health Sciences. Dr. Lala completed his general surgery residency at UT Southwestern, and then moved to Florida to complete a two year fellowship in Vascular and Endovascular Surgery at the University of Florida.Learn more about Salim Lala, MD
Transcription:
Dr. Michael Smith (Host): A ruptured aortic aneurysm can lead to life threatening internal bleeding. But how would you know if you had one and if you did, what can you do about it? Welcome The GW Hospital HealthCast. I’m Dr. Mike Smith and today’s topic: The Dangerous Abnormal Bulge of the Aorta. My guest is Dr. Salim Lala. Dr. Lala is the Associate Professor of Surgery at the George Washington University School of Medicine and Health Sciences. Dr. Lala, welcome to the show.
Salim Lala, MD (Guest): Thank you for having me.
Host: So, why don’t we start off very simple. Can you explain to us exactly what is an aneurysm and then I guess specifically, the aortic aneurysm?
Dr. Lala: So, an aneurysm is basically an abnormal dilation of a blood vessel. The technical definition is when it’s more than 1.5 times its normal size. And there are blood vessels throughout the entire body and the aorta is one of the major blood vessels that supplies blood from the heart to the rest of the body. And it starts off at the heart, enters the chest and goes into the abdomen. And an aortic aneurysm is when you put the two together, is an abnormal bulge or dilation of the aorta, most commonly happens in the belly or the abdomen.
Host: And so, what are some of the risk factors for developing an aortic aneurysm?
Dr. Lala: So, most people who develop aortic aneurysms most commonly abdominal aortic aneurysms, are usually male gender and usually in the fifth or sixth decade of life. So, usually males in their 50s and 60s. And you are more likely to have an abdominal aortic aneurysm if you have a family member or a family history of an abdominal aortic aneurysm, because it tends to run in families. Also, people who are heavy smokers and have a history of high blood pressure also are more prone to develop abdominal aortic aneurysms.
Host: I definitely want to get into like what are some of the symptoms and signs that may worry you as a physician and would indicate somebody needs to seek help, but if you do have a family member as you say, who had an aneurysm, aortic aneurysm; should that person be seen more often by say a cardiologist? Is there some screening that they should go through? What’s the plan for somebody who has a family history?
Dr. Lala: So, if you do have a family history of an abdominal aortic aneurysm; I think the first thing to do is to let your primary care doctor know. So, again, it is a disease that tends to happen mostly in later stages of life; but if you do have a family member in their 50s and 60s who had an abdominal aortic aneurysm; usually when you reach that age, I would go to your primary care doctor first and state that yes, I have someone in my family and I think the first port of call is to organize a screening ultrasound. So, a screening ultrasound can be done as an outpatient and they look at the abdomen and it’s noninvasive. They put a probe on the abdomen and they look to see if there is an abnormal bulge in the aorta. And if they do find one, then you are referred to more specialist care and usually to a vascular surgeon such as myself, who then will be able to say what other tests need to be done in order to further diagnose and treat the problem.
Host: How many people actually are diagnosed with an aortic aneurysm that actually knew they had a family history? Or is it more common that people don’t know, and they came in because they had some symptoms?
Dr. Lala: Yeah, actually that’s a very good question. But most commonly, what I tend to see and what is happening currently is that most people actually do not know that they have an abdominal aortic aneurysm. It’s a silent disease. And most people who get diagnosed with the abbreviation is a triple A, AAA, an abdominal aortic aneurysm, is because it’s been picked up incidentally. So, nowadays, because of the advanced technology, people are getting CT scans for various other reasons and they will pick up an abdominal aortic aneurysm for one reason or the other. And then they usually get referred to specialist care that way. But there is a minority of patients obviously and this is part of the reason for having this podcast is to spread awareness is that if you do have a family history, yes, you could actually present earlier and actually have these screening ultrasounds done if you do have a family history.
Host: Right. So, what are some of the symptoms of a AAA? What are some of the things that people might want to be aware of, especially if they do have that family history, maybe there’s an issue, maybe it’s growing? Are there things that the body is telling us that we need to go seek help?
