Methods for Aortic Aneurysms Diagnosis - Essay Example

Aortic Aneurysms Modern treatment of aortic aneurysms began in the early 1930's. And much ado has occurred over the issue in regards to aortic aneurysms per se in the last three decades. Controversy has sprung up in the manner of diagnosing it clinically, confirmation for the establishment of a pre-operative diagnosis, its etiology and pathogenesis, its methods of surgical treatment and its probable outcome after surgery. Diagnosis at present is based on the clinical history, and the physical examination findings of the examiner. Confirmation of the diagnosis is made easier by the more sensitive, specific and accurate imaging techniques of our times. In its pathogenesis, articles have shown no sole explanation for its occurrence. And in its management, several studies have shown that the newer endovascular repair is much preferred over the conventional open surgery for practical and scientific reasons. Without trying to look like a meta-analysis, I have searched the World Wide Web for articles on this disease entity. And my purpose in doing this is to evaluate the advantages and disadvantages of the methods for its diagnosis, its indications for surgery, methods of surgery, and general outcome after treatment. Introduction An aneurysm in its most simple definition is a localized dilatation of an artery involving an increase in its diameter of at least 50 percent in comparison to its original normal diameter. Anatomically, it often represents a weakness in the wall of the artery at any given segment of the aorta. It is noted that there is an increasing incidence of aortic aneurysms lately. Hence, there is also a trend in seeking better methods for diagnosing and treating this pathology. Without trying to look like a meta-analysis, I did an on-line systematic Medline and PubMed search and then reviewed the retrieved articles on the diagnosis, pathogenesis, treatment and current management of aortic aneurysms. The purpose of this paper is to evaluate the advantages and disadvantages of the methods for its diagnosis, its indications for surgery, methods of surgery, and general outcome after treatment. Review of the Literature The dilatation in the aorta in aneurysms may be located either in the thoracic or abdominal part of the aorta. Just for the purpose of discussion in this paper, I shall classify aortic aneurysms based on their location, since these may appear elsewhere. If the dilation appears on the aortic root they are called aortic root aneurysm. If the dilatation is found in the thoracic aorta, they are called thoracic aortic aneurysms. Aneurysms are also classified based on their location in the thoracic segments of the thoracic aorta; hence we may have an ascending, an arch aneurysm or a descending thoracic aneurysm. Aneurysms found after the descending segment is termed abdominal aortic aneurysm. In the physical examination for suspected aortic aneurysm, the only maneuver of demonstrated value is abdominal palpation to detect abnormal widening of the aortic pulsation. Palpation appears to be safe and has not been reported to precipitate rupture. The diagnosis of aortic aneurysms is confirmed based on findings with ultrasonography or computerized tomography. There is limited data to suggest that abdominal obesity decreases the sensitivity of palpation. Abdominal palpation specifically directed at measuring aortic width has moderate sensitivity for detecting an aneurysm that would be large enough to be referred for surgery but cannot be relied on to exclude aortic aneurysm, especially if rupture is a possibility. The role of genetic factors influencing familial aggregation of aortic aneurysms has also been reviewed. Aortic aneurysms, particularly the thoracic ones, and those in association with multiplex pedigrees represent a new risk factor for aneurysm growth. Pedigree analysis suggests genetic heterogeneity. The primary mode of inheritance seems to be autosomal dominant, but X-linked dominant and recessive modes are also evident. In the past, aortic aneurysms have been characterized as being atherosclerotic, but this view is not that accepted since there is little support for atherosclerosis as the sole cause in view of recent observations that suggest a multifactorial etiology. The population affected most is the geriatric age group but these aneurysms may occur at any age. Surgery is the only effective known treatment and must be performed before the risk for rupture increases. Many investigators have focused on the relationship of size of the aneurysm and increasing rate to the risk of rupture. Known risks factors for rupture included the initial diameter of the aneurysm, hypertension, and the presence of chronic obstructive pulmonary disease. Lately, there have been advances from