About 70% of peripheral arterial aneurysms are popliteal aneurysms; 20% are iliofemoral aneurysms. Aneurysms at these locations frequently accompany abdominal aortic aneurysms, and > 50% are bilateral. Rupture is relatively infrequent, but these aneurysms may lead to thromboembolism. They occur in men much more often than women (> 20:1); mean age at presentation is 65. Aneurysms in arm arteries are relatively rare; they may cause limb ischemia, distal embolism, and stroke.
Infectious (mycotic) aneurysms may occur in any artery but are most common in the femoral. They are usually due to salmonellae, staphylococci, or Treponema pallidum (which causes syphilitic aneurysm).
Common causes include atherosclerosis, popliteal artery entrapment, and septic emboli (which cause mycotic aneurysms).
Peripheral arterial aneurysms are usually asymptomatic at the time of detection. Thrombosis or embolism (or rarely, aneurysm rupture) causes extremities to be painful, cold, pale, paresthetic, or pulseless. Infectious aneurysms may cause local pain, fever, malaise, and weight loss.
Diagnosis is by ultrasonography, magnetic resonance angiography, or CT. Popliteal aneurysms may be suspected when physical examination detects an enlarged, pulsatile artery; the diagnosis is confirmed by imaging tests.
Risk of rupture of extremity aneurysms is low (< 5% for popliteal and 1 to 14% for iliofemoral aneurysms). For leg artery aneurysms, surgical repair is therefore often elective. It is indicated when the arteries are twice normal size or when the patient is symptomatic. However, surgical repair is indicated for all arm artery aneurysms because serious complications (eg, thromboembolism) are a greater risk. The affected segment of artery is excised and replaced with a graft. Limb salvage rate after surgical repair is 90 to 98% for asymptomatic patients and 70 to 80% for symptomatic patients.
Types Of Aneurysms
Although aneurysms can occur in any blood vessel, artery or vein, three areas are responsible for most serious aneurysms.
These areas include:
- Abdominal aorta
- Brain arteries
- Heart and thoracic aorta.
In older people, most aneurysms develop because the arteries have been weakened by years of atherosclerosis. High blood pressure (which puts added pressure on arteries) and cigarette smoking (which can damage arteries) make aneurysms more likely to develop. High blood pressure also tends to make existing aneurysms enlarge and sometimes rupture.
Often, aneurysms do not produce symptoms until just before they rupture.
Before an abdominal aortic aneurysm ruptures, a pulsing sensation may be felt in the abdomen. Typically, when the aneurysm begins to rupture, pain is first felt as a deep, penetrating pain in the back or abdomen. The area over the aneurysm may become tender. As the rupture progresses, it often causes sudden, excruciating pain in the lower abdomen and back. If the resulting internal bleeding is severe, the person rapidly goes into shock, often losing consciousness and collapsing. Sometimes an aneurysm causes mild pain in the back or abdomen that comes and goes. The pain is usually caused by a series of small ruptures that become covered with blood clots.
Thoracic aortic aneurysms may become very large without causing symptoms. Symptoms vary but can include pain (usually high in the back), coughing, and wheezing. Rarely, a person coughs up blood if an aneurysm presses on an airway wall, causing it to break down. Swallowing may be difficult and hoarseness may develop if an aneurysm presses on the lower part of the throat.
Rupture of a thoracic aortic aneurysm usually causes excruciating pain high in the back. The pain may radiate down the back and into the abdomen as the rupture progresses. Pain may also be felt in the chest and arms. Internal bleeding may cause the person to rapidly go into shock.
Usually, aneurysms in arteries in the limbs do not cause pain unless they rupture, and they rupture much less often. But if blood clots develop and part of the clot breaks off and blocks a small artery, the skin over areas beyond the blockage may become pale and cool. If the blockage persists, gangrene may develop in the limb, which sometimes must be amputated.
Controlling blood pressure as closely as possible with drugs can help prevent an aneurysm from enlarging. Beta-blockers, which decrease the force of the heart's contraction, are particularly useful.
Whether surgery to repair or remove an unruptured aortic aneurysm is advisable depends on which risk is greater: the risk of surgery or the risk of aneurysm rupture. For example, if an abdominal aortic aneurysm is larger than 2 inches (5 centimeters) wide and the person is otherwise in good health, surgery is usually necessary. Surgery is also done if the aneurysm causes pain.
For an unruptured abdominal aortic aneurysm, surgery to repair the aorta may be done. It often involves making an incision into the abdomen and inserting an artificial tube (graft) inside the aorta without removing the aneurysm. This procedure prevents rupture of the aneurysm. For an unruptured thoracic aortic aneurysm, the aneurysm must be surgically removed through an incision in the chest.
Surgery to repair aneurysms has risks. The average chance of dying during repair of an abdominal aortic aneurysm is about 1 in 20. Certain conditions increase the chance of death during surgery. They include older age and heart, lung, or kidney disorders (which are common among people with aneurysms). For people without any of these conditions, the chance of death is about 1 in 50. Surgery to remove thoracic aortic aneurysms can be comparably risky.
A new, nonsurgical technique (called endovascular repair) can be used to repair unruptured abdominal aortic aneurysms. After numbing the insertion site with a local anesthetic, the doctor inserts an artificial tube into an artery near the top of the leg and guides it into the aneurysm. The tube is similar to the one inserted during surgery, but it is collapsed, so that it can fit into a blood vessel. Once inside the aneurysm, the tube expands, forming a new channel for blood flow. This technique appears to be effective.
If an aneurysm causes pain, surgery is usually necessary because rupture is very likely. If an abdominal or thoracic aortic aneurysm ruptures, the only chance for survival is emergency surgery. The goal of emergency surgery is to replace the ruptured part of the aorta with a graft. Even with surgery, rupture of an abdominal or a thoracic aortic aneurysm is fatal more than half of the time. Death often results from loss of blood.
Leg artery aneurysms, whether ruptured or not, are usually repaired surgically. The risk of death during surgery is slight, and if surgery is not done, the risk of losing the leg is high because clots can form and block blood flow.
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