Dr. Lala: Yes, so, again, unfortunately most patients who have an abdominal aortic aneurysm, they are asymptomatic which means that they have no symptoms. And they just grow the size and then they come to a certain size where we deem it necessary to fix. If patients have sudden onset abdominal pain or tearing back pain; that usually is a sign that the aneurysm has started to leak or started to rupture. Now, in a patient who has a known abdominal aortic aneurysm and they have sudden onset of abdominal pain or back pain; you would definitely need to present to the emergency room immediately because that would indicate that something is going wrong with your aneurysm. In patients who again, this is the majority, who have no history of having been diagnosed with a AAA and has sudden onset of abdominal or back pain; they usually present to the emergency room because they are having problems and then when they get further workup done, we find out that they have a ruptured abdominal aortic aneurysm. So, I think basically, if as a patient, you think you are like I said, have a family history and get diagnosed with an abdominal aortic aneurysm or you have been incidentally diagnosed with an abdominal aortic aneurysm and are being followed by your surgeon or your primary care doctor; if you suddenly started developing abdominal pain; you definitely want to seek medical care urgently.
Host: Right, right. And so, let’s move into how this is actually treated. Is there – when we talk about - because you have mentioned this before, the size of the aneurysm. Is there a certain size that it can grow to that at that point someone like you a surgeon would say heh we need to go in and fix that?
Dr. Lala: Yes, absolutely. And so, the normal abdominal aorta measures approximately two centimeters in size. And so, when the aorta gets to about three centimeters, that’s when we say it is starting to look aneurysmal, but we don’t have to fix it right at that point. Really for us as surgeons, the risk versus benefits of repairing an aneurysm tends to become more apparent once the aneurysm reaches in males, 5.5 centimeters and in females it’s 5.0 centimeters. So, usually, at that point, at that size criteria; we would advocate for repair of the aneurysm.
Host: And what exactly – how is it repaired basically? What is the surgery like? What is done? And how successful is the surgery?
Dr. Lala: Yeah, so, nowadays, again, most abdominal aortic aneurysms, if you take all comers in the population, most of them have what we call as an infrarenal abdominal aortic aneurysm. That basically means that the aneurysm is located below where the arteries to the kidneys come off and that kind of anatomy is present in more than 95% of patients again, all comers who have these AAAs. And so, because of the technology that we have these days; those aneurysms can be fixed by minimally invasive means, which is what we call an endovascular aneurysm repair. Those surgeries can be done with specialized stent grafts that are manufactured by a variety of companies that we have access to and depending on the patient’s anatomy, the size of the aneurysm and certain other measurements that we take with specialized software; we can select the appropriate stent graft to appropriately fix the aneurysm for that patient and usually that’s done within a couple of hours and usually the patients go home the next day.
Host: And so that specifically is for the aneurysm that is below where the arteries to the kidneys come off of the aorta, correct? What about aneurysms that are higher up, maybe even into the chest, like a thoracic aortic aneurysm? Is it the same procedure?
Dr. Lala: It is a – the principles of the operation are the same. Again, so, I’ll just interject here that there are obviously – there is a way to fix the aneurysm which is through traditional open means which we are also very capable of doing; but again, in the interests of patients getting home sooner; we like to do endovascular aneurysm repairs if feasible. Now, for more complex aneurysms that involve the what we call visceral aorta which stands for the portion of the aorta that gives off the blood vessels to the intestines and the kidneys and then going up higher into the chest; there are more advanced stent grafts available and there are more advanced techniques available, which include again, this may be technical, but just so there are listeners you can use snorkels and also fenestrated repairs which some of these companies make fenestrated grafts or you can design your own fenestrated graft which we are also capable of doing here at GW. So, for these patients, again these tend to represent a rarer form of aneurysm. Again, like I said, most patients, greater than 95% of patients have an infrarenal which is below the kidneys, aortic aneurysm. For those patients who have these complex type aneurysms we are capable of also fixing them with endovascular means.
Host: So, again, just to reiterate, most people have the aneurysm below the arteries that come off to the kidneys and in those cases assuming it’s nonemergency, what is the success of the repair of those aneurysms? Do they have to go – come back at some point to get repaired again? Or do these kind of stents last a lifetime?