the conventional open surgery to the newer endovascular surgery techniques. Mortality and morbidity rates are also different now in comparison to early 50's when modern treatment of aortic aneurysms began. Again, this paper is not a meta-analysis. It just wishes to evaluate the advantages and disadvantages of the methods for its diagnosis, its indications for surgery, types of surgical technique, and general outcome after treatment. Discussion Literature shows that there is no one sole concept in the pathogenesis of aortic aneurysms. Studies have shown that several factors such as familial clustering, genetically predisposed and acquired biochemical alterations in the structural matrix of the aortic wall, and hemodynamic mechanical factors appear to have an important role (Brophy, 1991, p. 653-57; Cohen, 1987, p. 355-58; Johansen 1986, p. 1934-36; Sumner, 1970, p. 459-66; Webster, 1991, p. 366-72). Also stated in these articles is that pathogenesis is not simply a complication of atherosclerosis. Atherosclerosis per se may, as a matter of fact represents a secondary and non-specific response to vessel-wall injury. Its immediate diagnosis so as to decide on a prompt intervention is one of the keys to a low mortality rate. As early as 1984, 2 reports from the Mayo Clinic documented a "threefold increase from 12.2 per 100,000 to 36.2 per 100,000 during the three decades from 1951 through 1980" (Melton, 1984, p. 379-86 & Bickerstaff, 1984, p. 6-12). Literally, there were people from the geriatric age group who would suddenly collapse and end up dead on the emergency room. Autopsy findings would show ruptured aortic aneurysm in most cases. Therefore, much ado over the entity of aneurysms became obvious hence studies sprung up left and right. Looking into the familial predesposition of aortic aneurysms, Coady, Davies, Roberts, Goldstein , Rogalski, Rizzo, Hammond, Kopf, & Elefteriades (1999) wanted to provide evidence that genetic factors contribute to the development of thoracic aortic aneurysms (TAA) by demonstrating familial patterns of the disease. They did a retrospective hospital-setting case analysis of 598 patient's records which showed that they were evaluated and treated for TAA in a period range of 13 years. The records were examined for statistical differences loking at variables such as 1.)age of the patient, 2.) aortic size at the time of diagnosis, 3.) growth rates of the aneurysm, and 4.) rates of present concomitant diseases. Non-syndromic family pedigrees were also analyzed and possible modes of inheritance were determined. The study documented the role of genetic factors influencing familial aggregation of TAA. Thoracic aortic aneurysms in association with multiplex pedigrees represent a new risk factor for aneurysm growth. Genetic heterogeneity was sugegsted by the pedigree analysis. In conclusion, the authors stated that the autosomal dominant mode seemed to be its primary mode of inheritance, but X-linked dominant and recessive modes were also evident. Now, let me discuss the value of abdominal examination in the diagnosis of aortic aneurysms. A study was done by Venkatasubramaniam, Mehta, Chetter, Bryce, Renwick, Johnson, Wilkinson, & McCollum (1991) to determine the value of abdominal examination in cases of abdominal aortic aneurysms. The article suggested that "there is considerable variability in the reported value of clinical examination in the diagnosis of aortic aneurysms made by a physician, a nurse of felt by the patient himself." A total of 164 patients with a median age of 71 years, consented to participate in this prospective, single blind, controlled study. Thirty-nine patients attending for carotid duplex were used as controls. Abdominal examination was performed by a doctor and a nurse. After which, patients then performed self-examination. The authors of the study concluded that examination by a physician, a nurse followed by the patient himself is of value in the exclusion and diagnosis of significant aortic aneurysms. The examination should be done as early as possible so as to screen for possible aneurysm then followed by ultrasonography for confirmation. Another article (Lynch, 2004, p. 99-107) emphasizes on the importance of an early examination specifically for an abdominal aortic aneurysm. The physical examination per se is assessed and then compared to the cold standard for diagnosis i.e. ultrasonography. The author states that even if the physical examination (PE) per se has a sensitivity rate at 33 to 100% and a specificity of 75 to 100%, PE alone cannot be used to exclude the suspicion for an aortic aneurysm since the rate differs variably for obese and slim patients. Furthermore, detection rates are increased when there are other risk factors present such as increased dilation size, the patient being