Transcription:
Spotting and Treating Aortic Aneurysms

Melanie Cole (Host): For patients with aortic aneurysms, symptoms often don’t begin until the aneurysm ruptures, which can be fatal for patients. My guest is Dr. Ravi Ghanta. He’s a board certified surgeon who specializes in caring for patients who need heart surgery, including patients with aortic aneurysms. Welcome to the show, Dr. Ghanta. What is an aortic aneurysm?

Dr. Ravi Ghanta (Guest): Well, thank you, Melanie. Thank you for having me on your program. An aortic aneurysm is an enlargement of the aorta that is one and a half times its normal size. I don’t know if everyone knows, but the aorta is the largest blood vessel in the body. It extends from the heart all the way down to the abdomen. The feared complication of an aortic aneurysm is that it may burst or tear. We call bursting a ruptured aneurysm, and we call tearing an aortic dissection. Larger aneurysms are more at risk for bursting or tearing, and when it happens, the outcomes can be poor. So our goal as doctors is to prevent this from happening. We characterize aortic aneurysms based on their location in the body. I kind of think when I talk about the aorta, I describe it as shaped like a candy cane and a short stalk emerges from the heart, and that short part of the candy cane is called the ascending aorta, and this gives rise to arteries to the heart, actually. The curve of the candy cane is called the aortic arch, and this gives rise to the blood vessels, to the shoulder, to the arms, and the head. The long stalk of the candy cane is called the descending aorta, and the descending aorta is also divided into the chest and the abdomen. The chest portion is called the thoracic aorta, and the abdominal portion is called the abdominal aorta. The diagnosis and management of aortic aneurysms really depend on where in the body the aneurysm is located.

Melanie: Okay. Who is at risk? Are there certain risk factors controllable and maybe non-controllable for aortic aneurysm?

Dr. Ghanta: There are. Older patients or elder folks are definitely more of a risk for aortic aneurysm. They do develop over time. Patients with a long-standing history of high blood pressure or hypertension are at risk for developing aortic aneurysms. Patients who have a long history of smoking are at risk for developing aortic aneurysm. And certain aortic aneurysms tend to reign in families, so if you have someone in your family who’s had an aortic aneurysm, or multiple family members who’ve had an aortic aneurysm, you’re at a higher risk for having one yourself. Patients who have connective tissue disorders, such as Marfan’s disease, Ehlers-Danlos syndrome, Loeys-Dietz syndrome. And these are rarer conditions, but they are definitely genetic conditions that run through families. Other patients have what’s called a bicuspid aortic valve or an abnormal aortic valve, where a normal aortic valve, which is a valve in the heart, has three leaflets. A bicuspid aortic valve only has two leaflets, and patients who have those tend to also have aortic aneurysms. So, those type of patients who are elderly, who smoke, who have long-standing history of hypertension, or who have had other family members with aortic aneurysms, they are at an increased risk of having an aneurysm themselves.

Melanie: Are there some symptoms, Dr. Ghanta -- so that people are afraid as you discuss a tear or rupture, are there some symptoms that would send us to see a doctor that could catch this before that happens?

Dr. Ghanta: There are, but unfortunately, most aortic aneurysms are asymptomatic or have no symptoms. They often are identified incidentally. For example, often they’re identified when a patient needs to have another procedure and gets a chest x-ray just in preparation for that procedure—say, they have any shoulder operation, or a knee operation, and then on the chest x-ray, their aorta looks a little big. That’s how they’re identified as having aortic aneurysm. That’s often why that the first presentation is either bursting or tearing, which can be problematic. But some people do have symptoms with aortic aneurysm, and pain is a common symptom in those that have symptoms. Pain can be either in the chest or in the back or in the abdomen. Some patients have symptoms of a cough, unexplained cough, and that’s due to the aneurysm compressing on their airway. Some patients present with a change in their voice. They have a hoarse voice, and that’s because the aneurysm is compressing on the recurrent laryngeal nerve, which supplies the vocal cord. Symptoms of pain, cough, hoarse voice are associated with aortic aneurysm. That could also be due to other things, but they are associated with aneurysms. But a lot are asymptomatic.

Melanie: If someone does come to see you, how does this get identified? Are there certain tests?

