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Aortic Branch Aneurysms

by John W. Hallett, Jr., MD

Aneurysms may occur in any major aortic branch; such aneurysms are much less common than abdominal or thoracic aortic aneurysms.

Risk factors include atherosclerosis, hypertension, cigarette smoking, and older age. Localized infection can cause mycotic aneurysms.

Subclavian artery aneurysms are sometimes associated with cervical ribs or thoracic outlet syndrome.

Splanchnic artery aneurysms are uncommon. About 60% occur in the splenic artery, 20% in the hepatic artery, and 5.5% in the superior mesenteric artery. Splenic artery aneurysms occur in more women than men (4:1). Causes include medial fibromuscular dysplasia, portal hypertension, multiple pregnancies, penetrating or blunt abdominal trauma, pancreatitis, and infection. Hepatic artery aneurysms occur in more men than women (2:1). They may result from previous abdominal trauma, illicit IV drug use, medial degeneration of the arterial wall, or periarterial inflammation. Renal artery aneurysms may dissect or rupture, causing acute occlusion (see Acute renal artery occlusion).

Symptoms and Signs

Symptoms vary. Subclavian aneurysms can cause local pain, a pulsating sensation, venous thrombosis or edema (due to compression of adjacent veins), distal ischemic symptoms, transient ischemic attacks, stroke, or hoarseness or impaired motor and sensory function (due to compression of the recurrent laryngeal nerve or brachial plexus). Superior mesenteric aneurysms may cause abdominal pain and ischemic colitis.

Regardless of location, mycotic or inflammatory aneurysms may cause local pain and sequelae of systemic infection (eg, fever, malaise, weight loss).

Diagnosis

  • Ultrasonography or CT

Most aortic branch aneurysms are not diagnosed before rupture, although calcified asymptomatic or occult aneurysms may be seen on x-rays or other imaging tests done for other reasons. Ultrasonography or CT is typically used to detect or confirm aortic branch aneurysms. Angiography can be used as needed to evaluate distal symptoms thought to be due to the aneurysm or embolism.

Treatment

  • Open repair or sometimes endovascular stent grafting

Treatment is surgical removal and replacement with a graft. Endovascular repair is an option for some patients. The decision to repair asymptomatic aneurysms is based on risk of rupture, extent and location of the aneurysm, and perioperative risk.

Surgery for subclavian artery aneurysms may involve removal of a cervical rib (if present) before repair and replacement.

For splanchnic aneurysms, risk of rupture and death is as high as 10% and is particularly high for women of childbearing age and for patients with hepatic aneurysms (> 35%). Elective repair of splanchnic aneurysms is therefore indicated for women of childbearing age, for symptomatic aneurysms in other age groups, and for hepatic aneurysms. For splenic aneurysms, repair may consist of ligation without arterial reconstruction or aneurysm exclusion and vascular reconstruction. Depending on location of the aneurysm, splenectomy may be necessary.

Treatment of mycotic aneurysms is aggressive antibiotic therapy directed at the specific pathogen. Generally, these aneurysms must also be surgically repaired.

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