
What is an aortic aneurysm?
The aorta is the largest artery in the human body, responsible for transporting blood and oxygen to various organs, including the upper and lower extremities.
When the diameter of the aorta increases, the aorta has an aneurysmal dilatation or, more simply, develops an aortic aneurysm (usually more than 3 cm). The aorta is divided into the ascending aorta, the aortic arch, the descending thoracic aorta, and the abdominal aorta. Any of these segments can develop an aneurysm.
Similar aneurysms can also form in the iliac arteries, which receive blood from the abdominal aorta and direct it to the pelvis and the lower extremities.

Causes and factors leading to an aneurysm
The main factors responsible for the development of an aneurysm are:
- smoking,
- hypertension,
- atherosclerosis
- family history.
Family history of aortic aneurysm is a strong risk factor of developing an aneurysm. Thus, men and women with family history of aortic aneurysm should be screened to evaluate for aneurysm development.
Other causes include infections, inflammatory reactions, autoimmune diseases, and trauma.
Diagnosis
In recent years, with screening ultrasound in high-risk patients, we are able to diagnose aneurysmal disease of the abdominal aorta promptly. Patients 65 and older, especially those with a history of smoking, should undergo a preventive ultrasound examination. Also, if someone has a first degree relative with an aortic aneurysm they should have an ultrasound scan to rule out the presence of an aneurysm.
Quite often the abdominal aortic aneurysm is diagnosed incidentally in an imaging test (computed tomography, magnetic resonance imaging, x-ray) that the patient has undergone for other reasons.

Abdominal aortic aneurysm (Computed Tomography Scan)
Most aneurysms do not cause any symptoms. Larger aneurysms may present as a pulsating mass in the abdomen.
Symptomatic aneurysm with impending rupture and ruptured aneurysms present with severe abdominal or lower back pain and hypotension. These situations are life-threatening emergencies that must be treated immediately by a Vascular Surgeon.
Treatment
The aneurysms do not shrink or go away without surgical intervention. They grow slowly so it is important to monitor them closely.
The appropriate treatment of abdominal aortic aneurysms depends mainly on the size. Surgery is usually chosen for aneurysms between 5 and 5.5 centimeters in size. The rate of increase, the morphology as well as the underlying cause of aneurysm growth are also taken into consideration so that it can be treated appropriately. Aneurysms with a rapid rate of increase in size and aneurysms with a saccular morphology may need to be treated before they reach 5 cm. Patient’s status and comorbidities are also important factors of the decision making process.
For aneurysms smaller than 5 cm, follow-up with imaging such as ultrasound/aortic triplex or computed tomography is recommended. The interval between surveillance is determined by the size of the aneurysm.
Avoiding smoking, controlling blood pressure with appropriate diet and medications, and also improving cardiovascular risk with aspirin and lipid-lowering drugs are significant interventions in conservative management that may slow aneurysm progression.
When surgical treatment is chosen, each patient undergoes an imaging test with CT or MRI. The majority of aneurysms are now treated with endovascular stent graft placement. In some cases, the open method is preferred, especially in younger patients. If endovascular repair is not feasible, the aneurysm is treated with the traditional open method, with aneurysm resection and placement of a synthetic graft.
Endovascular treatment of abdominal aortic aneurysm (EVAR)
Prior to surgery, the patient undergoes a CT scan (CT angiography unless there is renal insufficiency) to analyze aneurysm characteristics and choose a suitable stent graft.
The procedure is performed under general anesthesia with bilateral femoral artery puncture for access. In some cases, small incisions in the groin area may be necessary. Special endovascular wires and catheters are used with the aid of fluoroscopy and contrast injection to precisely position the stent graft and exclude the aneurysm. The patient is typically mobilized around 3-6 hours after the procedure, and hospital stay lasts one to two days.
After discharge, a gradual return to daily activities is recommended, avoiding heavy lifting. Driving is also discouraged for approximately two to three weeks. The patient visits the clinic 10 days postoperatively, and imaging with CT is performed one month after the intervention.
The advantages of the method and potential complications are discussed in detail with the patient during clinic visits before surgical intervention.
Endovascular repair of abdominal aortic aneurysm- Computed tomography Angiography 1 month postoperatively

Open repair of abdominal aortic aneurysm
In such cases where open reconstruction is chosen, the patient undergoes a pre-operative check-up with cardiology and pulmonary assessment.
Open repair involves a mid-abdominal incision, resection of the aneurysm, and placement of a synthetic graft. The patient then remains in the hospital for about four to six days, while full recovery and return to basic activities takes one and a half to two months.
The advantages of the method and potential complications are discussed in detail with the patient during clinic visits before surgical intervention.
Patients with renal failure and abdominal aortic aneurysm
Patients with renal failure and abdominal aortic aneurysm are carefully managed to protect their kidney function. Modern methods to avoid exposure to the contrast agent (such as CO2 injections and intravascular ultrasound) are being used to prevent further kidney damage.

Endovascular repair of a large abdominal aortoiliac aneurysm with EVAR and iliac branch device