Dr. Lala: Yeah, they are actually very successful and there are some research studies out there that actually talk about the success rates of these endovascular repairs and as the technology continuously improves; the success rate improves as well. So, from a technical standpoint, at the time of the operation; the success rate of the operation is almost 100%, close to 100% because using CT scans and other specialized software to kind of accurately measure the aorta and to get the appropriate stent graft; we are able to fix the aneurysm. Now what happens is that as time goes on; we have to serially monitor these patients with CT scans to make sure that as the aorta grows and remodels, that the stent graft is still holding in place. So, if you look at the long-term success rate, even going out five to ten years; we are looking for basically leaks around the stent graft as the aorta tends to model in these patients and even then, the success rate is over 90%. And in those patients who do develop these small leaks, we are able to bring these patients back and able to repair them by putting additional components in or by using specialized techniques to kind of seal the stent graft into the aneurysm again.
Host: Got you. So, Dr. Lala, let’s end with this. What would you like the listeners to know about aortic aneurysms?
Dr. Lala: Yeah, so that’s a very good question. I think for our patients, one is to be aware of what an abdominal aortic aneurysm is and to know if you are at risk. So, again, if you are a male over the age of 65 and are a heavy smoker and have high blood pressure; then you are actually eligible for a screening ultrasound to make sure that you do or do not have an abdominal aortic aneurysm. If you are a patient who has a strong family history of an abdominal aortic aneurysm that you want to tell your primary care doctor that and get an ultrasound done to make sure that you don’t have one or have an aneurysm evolving within your abdomen. And then if you are incidentally discovered with an abdominal aortic aneurysm; to seek care with a specialist, such as a vascular surgeon who will be able to guide you through the process, order the appropriate steps and follow you because like I mentioned; just because you have an aneurysm does not mean that you need it fixed right away because our size criteria is 5 centimeters in a woman, 5.5 centimeters in a male and so, if you do have an aneurysm that’s smaller than that; then we will serially follow you over time with serial CAT scans and select the appropriate time for these to get fixed.
Host: Excellent summary Dr. Lala. I want to thank you for coming on the show today. You’re listening to The GW Hospital HealthCast. For more information, go to www.gwdocs.com, that’s www.gwdocs.com. I’m Dr. Mike Smith. Thanks for listening.
Dr. Michael Smith (Host): A ruptured aortic aneurysm can lead to life threatening internal bleeding. But how would you know if you had one and if you did, what can you do about it? Welcome The GW Hospital HealthCast. I’m Dr. Mike Smith and today’s topic: The Dangerous Abnormal Bulge of the Aorta. My guest is Dr. Salim Lala. Dr. Lala is the Associate Professor of Surgery at the George Washington University School of Medicine and Health Sciences. Dr. Lala, welcome to the show.
Salim Lala, MD (Guest): Thank you for having me.
Host: So, why don’t we start off very simple. Can you explain to us exactly what is an aneurysm and then I guess specifically, the aortic aneurysm?
Dr. Lala: So, an aneurysm is basically an abnormal dilation of a blood vessel. The technical definition is when it’s more than 1.5 times its normal size. And there are blood vessels throughout the entire body and the aorta is one of the major blood vessels that supplies blood from the heart to the rest of the body. And it starts off at the heart, enters the chest and goes into the abdomen. And an aortic aneurysm is when you put the two together, is an abnormal bulge or dilation of the aorta, most commonly happens in the belly or the abdomen.
Host: And so, what are some of the risk factors for developing an aortic aneurysm?
Dr. Lala: So, most people who develop aortic aneurysms most commonly abdominal aortic aneurysms, are usually male gender and usually in the fifth or sixth decade of life. So, usually males in their 50s and 60s. And you are more likely to have an abdominal aortic aneurysm if you have a family member or a family history of an abdominal aortic aneurysm, because it tends to run in families. Also, people who are heavy smokers and have a history of high blood pressure also are more prone to develop abdominal aortic aneurysms.
Host: I definitely want to get into like what are some of the symptoms and signs that may worry you as a physician and would indicate somebody needs to seek help, but if you do have a family member as you say, who had an aneurysm, aortic aneurysm; should that person be seen more often by say a cardiologist? Is there some screening that they should go through? What’s the plan for somebody who has a family history?