a male, the elderly, increasing age and even the experience of the examiner. Following the golden standard of ultrasonography for aortic aneurysm confirmation, anther article (Catalano, 2005, p.423-37) described the contrast-specific sonography features of ruptured abdominal aortic aneurysm, and they hypothesized that the technique would be useful for emergency imaging of patients with suspected aneurysm rupture. They found out that a contrast-enhanced sonography revealed features specific for ruptured aortic aneurysm early, thus causing no significant delay in surgery. This technique according to them may be as effective as computerized tomography but is definitely more rapid and noninvasive. Aortic aneurysms are common in the geriatric age group and are shown to be a frequent cause of sudden death. When diagnosed early, an elective aneurysm repair drastically lowers the mortality rate than those cases associated with rupture. Thus, emphasis was placed on early detection and repair. Recent advances in diagnosis include ultrasound screening for asymptomatic aortic aneurysm and clinical trials on the size of aortic aneurysms that require repair. Pre-operative assessment, management of cardiac risk, autologous blood transfusion strategies, and endovascular stent graft technology to avoid major open surgery were issued addresses in a review of pubications by Daly, Torella, Ashleigh, & McCollum. (2004) They concluded that combining 1.) screening, 2.) reduced pre-operative risk, and 3.) the use of new, minimally invasive techniques make aortic aneurysm treatment available to the increasingly geriatric population. The combination of these techniques will reduce mortality from ruptured aortic aneurysm in the elderly and also reduce the stress associated with aneurysm surgery. I could not find any new precise data on natural history of aortic aneurysms but only found two very old articles, (Szilagyi, Smith, DeRusso, Elliott, & Sherrin. 1996, p. 678-99 & Estes, 1950, p. 258-64) and their concepts do not anymore exit anymore. Many investigators have focused on the relation of aneurysm size and expansion rate to the risk of rupture. The initial diameter of the aneurysm, elevated blood pressure, and the presence of chronic obstructive pulmonary disease are the risk factors singled out by three articles sited (Venkatasubramaniam et al. 1991, p. 56-60; Lynch, 2004, p. 99-107 & Catalano, 2005, p. 423-37). It was noted that 15 to 20 percent of small aneurysms do not expand substantially, but 80 percent increase progressively in diameter and approximately 20 percent increase by more than 0.5 cm per year. Unfortunately, it is impossible to predict the rate of expansion in any one patient; since some aneurysms remain stable for years and then expand rapidly at a certain point range in time. Data on the risk of rupture for aortic aneurysms sized 4 to 5 cm in diameter are rare, but such lesions have been reported to have five-year rupture rates of 3 to 12 percent (Glimaker, Holmberg, & Elvin, 1991, p125-30). In the early detection and diagnosis of aortic aneurysms, "abdominal ultrasonography detects aneurysms with a sensitivity that approaches 100 percent" according to LaRoy et al. (1989). They stated that both longitudinal and transverse aortic diameters can be measured, and intravenous contrast agents or ionizing radiation is not required. Measurements of aneurysm size are reproducible within a range of 0.6 cm. The success of sonography is also highly dependent on the ultrasonographer, however, and it may not be possible in obese patients, those with excessive bowel gas, or those with periaortic disease. Furthermore, ultrasonography yields inaccurate data for the surgeon contemplating aortic reconstruction, because it cannot accurately document the proximal or distal extent of the aneurysm. Similarly, it does not image the visceral vessels with sufficient detail to be useful in planning the operation being contemplated. On the other hand, comupterized tomography (CT) is not recommended for screening of aortic aneurysmsor as a routine preoperative study. However, if a plan of monitoring is adopted with a decision to operate on the basis of precise increases in aneurysm diameter, then CT imaging, because of its accuracy among different studies, is appropriate for sequential follow-up (Ruff, & Watson. 