A reconstruction of a wholly endovascular aortic arch repair for aneurysmal disease.

Aortic Disease: Aneurysm, Dissection and Occlusive Disease Surgery in Singapore

Background

The aorta is the largest blood vessel in the body. It arises directly from the heart and supplies oxygen-rich blood to every part of the body. Because of its size and importance, problems with the aorta—known collectively as aortic disease—can have serious consequences. Conditions may affect the aorta itself, or cause complications further downstream by limiting or blocking blood flow to vital organs and limbs.

Aortic aneurysms

The normal aortic diameter varies depending on the region of the aorta being measured. In general, it is usually between 15–30 mm. An aortic aneurysm is defined as a ballooning or enlargement of the aorta to at least twice its normal diameter.

Aortic aneurysms can cause problems in several ways. They may:

• Collect blood clot within the aneurysm sac

• Send clots downstream to smaller vessels, causing blockages (embolisation)

• Most worryingly, rupture and cause life-threatening internal bleeding

Ruptured aortic aneurysms are almost always fatal without urgent treatment.

The threshold for surgery or repair depends on the size, location and growth rate of the aneurysm. Larger aneurysms carry a higher risk of rupture. Much of the existing evidence is based on Caucasian populations, and whether the same thresholds apply to Asian patients is still debated in the vascular community.

Aortic Dissections

An aortic dissection occurs when the inner lining of the aorta (the intima) tears, allowing blood to split or dissect the layers of the aortic wall apart. This creates a false channel within the wall of the vessel.

Dissections can happen suddenly and are often described as one of the most painful events a person can experience. Symptoms may include:

• Sudden severe chest or back pain

• Pain radiating to the neck, jaw or abdomen

• Collapse, shock or even sudden death in severe cases

Aortic dissections are medical emergencies. They can cut off blood supply to vital organs such as the brain, kidneys or intestines, and may also lead to rupture. Treatment depends on the location and extent of the dissection. Some require urgent open or endovascular surgery, while others can initially be managed with blood pressure control under close monitoring.

Aorto-occlusive Disease

While aneurysms and dissections involve enlargement or tearing of the aorta, aorto-occlusive disease refers to narrowing or blockage of the aorta, most often due to atherosclerosis (hardening of the arteries).

This condition reduces blood flow to the legs and pelvis and may cause:

• Leg pain on walking (claudication)

• Severe pain at rest

• Non-healing ulcers or gangrene in advanced cases

Aorto-occlusive disease is less dramatic than aneurysms or dissections but can severely affect quality of life. It is part of the spectrum of peripheral arterial disease and is managed by a vascular surgeon using lifestyle modification, medications and, when needed, surgical or endovascular procedures.

Aortic Intervention

Modern vascular surgery offers a range of treatments for aortic disease. The most appropriate treatment depends on the type of aortic problem, its location, its severity, and the patient’s overall health and fitness.

• Endovascular (minimally invasive, “keyhole” surgery): Using stent grafts delivered via the arteries in the groin, we can repair aneurysms and some dissections without the need for large incisions. This is known as EVAR (EndoVascular Aneurysm Repair) or TEVAR (Thoracic EndoVascular Aortic Repair).

• Open surgery: Involves replacing the diseased section of aorta with a surgical graft through an abdominal or chest incision. This is still the gold standard for certain patients and situations, especially in younger, fitter individuals or where anatomy is not suitable for stent grafts.

• Hybrid approaches: Sometimes, a combination of open and endovascular techniques offers the safest and most durable outcome.

Before any intervention, patients undergo detailed imaging (such as CT angiography) and a comprehensive assessment of heart, lung and kidney function. This ensures that the benefits of surgery outweigh the risks.

Summary

Aortic disease—including aortic aneurysms, aortic dissections and aorto-occlusive disease—represents some of the most serious conditions in vascular surgery. Early diagnosis, careful monitoring and timely treatment are essential to prevent life-threatening complications.

As a vascular, endovascular and aortic surgeon in Singapore, I provide tailored treatment for patients with aortic disease, using the latest minimally invasive and open surgical techniques. If you have been diagnosed with an aortic condition, or are concerned about symptoms such as persistent abdominal or back pain, leg pain when walking, or a family history of aneurysms, seek prompt specialist review.

Frequently Asked Questions (FAQ) about Aortic Disease

Patients often ask me about the causes, symptoms and treatments of aortic disease. To help you better understand these complex conditions, I’ve put together answers to some of the most common questions I hear in clinic. This section is designed to provide clear, practical information, but it should never replace a personalised consultation with a vascular surgeon.

What causes an aortic aneurysm?

Aortic aneurysms are most often caused by a combination of factors including high blood pressure, smoking, hardening of the arteries (atherosclerosis), and genetic predisposition. Some patients may develop aneurysms because of inherited connective tissue disorders such as Marfan’s syndrome.

Are aortic aneurysms hereditary?

Yes, family history plays an important role. If a parent, brother or sister has had an aortic aneurysm, your risk is higher. Screening with an ultrasound or CT scan may be recommended for close relatives, especially men over the age of 60.

What are the warning signs of an aortic aneurysm?

Most aneurysms do not cause symptoms until they become very large or rupture. Some patients may experience back pain, abdominal pain, or a pulsating feeling in the abdomen. Because symptoms are often absent, aneurysms are frequently detected during scans for other reasons.

What are the symptoms of an aortic dissection?

The hallmark symptom is sudden, severe chest or back pain, often described as “tearing” or “ripping.” Some patients may also experience fainting, stroke symptoms, difficulty breathing, or loss of pulse in the legs. Aortic dissection is a life-threatening emergency and requires immediate medical attention.

How is aortic occlusive disease treated?

Treatment depends on severity. Early stages may respond to lifestyle changes (such as stopping smoking, exercise, and diet modification) and medications to control blood pressure and cholesterol. More advanced cases may require angioplasty, stenting, bypass surgery or open aortic reconstruction.

What is the difference between endovascular repair and open aortic surgery?

• Endovascular repair (EVAR/TEVAR): Minimally invasive, performed through small groin incisions, faster recovery, usually shorter hospital stay. Not suitable for all patients, depending on anatomy.

• Open aortic surgery: Traditional approach through the abdomen or chest. More invasive, longer recovery, but may provide a more durable solution in some patients, particularly younger individuals.

How long is recovery after aortic surgery?

• After endovascular repair, most patients can return home within a few days, with full recovery in 2–4 weeks.

• After open aortic surgery, hospital stay is usually 7–10 days, and recovery can take 6–12 weeks.

When should I see a vascular surgeon about my aorta?

If you have been told you have an aortic aneurysm, dissection, or significant narrowing of the aorta, or if you have symptoms such as severe chest or abdominal pain, unexplained back pain, or leg pain on walking, you should see a vascular surgeon urgently. If you have a strong family history of aneurysms, screening is also advised.