Dr. Lala: So, if you do have a family history of an abdominal aortic aneurysm; I think the first thing to do is to let your primary care doctor know. So, again, it is a disease that tends to happen mostly in later stages of life; but if you do have a family member in their 50s and 60s who had an abdominal aortic aneurysm; usually when you reach that age, I would go to your primary care doctor first and state that yes, I have someone in my family and I think the first port of call is to organize a screening ultrasound. So, a screening ultrasound can be done as an outpatient and they look at the abdomen and it’s noninvasive. They put a probe on the abdomen and they look to see if there is an abnormal bulge in the aorta. And if they do find one, then you are referred to more specialist care and usually to a vascular surgeon such as myself, who then will be able to say what other tests need to be done in order to further diagnose and treat the problem.
Host: How many people actually are diagnosed with an aortic aneurysm that actually knew they had a family history? Or is it more common that people don’t know, and they came in because they had some symptoms?
Dr. Lala: Yeah, actually that’s a very good question. But most commonly, what I tend to see and what is happening currently is that most people actually do not know that they have an abdominal aortic aneurysm. It’s a silent disease. And most people who get diagnosed with the abbreviation is a triple A, AAA, an abdominal aortic aneurysm, is because it’s been picked up incidentally. So, nowadays, because of the advanced technology, people are getting CT scans for various other reasons and they will pick up an abdominal aortic aneurysm for one reason or the other. And then they usually get referred to specialist care that way. But there is a minority of patients obviously and this is part of the reason for having this podcast is to spread awareness is that if you do have a family history, yes, you could actually present earlier and actually have these screening ultrasounds done if you do have a family history.
Host: Right. So, what are some of the symptoms of a AAA? What are some of the things that people might want to be aware of, especially if they do have that family history, maybe there’s an issue, maybe it’s growing? Are there things that the body is telling us that we need to go seek help?
Dr. Lala: Yes, so, again, unfortunately most patients who have an abdominal aortic aneurysm, they are asymptomatic which means that they have no symptoms. And they just grow the size and then they come to a certain size where we deem it necessary to fix. If patients have sudden onset abdominal pain or tearing back pain; that usually is a sign that the aneurysm has started to leak or started to rupture. Now, in a patient who has a known abdominal aortic aneurysm and they have sudden onset of abdominal pain or back pain; you would definitely need to present to the emergency room immediately because that would indicate that something is going wrong with your aneurysm. In patients who again, this is the majority, who have no history of having been diagnosed with a AAA and has sudden onset of abdominal or back pain; they usually present to the emergency room because they are having problems and then when they get further workup done, we find out that they have a ruptured abdominal aortic aneurysm. So, I think basically, if as a patient, you think you are like I said, have a family history and get diagnosed with an abdominal aortic aneurysm or you have been incidentally diagnosed with an abdominal aortic aneurysm and are being followed by your surgeon or your primary care doctor; if you suddenly started developing abdominal pain; you definitely want to seek medical care urgently.
Host: Right, right. And so, let’s move into how this is actually treated. Is there – when we talk about - because you have mentioned this before, the size of the aneurysm. Is there a certain size that it can grow to that at that point someone like you a surgeon would say heh we need to go in and fix that?
Dr. Lala: Yes, absolutely. And so, the normal abdominal aorta measures approximately two centimeters in size. And so, when the aorta gets to about three centimeters, that’s when we say it is starting to look aneurysmal, but we don’t have to fix it right at that point. Really for us as surgeons, the risk versus benefits of repairing an aneurysm tends to become more apparent once the aneurysm reaches in males, 5.5 centimeters and in females it’s 5.0 centimeters. So, usually, at that point, at that size criteria; we would advocate for repair of the aneurysm.
Host: And what exactly – how is it repaired basically? What is the surgery like? What is done? And how successful is the surgery?