1998, p. 651-654; Amparo, Hoddick, & Hricak, 1985, p. 451-456). Magnetic resonance imaging (MRI) may be a better method of imaging than either ultrasonography or CT, both for accurate aneurysm measurements and for views of the relevant vascular anatomy. The use of MRI is still preferred compared to ultrasonography or CT especially when the surgeons contemplate on a detailed dissection of the aneurysm's surrounding parenchyma for its repair. A great majority of surgeons will prefer MRI for aortic aneurysm screening but, the process is limited since it is expensive and not readily available in certain if not a majority of locations, it is contraindicated in patients who have pacemakers, and MRI is not that specific in identifying occlusive vascular disease. In general, MRI offers no practical advantage over ultrasonography or CT. In summary, diagnostic abdominal ultrasonography for aortic aneurysm screening should be performed and sequential follow-up religiously done. Computerized tomography should be done when ultrasonography is not possible and precise sizing of the dilatation is required, and aortography to acquire anatomical information useful for aortic reconstruction, but only after the decision to operate has been made. For the majority of patients, only abdominal ultrasonography followed by aortography is necessary. Once the diagnosis of aortic aneurysm has been established, the decision to operate on a patient must be made on a case-to-case basis, since all aneurysms are potentially lethal and rates of expansion and frequencies of rupture are unpredictable. The size of the dilatation makes a great difference in the management of these lesions. A great number of vascular surgeons recommend repair for all symptomatic or ruptured abdominal aortic aneurysms and for all asymptomatic aneurysms more than 5 cm in diameter, provided coexisting conditions do not preclude operation. (Glimaker, Holmberg, & Elvin, 1991, p. 125-30 & Cronenwett, Sargent, & Wall, 1991, p. 260-268). During the preoperative evaluation, it is important to identify any coexisting conditions in the patient, such as diabetes, hypercholesterolemia, and most importantly coronary artery disease. In order to achieve the best prognostic status his condition must be immediately addressed preoperatively if one is to achieve optimal results. Hertzer's (1980) comprehensive analysis of aortic reconstruction for aneurysmal disease documented that "myocardial infarction accounted for 37 percent of early postoperative deaths." He suggested that for those patients with diagnosed coronary artery disease, they should undergo coronary arteriography, with the suggestion that myocardial revascularization should be performed before aortic reconstruction. If a person with an abdominal aortic aneurysm lives long enough, rupture of the aneurysm is to be expected. Although the general mortality after rupture may exceed 90 percent, just about 50 percent of those who get to the hospital alive live. Moreover, the long-term survival rate is not significantly different from that of a general population matched for age and sex or that of patients undergoing elective repair (Rohrer, Cutler, & Wheeler, 1988, p. 1213-17). Non-surgical treatment of aortic aneurysms begins with strict blood pressure monitoring, control and monitoring again. Since it has been documented that high blood pressure is a risk factor in these patients, maintaining an optimum low blood pressure lowers the risk of rupture of the aneurysm due to the continuous expansion of its dilated portion. A rapidly expanding aneurysm should be operated on as soon as it is possible for the patient since this kind has a higher chance of rupture. Slowly expanding aortic aneurysms may be followed by routine diagnostic testing such as CT or ultrasonography. If the aortic aneurysm grows at a rate of more than 1 cm/year, surgical treatment should be electively performed (Cronenwett, 1990). Deciding when the surgery should be performed is not an easy task. Final decision on the date of surgery depends on the particular case. The prevailing consideration is that, surgery be performed when the risk of rupture exceeds the risk of surgery. The diameter of the aneurysm, its rate of growth, the presence or absence of connective tissue disorders, (Brophy, 1991; Cohen, 1987; Johansen, 1986; Sumner, 1970; & Webster, 1991) and other coexisting medical conditions are all important factors in its determination to proceed to surgery. A high morbidity and mortality has been associated with open repair of abdominal and thoracic aortic aneurysms. Significant reduced is the morbidity rate due to the introduction of the endovascular repair of aortic aneurysms as compared to the standard open surgical procedures. And through the years till 2008, several devices have been approved for clinical use for this purpose. This has allowed the treatment of patients who are otherwise at high risk for open repair. (Chaer, Makaroun, Chedrawy, Abdelhady, Lele, & Massad, 2008, p. 145-53) Prosthetic-graft replacement of the diseased aorta is the current, accepted standard of care for aortic aneurysms. Easily said than done is its opening of the dilated portion of the aorta and insertion of a synthetic patch tube. This patch tube is anastomosed into the