Thoracic Aortic Aneurysm

An aneurysm can occur in many parts of the artery, the organ that is responsible for the flow of oxygen-rich blood from the heart to the other parts of the body. An aortic aneurysm happens when a section of the aorta, the body’s main artery, expands, or balloons. As an aneurysm continues to enlarge, the walls of the aorta stretch making them much thinner. Untreated, aneurysms may rupture, causing potentially fatal bleeding. Aneurysms occurring within the chest, or thorax region of the body, are called thoracic aortic aneurysms (TAA). Other names are descending aortic aneurysm, thoracic aortic dissection or thoracic aneurysm.

Causes and Symptoms of Thoracic Aortic Aneurysm

The most common cause of TAA is hardening of the arteries, or atherosclerosis. Other causes include aging, inflammation of the aorta, injury from falls or other trauma and certain genetic conditions, such as Marfan syndrome in which an enlarged aorta is found. Syphilis is another risk factor. In addition, family medical history accounts for about 20% of cases, according to the Society for Vascular Surgery (SVS). Adding to all of these risk factors are smoking and high blood pressure (hypertension).

It is possible that no symptoms will occur until the aorta begins to expand or to “leak” blood onto other tissues. When symptoms do arise, they can include hoarseness, pain or swelling in the back, chest pain, rapid heart rate or the feeling of impending doom. Nausea, clammy skin or problems swallowing may also signal TAA, as can vomiting and high-pitched breathing (wheezing).

Several methods can be used to diagnose TAA. Computed tomography (CT) scans, magnetic resonance imaging (MRI), and chest X-rays are among them. A cardiologist may also use an echocardiogram or transesophageal echocardiogram to confirm the diagnosis.

Several Treatment Options Exist

If an aneurysm is discovered early, is still small (less than 5.5 centimeters), and no symptoms have occurred, surgery may not yet be necessary. The vascular surgeon will closely monitor the aneurysm growth every six to twelve months with CT scans. Additionally, it is important to quit smoking and to control risk factors, such as high blood pressure or high cholesterol, with medication.

An aneurysm that has reached 5.5-6 centimeters presents a much higher risk of rupture and surgery is recommended.  With the traditional open repair of TAA, an incision is made into the chest or just under the breastbone to visualize the area of the aneurysm. The aneurysm is opened and a cylinder-like tube called a graft is placed within the aorta to repair it.  Ultimately, the weakened area of the artery is relined with a sleeve of material to strengthen it and prevent rupture of the aneurysm. At times, there is also involvement of the aorta adjacent to the heart. If this is the case, sometimes heart surgery may be required at the same time. Hospital stay with this procedure is about 7-10 days, with full recovery depending on other conditions present.

Endovascular stent grafting is a less invasive option. Intervention through the bilateral groin region allows for deployment of stent grafts with minimal recovery time. This repair may only be used if the location and shape of the aneurysm is suitable to allow for correct deployment of the graft.  This repair involves a small incision in the groin. Under guidance of an x-ray, a small catheter is placed through the groin incision and used to pass a graft up into the aneurysm. This graft is placed so that the ends fit neatly into the non-diseased portion of the artery at the opposite ends of the aneurysm. This is relining the weakened area of the aorta with a strong sleeve of material, thus preventing rupture of the aneurysm.

To learn more about thoracic aortic aneurysm, log on to vascularhealthclinics.org.

Overview

Thoracic Aortic Aneuysm diagramThe aorta is a large artery that carries blood from the heart through the abdomen to the legs. The thoracic aorta is located in the chest and is made up of three segments: the ascending aorta, aortic arch, and descending aorta. A thoracic aortic aneurysm is a bulging or ballooning of any of these segments of the aorta. Similar to a balloon, as an aneurysm continues to enlarge, the walls of the aorta stretch making them much thinner. The aortic aneurysm eventually reaches a point where it loses its ability to stretch any further. At this point, without any treatment it may rupture, causing potentially fatal bleeding.

Why Do I Have a Thoracic Aortic Aneurysm?

There are many factors that can put you at risk of developing a thoracic aortic aneurysm. They may vary significantly depending on the location of the aneurysm itself:

  • Cystic medial degeneration
  • Inherited connective tissue disorders: Marfan syndrome or Ehler-Danlos syndrome
  • Family history of thoracic aortic aneurysm
  • Coronary artery or heart disease; including associated risk factors such as high blood pressure, high cholesterol, diabetes, smoking, age greater than 55, and male gender
  • Infection or syphilis
  • Takayasu’s arteritis
  • Trauma

How Is It Diagnosed?