Dr. Ghanta: There are multiple different tests. The best test is a CAT scan. It’s a two-dimensional, cross-sectional image of the body so you can see the aorta and its entirety and you can measure its size along the entire extent. And so, CAT scans are the best measurement, and they’re non-invasive, but they do involve some radiation. At present, we don’t use them as screening tests per se, unless there’s a high suspicion for an aneurysm based on risk factors or any symptoms. Other tests, as I mentioned earlier, many patients are noted to have an aneurysm on chest x-rays, so you can identify them on x-rays. Ultrasounds are also useful for identifying aneurysms. You can get an ultrasound of the heart, which does look at the initial portion of the aorta, and if that can detect enlargement, and we use ultrasounds of the heart as screening tools for aortic aneurysm to certain people, specifically people with connective tissue disorders, because they tend to have aneurysms formed at the early part of the aorta, which can be easily seen with the ultrasound of the heart. It’s also called an echocardiogram. Patients who have abdominal aortic aneurysms can also be evaluated with ultrasound at the abdomen, where the aorta can be well visualized. Unfortunately, the ultrasound cannot be used to see very well the aneurysms that involve the arch or the descending thoracic aorta. So, to identify those, we have to use a CT scan.

Melanie: So what are some treatment options? If someone comes in, they’ve been diagnosed with an aortic aneurysm, what do you do for them?

Dr. Ghanta: Well, when we see, identify an aortic aneurysm, the first thing that has to be done is optimal medical management. We have to maintain good control of a patient’s blood pressure, and we have to make sure they’re on appropriate medications. The appropriate medications include a class of medications called beta blockers. Some common ones are Metoprolol or Lopressor and ACE inhibitor. A common one is Lisinopril. These medications control the blood pressure and also alters the way the aorta remodels, and both those things, we believe, will reduce the rate of growth of aortic aneurysms. So it’s important when someone has identified to have an aortic aneurysm, as we have to determine the size and location and extent of the aneurysm. If the aneurysm is not large enough for us to recommend an invasive treatment, we optimize the medical management and then surveillance of the aneurysm over time. So the doctor may say, “You have an aneurysm. It measures 3.7 centimeters. It’s not large enough to require surgery or any intervention. We’ll keep your medication under optimal control, and we’ll reimage you in three months or six months.” So, surveillance. Now, when aneurysm’s either enlarged or they enlarge further or they’re already big when we identified them, then we may opt for an interventional treatment. And the intervention does depend on where the aneurysm is located, and there are really two types of interventions we do. One is open surgery, and it’s a big but safe operation. It involves the ascending aorta. It involves an incision through the breastbone, and it will be open heart surgery with the heart-lung machine, where the enlarged aorta is removed and a new aorta that’s consisted of a fabric tube is sewn in its place. If it’s an aneurysm that involves the descending thoracic aorta, surgery can be done through the ribs. And that also is a big, big operation, but it’s safe and involves replacement of the abnormal aorta with the fabric tube. Depending on the exact anatomy and location, we typically deal with descending thoracic aneurysms with a catheter-based approach, where we go through the groin with a catheter and put in a stent with a stent graft into the groin up into the descending thoracic aorta and cover the aneurysm with the stent graft. That is an evolving technology that we use quite frequently now in descending thoracic aneurysms.

Melanie: Dr. Ghanta, in just the last minute, please tell us why patients should choose UVA for their aneurysm care.

Dr. Ghanta: Well, UVA has a long history in management of complex aortic and cardiovascular disease. We have taken care of patients with connective tissue disorders such as Marfan’s and complex aortic aneurysms that involve virtually the entire aorta. We’re fortunate to have a multidisciplinary team here at UVA consisting of medical cardiologists who specialize in the treatment of aortic conditions and medically genetic team, which can help evaluate aneurysms that run in families and help identify other members of your family that might be at risk for aortic aneurysms. We have interventional radiologists who are really at the forefront in pioneering new interventional techniques that reduce the invasiveness of aneurysm procedures. We have vascular surgeons who also do open surgery and endovascular surgery, and we have heart surgeons who do complex aortic surgery. And so, this multidisciplinary team allows us to tailor treatments individually for patients, and really, we’re pioneering new techniques for the entire country in terms of using this new endovascular and open techniques.

Melanie: Thank you so much, Dr. Ravi Ghanta. You’re listening to UVA Health Systems Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thank you so much for listening. Have a great day!