proximal and distal portions of the aorta; the dilated portion is collapsed and closed around the artificial tube. In some cases, instead of sewing the patch's ends, it is made rigid and expandable by a wire mesh. This technique is much simpler and permanently fixed by external ligature on the serosa of the aorta. Endoluminal graft-implantation from the femoral artery has been introduced by Parodi in 1991 by performing the first surgery of this kind. (Parodi, Palmaz, & Barone, 1991, p. 491-499) This technique reported a lower mortality rate compared to open surgical repair as mentioned earlier. The new technique is now being widely used in individuals with co-morbid conditions that make them high risk patients for open surgery. Optimistically, some centers are expected to report very promising results for this method in patients that do not constitute a high surgical risk group. Other authors however have reported this technique as having no benefit on survival of the patient. (Johnston, Rutherford, Tilson, Shah, Hollier, & Stanley, 1991, p. 452-458) Controversy has erupted when operations for certain patients were withheld, particularly those with history or high risk of cardiac arrest, in patients with hematocrit values less than 25 percent, those with continual hypotension, and patients in their 70s or 80s. The current accepted view among surgeons, however, is that operation should not be denied, since it provides the only hope for survival for this patients and a survival rate of 25 percent can be expected among these said patients (Harris, Faggioli, Fiedler, Curl, & Ricotta, 1991, p. 812-20; Gloviczki, Pairolero, & Mucha, 1992, p. 851-59). The classic triad of hypotension, back pain, and a palpable pulsating abdominal mass may be present in only half of patients with obvious abdominal aortic aneurysm. However, these manifestations are a sign that immediate operation should be performed even without confirmatory tests such as ultrasonography or CT. A wrong diagnosis by the examiner may occur in up to 30 percent of patients, the most common conditions of which are renal colic, diverticulitis, and gastrointestinal hemorrhage according to Marston (1992). The left retroperitoneum is the most common site where aortic aneurysms ruptures into. During rupture, the patient may have hypovolemic shock, exsanguination is not the rule because of clotting and the tamponade effect of the retroperitoneum. As long as the patient is conscious and has adequate peripheral perfusion, blood volume replacement approximated to the actual blood volume loss (euvolemic resuscitation) should be deferred until the rupture is controlled in the operating room. Keeping the blood pressure raised but without control of the aneurysm may lead to loss of retroperitoneal tamponade, resulting to further bleeding, profound hypotension, and coming up death. When the diagnosis is unclear and the patient is hemodynamically stable, abdominal ultrasonography will document an aneurysm, and CT imaging may prove useful in identifying rupture. It must be emphasized, however, that in an unstable patient with a suspected ruptured aneurysm, immediate operation without confirmatory testing or full resuscitation is mandatory. The earlier data of success and failures from endovascular repair of abdominal aortic aneurysms were promising, but these changed when the procedure was subjected or used in controlled clinical studies which then showed a decreased in the 30-day mortality in comparison to that achieved with the conventional method of open repair. Prinssen, Verhoeven, Buth, Cuypers, van Sambeek, Balm, Buskens, Grobbee, & Blankensteijn J. (2004) conducted a multicenter, randomized trial comparing the conventional open repair with the new endovascular repair in about 345 patients who had received a diagnosis of abdominal aortic aneurysm of at least 5 cm in diameter and who were considered suitable candidates for both techniques. The outcome events analyzed were operative (30-day) mortality and two composite end points of operative mortality and severe complications and operative mortality and moderate or severe complications. Based on their studies, they concluded that the new endovascular repair is preferable to the old conventional open repair in patients who have an abdominal aortic aneurysm that is at least 5cm in diameter. This makes the previous studies in the late 80s more concrete. However, a long-term follow-up is needed to determine how long these patients survive. A recent study in 2002 showed that the significance of the portion of the aorta affected is important and may be considered the determining factor to decide whether to use another new technique of repair (Sternik, Zehr, & Schaff, 2002, p. 1332-4). The authors noted that in the past, an aneurysm whose anatomy and surrounding