There may be no symptoms until the aneurysm has enlarged significantly, is leaking, or has ruptured. In this instance, symptoms that may be reported include neck, chest, or back pain; swelling of the head, neck, or arms; and wheezing, coughing, or shortness of breath.

Tests that may confirm diagnosis:

  • Computed tomography scan (CT)
  • Magnetic resonance imaging (MRI)
  • Echocardiogram
  • Transesophageal echocardiogram (TEE)
  • Chest x-ray

What Are My Treatment Options for a Thoracic Aortic Aneurysm?

If your aneurysm has been discovered early, is still small (less than 5.5 centimeters), and you have no symptoms, surgery may not yet be necessary. In this case, your vascular surgeon will closely monitor the growth of your aneurysm every 6-12 months by obtaining CT scans. Additionally, it is important to quit smoking and control your risk factors, such as keeping your blood pressure or high cholesterol under control with medication.

Once your aneurysm has reached 5.5-6 centimeters, the risk of rupture is much higher, and surgery is recommended. Your vascular surgeon will decide what the best options are for you at that time and discuss complications and risks. There are two choices for treatment:

  • Traditional Open Repair of TAA: An incision is made into your chest or just under the breastbone to visualize the area of the aneurysm. The aneurysm is opened, and a cylinder-like tube called a graft is placed within the aorta to repair it. Ultimately, the weakened area of the artery is relined with a sleeve of material to strengthen it and prevent rupture of the aneurysm. At times, there is also involvement of the aorta adjacent to the heart. If this is the case, sometimes heart surgery may be required at the same time. Hospital stay with this procedure is about 7-10 days, with full recovery depending on other conditions present.
  • Endovascular Repair of TAA: This repair may only be used if the location and shape of the aneurysm is suitable to allow for correct deployment of the graft. It is a less invasive approach than traditional surgery, with this repair involving only a small incision in the groin. Endovascular means that the procedure uses long thin tubes inside your body called catheters. Under guidance of an x-ray, a small catheter is placed through the groin incision and used to pass a cylinder-like tube called a graft up into the aneurysm. This graft is placed so that the ends fit neatly into the non-diseased portion of the artery at the opposite ends of the aneurysm. This is relining the weakened area of the aorta with a strong sleeve of material, thus preventing rupture of the aneurysm. Hospital stay for this procedure is 2-3 days, with full recovery about 1 week.

Prevention of Thoracic Aortic Aneurysm

Thoracic aortic aneurysm (TAA) is a complication of degeneration of the wall integrity of the aorta from conditions that are risk factors for atherosclerosis. Other causes include aortitis as part of a systemic autoimmune disease and inherited connective tissue disease.

When TAA is present, risk of rupture rises as TAA expansion increases.

Prevention of TAA Due to Atherosclerosis

  • Management/treatment of atherosclerosis and hypertension via smoking cessation, weight control, exercise, and when necessary, antihypertensive and/or statin medication
  • Rule out co-existing aneurysms elsewhere via imaging
  • Genetic testing for inherited aortic disease in those with a strong family history of aneurysm

Prevention of TAA Due to Aortitis

  • Aggressively treat bacteremia, sepsis, or septic embolization 
  • Manage autoimmune disorders such as giant cell arteritis, Takayasu arteritis, rheumatoid arthritis, ankylosing spondylitis, Wegener’s granulomatosis, reactive arthritis, and Behcet syndrome
  • Genetic testing for inherited aortic disease in those with a strong family history of aneurysm 

Prevention of TAA Due to Connective Tissue Disease

In disorders such as Marfan syndrome, vascular Ehlers Danlos syndrome, Loeys-Dietz syndrome, and Turner syndrome, prevention of the actual aneurysm may be possible only by eliminating other risk factors, such as hypertension. When TAA is already present, prevention centers on expansion and dissection.

Prevention of TAA Dissection and Rupture

  • Elective (pre-emptive) repair of a TAA after diameter expands >5.5 cm, due to increased incidence of rupture beyond 6 cm. Those with connective tissue etiologies or with rapidly expanding TAA should be repaired earlier 
  • Identify other co-existent aneurysms via aggressive surveillance with imaging
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