The specialist: Dr. Gabriele Di Luozzo on aortic aneurysms
Dr. Gabriele Di Luozzo is associate director of Mount Sinai Hospital’s Aortic Aneurysm Program, one of the largest of its kind in the U.S., overseeing 150 to 200 complex aortic operations every year.
Who’s at risk
An aneurysm is a general term that doctors use when part of an artery widens or balloons out as the result of weakness in blood vessel walls, an event which can occur anywhere in the body.
“A thoracic aortic aneurysm is an aneurysm or ballooning of the aorta that is confined to the chest cavity,” says Di Luozzo. “If left untreated, large aneurysms can lead to rupture and death.” About 10,000-20,000 Americans are diagnosed with thoracic aortic aneurysms each year.
There are about 3,000 new cases of acute aortic dissections diagnosed every year, although this number may underestimate the true number of people affected by the disease.
An acute aortic dissection occurs when the inner lining of the aorta separates from the other layers of the aortic wall, creating a new passageway for blood. This immediately weakens the aorta and can lead to death.
Who’s at risk
The most common causes of thoracic aortic aneurysms are high blood pressure, smoking and genetics. “These aneurysms are more common in men than in women, and usually occur in the sixth or seventh decade of life,” says Di Luozzo.
“However, patients with the genetic predisposition can develop thoracic aortic aneurysms as early as adolescence or early adulthood,” says Di Luozzo.
Patients known to have an abnormally developed aortic valve are at a higher risk of developing the condition.
Signs and symptoms
Thoracic aortic aneurysms catch most patients completely off guard.
“Unfortunately, the majority of aneurysms are silent and grow undetected for many years,” says Di Luozzo. “Usually they’re found incidentally, when the patient has an imaging study for a different medical condition.”
Most of these aneurysms are detected by a chest X-ray, echocardiogram or CT scan. CT scans or MRIs are considered the most precise methods of evaluating the aneurysm. In some cases, patients develop symptoms that are fairly unspecific to the aneurysm.
“Patients can have dull chest pain, shortness of breath, back or abdominal pain,” says Di Luozzo. “Occasionally they develop a change in the character of their voice.” The symptoms of aortic dissections are very similar to having a heart attack. Doctors hope that in the future they will be able to pinpoint who is at risk, but currently most diagnoses remain incidental.
Treatment options depend on the aneurysm’s size, location and underlying cause, as well as the patient’s age and general health.
“The majority of patients can be treated medically by controlling their blood pressure, avoiding strenuous activities and lowering their cholesterol,” says Di Luozzo. “A key to recovery is to stop smoking, in order to reduce the likelihood the aortic aneurysm will expand.”
Patients with large aneurysms have the option of open surgery or endovascular stents. “In surgery, the portion of the aorta where the aneurysm is located is removed and replaced with a synthetic tube to reconstruct the aorta,” says Di Luozzo.
“In the endovascular procedure, the stent is placed using a catheter that travels to the aorta through an artery in the leg,” he says. The stent provides the aorta with a new lining. Modern aneurysm surgery and endovascular stenting approaches to thoracic aortic aneurysms are safe.
“The risk depends on the location of the aneurysm, the extent of damage to the aorta, age of the patient, and complicating medical problems,” says Di Luozzo.
“Surgical risk can be as low as 2%-3% or as high as 5%-8%; for the endovascular procedure it’s about 5%.”
However, not having surgery can carry an even higher risk of thoracic aortic aneurysms rupturing. “An aneurysm with a 6-centimeter diameter has a 10% risk of rupture per year,” says Di Luozzo. “Larger thoracic aortic aneurysms have a 50% rupture risk within three years if untreated.” Surgery and endovascular procedures are very effective at preventing ruptures.
The only follow-up required of patients is a yearly checkup with CT scan or MRI and continued efforts to manage blood pressure and cholesterol. Patients with aortic aneurysms that are not large enough to need immediate repair should be seen at an aortic center regularly and have a CT scan or MRI. A formal aortic surveillance program, like Mount Sinai’s, specializes in monitoring and repairing patients’ aneurysms safely.
“Our research has allowed us to improve the protection of the brain and spinal cord during these particular operations,” says Di Luozzo.
“We’re also gathering more information regarding the genetic component of thoracic aneurysms — which we hope will help us determine better who may be at risk.”
Additionally, thousands of patients, over the last decade, have benefited from the advancement of catheter-based treatments of thoracic aortic aneurysms and dissections.
Questions for your doctor
If you’re diagnosed with a thoracic aortic aneurysm, the first question to ask is, “Can my aneurysm be treated medically?” If your aneurysm does require intervention, ask “Is open surgery or an endovascular procedure my best option?”
Because the surgeon’s experience level can make a huge difference, be sure to ask, “How many of my procedures do you perform a year?”