tissue of the sinotubular junction and the distal ascending aorta is preserved has classically been treated with resection and replacement with a tube graft. They suggested and tried an alternate method of resection of asymmetric aneurysmal dilatation of the ascending aorta with primary end-to-end anastomosis. They used this new technique in 14 patients and the patient showed complete resection of the aneurysm with tension-free anastomosis. Only one suture line was used and theoretically reduced bleeding. The endothelial surface of the aorta was preserved without an interposed synthetic graft. This method, they concluded, can be performed safely and the repair, long-lasting with regular follow-up done. Another paper I reviewed was that of Bortone, De Cillis, D'Agostino, Luca, & Schinosa, (2004). They investigated the efficacy and middle-term results of the stent graft treatment for diseases of descending thoracic aorta. To achieve this, they looked at records four years back. All these enrolled patients underwent CT and angiography as preoperative assessment. A successful repair was noted in 96.4% of all enrollees and they were discharged improved before the 7th hospital day. There were no stent graft-related complications reported. Follow-up of these enrollees which ranged from 1 to 55 months using CT scans was 100% complete. The overall mortality of 40.9% was observed. In conclusion, that stated that endovascular treatment in the acute phase of the aneurysm is a suitable option because of the low mortality rate. The efficacy is proven in the middle-term stage while the long-term follow-up is still pending. Dealing with ruptured aortic aneurysm is another thing I wish to tackle. In a community experience as reported by Katz & Kohl, (1994) he wanted to find out the impact of preoperative, operative, and postoperative factors to mortality in patients with ruptured abdominal aortic aneurysms. After doing a retrospective case series on 99 patients who were operated on for ruptured abdominal aneurysms, they concluded that the outcomes of these patients who underwent ruptured aortic aneurysm repair depends on their preoperative status. The expertise of the surgeon and the strict avoidance of technical error should always be taken with the utmost importance. Hans & Huang (2003) on the other hand presented a study of ruptured aortic aneurysm repairs using a single-surgeon-practice that is only one surgeon who performed the similar technique in all 101 cases. This was done in a university-hospital setting. All these variables were considered in order to eliminate the bias of expertise on the part of the performing surgeon. His main outcome measures were mortality before or during the procedure, complications of cardiac, pulmonary, renal, and gastrointestinal origins; and blood coagulation abnormalities. He also recorded iatrogenic complications observed and the length of hospital stay after the procedure. All preoperative and intraoperative factors affecting mortality were studied. He concluded that results of ruptured abdominal aortic aneurysm repairs from community-based practice are comparable to those reported from university referral medical centers. I have discussed results of elective treatment of abdominal aortic aneurysms which proved to be excellent in many institutions. This study shows an entire state being considered therefore having a much larger population study. The authors reviewed Medicare records in the state of Kentucky in the United States. A total of 136 operations were performed by 52 different surgeons as accumulated in 32 medical institutions statewide. The overall operative mortality was 18%; elective and emergency operative mortality rates were 6% and 49%, respectively. The age of the patient did not make a significance in the outcome of the procedure. But it was noted that mortality rates in physically small-scale institutions was higher compared to those performed in the physically large-scale institutions. "The low mortality for elective repair of abdominal aortic aneurysms in an elderly population by numerous surgeons in divergent hospitals is a strong indication for its liberal use compared with the high mortality and morbidity of emergency surgery" (Richardson, & Main, 1991). In a most recent population-based study, authors looked into a comparison of populations (United States and United Kingdom) both performing the endovascular aortic aneurysm repair (EVAR) (Timaran, Veith, Rosero, Modrall, Arko, Clagett, & Valentine, 2007, p. 520-25). They have shown that the EVAR technique is currently being performed in the United States having a low in-hospital mortality, even in patients considered to be of the highest risk. In a United Kingdom study, the results are not exactly the same. Thus, EVAR should not be denied to high-risk