Dr. Lala: Yeah, so, nowadays, again, most abdominal aortic aneurysms, if you take all comers in the population, most of them have what we call as an infrarenal abdominal aortic aneurysm. That basically means that the aneurysm is located below where the arteries to the kidneys come off and that kind of anatomy is present in more than 95% of patients again, all comers who have these AAAs. And so, because of the technology that we have these days; those aneurysms can be fixed by minimally invasive means, which is what we call an endovascular aneurysm repair. Those surgeries can be done with specialized stent grafts that are manufactured by a variety of companies that we have access to and depending on the patient’s anatomy, the size of the aneurysm and certain other measurements that we take with specialized software; we can select the appropriate stent graft to appropriately fix the aneurysm for that patient and usually that’s done within a couple of hours and usually the patients go home the next day.
Host: And so that specifically is for the aneurysm that is below where the arteries to the kidneys come off of the aorta, correct? What about aneurysms that are higher up, maybe even into the chest, like a thoracic aortic aneurysm? Is it the same procedure?
Dr. Lala: It is a – the principles of the operation are the same. Again, so, I’ll just interject here that there are obviously – there is a way to fix the aneurysm which is through traditional open means which we are also very capable of doing; but again, in the interests of patients getting home sooner; we like to do endovascular aneurysm repairs if feasible. Now, for more complex aneurysms that involve the what we call visceral aorta which stands for the portion of the aorta that gives off the blood vessels to the intestines and the kidneys and then going up higher into the chest; there are more advanced stent grafts available and there are more advanced techniques available, which include again, this may be technical, but just so there are listeners you can use snorkels and also fenestrated repairs which some of these companies make fenestrated grafts or you can design your own fenestrated graft which we are also capable of doing here at GW. So, for these patients, again these tend to represent a rarer form of aneurysm. Again, like I said, most patients, greater than 95% of patients have an infrarenal which is below the kidneys, aortic aneurysm. For those patients who have these complex type aneurysms we are capable of also fixing them with endovascular means.
Host: So, again, just to reiterate, most people have the aneurysm below the arteries that come off to the kidneys and in those cases assuming it’s nonemergency, what is the success of the repair of those aneurysms? Do they have to go – come back at some point to get repaired again? Or do these kind of stents last a lifetime?
Dr. Lala: Yeah, they are actually very successful and there are some research studies out there that actually talk about the success rates of these endovascular repairs and as the technology continuously improves; the success rate improves as well. So, from a technical standpoint, at the time of the operation; the success rate of the operation is almost 100%, close to 100% because using CT scans and other specialized software to kind of accurately measure the aorta and to get the appropriate stent graft; we are able to fix the aneurysm. Now what happens is that as time goes on; we have to serially monitor these patients with CT scans to make sure that as the aorta grows and remodels, that the stent graft is still holding in place. So, if you look at the long-term success rate, even going out five to ten years; we are looking for basically leaks around the stent graft as the aorta tends to model in these patients and even then, the success rate is over 90%. And in those patients who do develop these small leaks, we are able to bring these patients back and able to repair them by putting additional components in or by using specialized techniques to kind of seal the stent graft into the aneurysm again.
Host: Got you. So, Dr. Lala, let’s end with this. What would you like the listeners to know about aortic aneurysms?
Dr. Lala: Yeah, so that’s a very good question. I think for our patients, one is to be aware of what an abdominal aortic aneurysm is and to know if you are at risk. So, again, if you are a male over the age of 65 and are a heavy smoker and have high blood pressure; then you are actually eligible for a screening ultrasound to make sure that you do or do not have an abdominal aortic aneurysm. If you are a patient who has a strong family history of an abdominal aortic aneurysm that you want to tell your primary care doctor that and get an ultrasound done to make sure that you don’t have one or have an aneurysm evolving within your abdomen. And then if you are incidentally discovered with an abdominal aortic aneurysm; to seek care with a specialist, such as a vascular surgeon who will be able to guide you through the process, order the appropriate steps and follow you because like I mentioned; just because you have an aneurysm does not mean that you need it fixed right away because our size criteria is 5 centimeters in a woman, 5.5 centimeters in a male and so, if you do have an aneurysm that’s smaller than that; then we will serially follow you over time with serial CAT scans and select the appropriate time for these to get fixed.
Host: Excellent summary Dr. Lala. I want to thank you for coming on the show today. You’re listening to The GW Hospital HealthCast. For more information, go to www.gwdocs.com, that’s www.gwdocs.com. I’m Dr. Mike Smith. Thanks for listening.