At the tail end of 1944, Hitler’s last major assault, the Ardennes offensive, or Battle of the Bulge, was launched intended to kill the Allies desire to live and fight. It was a brutal episode, lasting six weeks and was the first time desegregated troops fought together on the USA side; seemingly fatal  bullets seem not to discriminate against who they kill!

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Emanating from the heart, and carrying blood to every organ lies the aorta, the largest blood vessel in the human body, a muscular, pulsating tube usually about an inch (2cm) diameter. It carries nutrients and oxygen saturated blood from its source, down the centre of the chest, through a hole in the diaphragm and travels down the rear of the abdomen, passing behind liver, stomach, pancreas and bowels. Around the level of the umbilicus, it splits into two, sending branches to the pelvic organs and lower limbs.  Along the way it buds off vitally important branches to liver, spleen, pancreas, stomach, small and large bowel, spine, kidneys and more. You get the picture – the clue was “vitally important,” as in, you die without it!

However, for several reasons, a weakness might appear in the aorta which allows an outward and offensive bulge to develop. As the wall stretches it weakens further and a vicious cycle has begun. If one thinks of another type of cycle, a bicycle, old fashioned tyres sometimes developed a bulge. This is the same. And we call this  bulge an Abdominal - what part of the  body it afflicts, Aortic - the affected blood vessel, Aneurysm - expensive medical word for a balloon. And like an over-inflated balloon it may burst,  which is as deadly as the other Battle of the Bulge. For expediency and to sound slick, we abbreviate this to “AAA,” but unlike AAA batteries, this character sucks energy, and literally, the lifeblood out of the patient; untreated, a ruptured AAA is fatal. But there is another way this story can end!

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AAA does not respect celebrity

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AAA has history and clearly shows as little respect for talent and status as bullets do for race.  Never mind that it took down Einstein, Lucille Ball, jazz musician Humphrey Littleton and many others, some believe that Tutankhamun’s family had one of a number of vanishingly rare syndromes that caused enlarged breasts in men and women, a mellifluous voice and, yes, AAA.

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Other victims of the bulging battle possibly include Rossini, renowned Italian composer who collapsed and died while rehearsing his orchestra. The American news anchor, Peter Jennings ruptured his AAA and succumbed and Presidential candidate, Senator Robert Dole, lost his father to the disease but caught his in time, was treated and survived this, and other health scares, passing away years later at the age of 98.

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What causes this silent killer:

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We have yet to figure out exactly why AAA’s develop, but there are risk factors, some of which you can avoid:

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• Age: Increasing age is associated with increasing risk, more so beyond 65 years of age.
• Sex: Men are more likely than women to develop AAA.
• Race:  Black races and those of Asian heritage are less likely to develop AAA than Caucasians, but nobody is immune.
• Smoking: This is one of the single biggest avoidable health risks for AAA and so much more. People tend to know about smoking and lung cancer, but it wrecks blood vessels all over the body causing heart attacks, stroke, kidney disease, high blood pressure, impotence and yes, AAA as all tobacco products weaken blood vessel walls.
• High Blood Pressure: A constant strain on the muscle in blood vessel walls is induced by this condition. Think of a garden hose that is getting a bit older, maybe the rubber wall has a few cracks. Now put a crimp in it and turn the pressure up. Congratulations, you now understand hypertension like I do!
• Family History: One cannot control one’s genes, but knowing what family members succumbed to, does help guide your doctor as to what to look out for.
• Other Health Conditions: Hardening of the arteries, atherosclerosis, comes from a poor diet, not exercising, smoking and so on.  Additionally, if one has high blood fats either from an inherited condition or lifestyle choices, this is a risk factor. Certain comparatively rare conditions, such as Marfan’s or Ehlers Danlos Syndromes that affect the “connective tissue” which holds structures together can cause this.

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Symptoms and signs

Sadly, AAA may present with six feet of unwanted real estate – a severe back pain, then collapse and death. AAA often grows slowly without symptoms, but being aware that this monster exists might alert one to be conscious of symptoms like:

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• Feeling a throbbing, pulsating mass in the belly: More commonly in thin patients.
• Severe/excruciating pain in abdomen, back or scrotum: This might suggest a rupture in which case rapid transfer to an acute care hospital can mean the difference between life and death. Sometimes one might notice bruising around the back, this is a very worrying sign.

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To prevent the often-fatal nature of a rupture, the key is to detect AAA early. If one has any risk factors, then an examination by a medical professional, as well as an ultrasound of the abdomen is hugely valuable. It takes mere minutes, and allows one to measure the size of any aneurysm. If more than 5.5cm across, early surgical intervention is merited. Between 2 – 5.5cm, it will likely be watched. Screening programs of those at risk saves lives, and as a doctor, to see a patient whose asymptomatic AAA is picked up in this fashion is so satisfying.

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Doctors might also request a CT scan of the aorta and nowadays a 3D model can be constructed from these scans, sometimes in conjunction with images obtained by injecting contrast, a substance that shows up on the scans, allowing for better characterisation of the anatomy.

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AAA gone critical

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We have established that an AAA can just burst, either causing immediate death (if it bursts towards the front this is more common) or allowing for the chance of surgical repair. But AA can cause other problems such as:

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• Dissection: Sometimes, the lining of the aorta splits internally rather than full thickness and blood enters the wall, splitting it into layers and compromising the central channel;
• Organ damage: As noted, the aorta supplies blood to the gut, kidneys and every other abdominal and pelvic organ. The AAA can block blood vessels meaning that the downstream organ is damaged. For instance, kidney failure is a not uncommon sequel to AAA.

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Treatment

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In patients with a growing but non-critical AAA, stopping smoking, reducing blood pressure and weight, and controlling other damaging factors are recommended. In emergency situations, an open repair is necessary, whereby a long incision is made from breast to pubic bone, the aorta is clamped above and below the offending AAA. This is then opened and a tube graft is sewn inside the aorta which is then closed on top of it.

In planned, or elective operations, the same concept can be affected by the endovascular approach. Here, a small incision is made in the groin and a tube is navigated into the aorta and courtesy of some incredible engineering prowess, a tube, or more complex, graft is passed into position and a series of hooks are deployed to hold the graft in position.

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Post operatively one needs to monitor these patients, regardless of technique of placement as there are some potentially serious downstream complications. Additionally, if one has the bad habits – or genes – that led to AAA, it is feasible that other cardiovascular conditions are lurking in the background, waiting to declare themselves!

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At time of writing, the Battle of the Bulge occurred just shy of 80 years ago; help make AAA history by kicking cigarettes, hypertension and bad habits into touch!

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