patients with abdominal aortic aneurysms in the United States on the basis of risk evidence from the United Kingdom study. The last entity I wish to describe is inflammatory aortic aneurysm. I cannot help but discussed this entity even briefly as it accounts for 5% to 10% of all cases of aortic aneurysms and differs much from typical atherosclerotic aneurysms in many important ways. It is a known fact that both inflammatory and atherosclerotic aneurysms are commonly noted to affect the infrarenal portion of the abdominal aorta. Also known is that patients with this type of inflammatory variant are seen in the younger population and most important is they are usually symptomatic, with presenting manifestations mainly presenting as tolerable to severe abdominal pain felt at the back. Not like the patients with atherosclerotic aortic aneurysm, patients with the inflammatory variant have an elevated erythrocyte sedimentation rate or abnormalities of other serum inflammatory markers. CT and MRI are both highly sensitive for demonstrating the area of soft tissue inflammation surrounding the aneurysm and is characteristic of inflammatory aortic aneurysms. In detailed microscopic examination, the inflammatory variant shows marked thickening of the aneurysm wall, rigid adherence of the adjacent structures to the anterior aneurysm wall and fibrosis of the adjacent retroperitoneum. This is not seen in atherosclerotic aneurysms. Also distinguishing inflammatory from atherosclerotic aortic aneurysms is an extraordinary expansion of the blood vessel's adventitia layer due to the inflammation per se. The etiology of the inflammatory reaction is unknown according to numerous studies in vascular pathology, but theories are being entertained. It is known that the inflammatory type appears to involve an immune response localized to the vessel wall; however, it is almost never associated with inflammation of other arteries. The male gender and smoking, which are the main risk factors for atherosclerotic aortic aneurysms, are even stronger risk factors for the inflammatory variant. Smoking cessation is the first step of medical therapy followed by control of hypertension if present. Immunosuppressive or corticosteroids therapies may also have roles. Even though an inflammatory aneurysm seems less likely to rupture than the atherosclerotic variant, surgical intervention appears practical once the diameter of the aneurysm exceeds 5.5 cm. Since clinicians know the distinguishing features of the inflammatory, atherosclerotic and systemic vasculitis, they should be able to manage it with the appropriate combination of medical and surgical therapies. Options for the management of abdominal and thoracic aortic aneurysms have been in a state of evolutionary change since 2002. (Najibi, Terramani, Weiss, Smith, Salam, Dodson, Chaikof, & Lumsden, 2002, p. 211-16.) The continued refinement and development in the techniques have decreased the need for the conventional open surgery. To date, much research is done in the field of stent graft technology. Likewise, the stents and materials used also undergo changes to tailor to the surgeons and patients needs. Conclusion Concluding from all references cited and analyses made, aortic aneurysms, whether abdominal or thoracic is a disease entity of our times. Irregardless if it is hereditary, inflammatory or atherosclerotic in etiology, we are having a rise if not a steady incidence of this in the past decade. And this should be addressed by medical people and researchers. Diagnosis of aortic aneurysm is made either by the physician, physician's assistant, hospital trainee such as an intern or resident, nurse or any allied health professional who comes in contact with a patient showing manifestations particular to the disease entity. These manifestations may be felt by the patient, hence called symptoms. And this is what prompted the patient to seek medical consultation. A few of these symptoms worth mentioning are difficulty in breathing or easy fatigability. These symptoms though are not pathognomonic to an aneurysm. It is actually more specific to cardiovascular disease like acute myocardial infarction. Once established, confirmation by ultrasonography or computed tomography is helpful for proper lesion localization and for preoperative baseline data gathering. Once established, patients who can proceed with the open method of surgery may proceed with the operation once cardio-pulmonary clearance is established. While patients with large aortic aneurysms and considerable cardiac co-morbidity can safely undergo endovascular aneurysm repair. Resources site on wound complications resulting in prolonged hospitalization will always remain the major cause of perioperative morbidity. 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