ELONGATED AORTA: CAUSES, RISKS AND TREATMENTS - MEDICINE - 2024

The elongated aorta is the imaging finding in which the aorta, the main artery of the human body, is seen to be longer than normal. It was initially described only in thoracic radiology, but the term was extrapolated to other studies that include images, such as CT scans, MRIs or catheterizations.

In chest radiographs taken anteroposterior or posteroanterior, the aortic arch is usually visualized without difficulties. It is located slightly above the cardiac silhouette and the median arch of the pulmonary artery, in the left hemithorax. It is one of the classic elements of chest X-rays and its alterations are easy to observe.

Image of normal artery and elongated artery. Source: heart.bmj.com

An increase in the size of the aforementioned aortic arch is compatible with elongation of the aorta. It appears prominent, occupying an important portion of the space corresponding to the left lung, accompanied by mediastinal widening. It can also be seen in the abdominal aorta through other more specialized studies.

Finding an elongated aorta forces the medical team to look for a cause for this alteration. Although it is not always a pathological finding and few cases require invasive treatment, strict and detailed control of the condition is necessary to preserve the health of the individual.

Causes

There are several conditions, typical of the cardiovascular system and other systemic, that can cause elongation of the aorta, including:

Age

Aging is one of the main causes of elongation of the aorta. Some authors consider that this phenomenon is normal and is due to the usual geometric changes that any blood vessel undergoes due to age. Some others are convinced that it is a pathological finding that is not present in all the elderly.

The normal aortic aging process occurs with lumen dilation and loss of vascular compliance. Likewise, the aortic apex is located between the large vascular trunks in young patients but changes to a more distal position in older adults.

In short, all studies suggest that the aorta lengthens over the years, even in healthy people. Most of the time, this elongation affects the ascending aorta (which corresponds to the radiological aortic arch) and does not usually cause significant symptoms or alterations in the distal pulse.

Arterial hypertension

Finding an elongated aorta in hypertensive patients is extremely common. The hardening of the arterial walls also affects the aorta, which despite its large diameter, ends up widening and lengthening. Inadequate blood pressure control and long-standing disease worsen the stretch condition.

The lumen of the aorta (its internal diameter) opens and closes normally with each beat of the heart. When the pressure exerted by the heart increases, the light remains open longer and the pumped blood enters the vessel with more force, hitting its walls and causing it to widen, like any muscle that is exercised.

In advanced stages of hypertensive disease, the aorta can reach considerable dimensions. Imaging studies are conclusive, and the large aortic button that appears above the heart is striking on chest radiographs. The complications are catastrophic at this time.

Dyslipidemias

Cholesterol and triglyceride abnormalities are largely associated with aortic elongation. These pathologies produce accumulation of fats or lipids on the walls of the vessel, generating the well-known atherosclerotic plaques, which can break or detach, with terrible consequences for the health of the patient.

Smoking habits

Smoking is associated with multiple systemic pathologies, including several diseases of the cardiovascular system that cause elongation of the aorta.

In fact, the main cause of elongated abdominal aorta is regular cigarette smoking. The pathophysiology of this condition has not been fully explained, but the statistics are clear about it.

Obesity

Being overweight was no longer considered a risk factor and became a formal disease. The range of complications of obesity ranges from cardiovascular to psychiatric.

High blood pressure and high cholesterol associated with the high body mass index of the obese appear to be the reason for aortic elongation in these individuals.

Connective tissue diseases

Although these pathologies are rare, the cardiovascular complications they generate can be severe. Marfan disease is characterized by cardiovascular conditions including the elongated aorta.

The same occurs with Loeys-Dietz and Sjörgen syndromes, Rheumatoid Arthritis, Polymyositis and Systemic Lupus Erythematosus.

Risks

Although most patients with an elongated aorta have no symptoms, there are certain complications that can be dangerous. The most feared complications are:

Aneurysms

Aneurysms are abnormal dilations of any artery in the body. In this case, they are aortic widening, both at the thoracic and abdominal level.

They are produced by the weakening of the vascular wall, which is more frequent when the aorta is elongated and its walls are thinner and less elastic.

The symptoms of aortic aneurysm are highly variable and will depend on the section of the vessel affected, the size and the rate of growth.

Many aneurysms never manifest themselves during a person's life, while others can generate important clinical signs that force the patient to visit the doctor.

Aortic dissection

Aortic dissection is the injury to the inner walls of the aorta. When this occurs, blood leaks through this injury and seeps between the walls, eventually separating them.

If the tear widens, it can reach the outer layers of the aorta and cause a fatal massive hemorrhage even with optimal treatment.

This complication occurs most often in weakened areas of the aorta with aneurysms. Dissection and rupture of the aorta occurs spontaneously, which makes its management even more complicated. They do not usually mediate previous trauma, but some blows can generate the aneurysm or rupture a preexisting one.

Treatment

Aortic elongation does not have a specific therapeutic management beyond treating the disease that causes it. Almost all causes are managed with drugs such as antihypertensives, statins, oral hypoglycemic drugs or steroids, as well as changes in lifestyle and diet.

Rapidly growing aneurysms that can be diagnosed require surgery. Surgical resolution may be done endovascularly, or an open operation may be necessary.

The same is true for aortic dissection, although this should be considered a medical emergency. Small, asymptomatic aneurysms are not manipulated.

References

1. Adriaans, Bouke P. et al. (2018). Aortic Elongation Part I: the normal aortic aging process. Heart, doi: 10.1136 / heartjnl-2017-312866.
2. Heuts, Samuel and collaborators (2018). Aortic Elongation Part II: the risk of acute type A aortic dissection. Heart, doi: 10.1136 / heartjnl-2017-312867.
3. Hodler, J; Vock, P and Schaffner, T (1995). Aortic elongation: merely mimicked in increased thoracic kyphosis? radiologic-pathologic correlation. Swiss Medical Weekly, 125 (6): 207-211.
4. Serrano Hernando, Francisco Javier (2007). What is a dilation of the thoracic and abdominal aorta. Cardiovascular Health Book, Chapter 57, 505-511.
5. Sugawara, J. et al. (2008). Age-associated elongation of the ascending aorta in adults. JACC Cardiovascular Imaging, 1 (6): 739-748.
6. Gleeson, Jane R. (2016). Observe or Operate? When an Enlarged Aorta Requires Action. Recovered from: healthblog.uofmhealth.org
7. Davis, William (2010). Your Neglected Aorta. Recovered from: healthcentral.com
8. Krüger, T. et al. (2016). Ascending aorta elongation and the risk of dissection. European Journal of Cardio-Thoracic Surgery, 50 (2): 241-247.
9. Mayo Clinic Staff (2018). Aneurysm of the Thoracic Aorta. Recovered from: Mayoclinic.org
10. Thrumurthy; SG et al. Aortic dissection, how to recognize it? What to do? Recovered from: intramed.net