Thoracic Aortic Aneurysm

Overview

The aorta is the main artery that carries blood out of the heart to the rest of the body. Blood flows out of the heart and into the aorta through the aortic valve. Roughly the diameter of a garden hose, the artery extends from your heart down through your chest and into your abdomen, where it divides into a blood vessel that supplies each leg.

An aneurysm is a weakening in the wall of an artery, which causes it to “balloon” or expand in size. Although an aneurysm can develop anywhere along your aorta, most occur in the section running through your abdomen (abdominal aneurysms). Others occur in the section that runs through your chest (thoracic aneurysms).

According to the US Centers for Disease Control and Prevention, aortic aneurysms were reported as the primary cause of 9,863 deaths in the US in 2014, but the actual number is likely much higher.

Aneurysms are often found incidentally during evaluation of other problems since they commonly cause no pain or discomfort. They can silently enlarge for long periods of time without being identified.  When the aneurysm gets too large, the wall of the blood vessel can split or tear (aortic dissection/dissecting aortic aneurysm) or even “burst” under the pressure (aortic rupture/ruptured aortic aneurysm).

Causes of Thoracic Aortic Aneurysms

Causes of Thoracic Aortic Aneurysms

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Many factors potentially can contribute to the development of an aortic aneurysm, and it’s often difficult to determine the exact cause. Some of the most common conditions associated with aneurysm formation are:

  • Congenital or genetic causes for weakness of the artery wall (present from birth)
  • Changes in your aorta due to advanced age
  • Connective tissue disorders such as Marfan or Ehlers-Danlos syndrome
  • Inflammation of your aorta
  • Hardening of the arteries (atherosclerosis) where fat, cholesterol, and other substances (plaque) clog your arteries
  • Injury from falls or motor vehicle accidents
  • Untreated infection such as syphilis or salmonella

In some cases, aneurysms run in families and are classified as “familial”, so several members of extended families may be affected by aneurysms in different locations.

Symptoms of Thoracic Aortic Aneurysms

Symptoms of Thoracic Aortic Aneurysms

Often, thoracic aortic aneurysms do not cause any symptoms because they usually develop slowly over time. However, if the aneurysm is big enough to put pressure on surrounding structures within your chest, you may experience symptoms such as:

  • Hoarseness
  • Trouble swallowing
  • Swelling in your neck
  • Pain in your chest or upper back
  • Nausea and vomiting
  • Rapid heart rate

Diagnosis and Treatment Options

Diagnosis and Treatment Options

Because thoracic aortic aneurysms usually develop slowly and do not cause many symptoms, they can be hard for doctors to detect and diagnose. Unless the aneurysm has ruptured, a physical exam with your doctor likely will be normal.

Undergoing imaging tests for other symptoms or conditions is often how thoracic aortic aneurysms are detected. These tests can include a chest x-ray, echocardiogram (ultrasound of the heart and part of the aorta), or a computed tomography (CT) scan. A CT scan will show the size of the aorta and the exact location of the aneurysm.


 

CT scan of a descending thoracic aneurysmCT scan of a descending thoracic aneurysm

Your doctor also may schedule an aortogram or angiogram (a special set of x-ray images made when dye is injected into the aorta), which can help identify the aneurysm and any branches of the aorta that may be involved.

For more information on these tests, visit our common diagnostic tests page.

Treatment options for a thoracic aortic aneurysm vary based on its size and location within your chest.

These options range from watchful waiting to surgery. If the aneurysm is small and you have no symptoms, your physician may suggest a “watch-and-wait” approach with regularly scheduled images of the aneurysm to check the size. Because aneurysms typically grow very slowly, it is common to monitor them over months or years to determine when the risk of a problem becomes high enough to warrant the consideration of surgery.

Whether your doctor recommends monitoring or surgery, it is very important to keep your blood pressure in a safe range. When your blood pressure is too high, it puts more stress on the wall of the aorta where the aneurysm is located, which can increase the risk of tearing or rupture. Talk to your doctor about your blood pressure and if any medication is recommended to help with this goal. If you are involved in activities or work that might increase your blood pressure significantly like heavy weight-lifting, moving furniture, or extreme stress, be sure to discuss these issues with your doctor to determine any restrictions that may be recommended for your safety.

If your aneurysm is large enough, or if the aneurysm is growing quicker than usual, surgery may be recommended.

If your aneurysm is detected before it tears or ruptures, surgery would ideally be planned and scheduled with a cardiothoracic surgeon. Be sure to speak with your heart specialist and cardiothoracic surgeon about the risks and benefits of surgery.

Once you decide to move forward with surgery, your cardiothoracic surgeon likely will recommend replacement or stenting of the affected portion of your aorta with an artificial graft. Not all options are appropriate for every patient, but your doctor will talk to you about the recommended approach for the operation, including the technique that is chosen and the incision that is made, depending on the location and features of the aneurysm.

A stent placed in the thoracic aorta A stent placed in the thoracic aorta

If the aneurysm is close to the aortic valve, or an ascending aortic aneurysm (located in the part of the aorta that exits the heart then travels up toward the neck), the valve may also have to be repaired or replaced through an incision on the front of the chest wall. This incision is called a median sternotomy and extends down the front of your chest, through your breastbone or sternum, which enables your cardiothoracic surgeon to see your heart and aorta.

Surgery on the aortic arch (the curve in the aorta after it leaves the heart and travels up toward the neck, then down into the chest toward the abdomen), is also usually done from an incision on the front of the chest wall. If the aneurysm involves the descending thoracic aorta (the part of the aorta after the curve in the neck which travels down toward the abdomen), an incision on the left side of the ribcage may be required.

The length of the operation and the risks involved depend on the extent of the repair required and on your overall health prior to the operation.

3D CT reconstruction of a descending thoracic aneurysm

3D CT reconstruction of a descending thoracic aneurysm

Recovery

Recovery

Recovery time following surgery varies based on the size and location of your aneurysm and on the length of your operation. Most people need at least 4 - 6 weeks to recover from the surgery, so you should plan on being out of work for at least a few weeks.

The length of the hospital stay depends on the patient’s condition and the operation performed, but typically patients should expect to stay in the hospital for about a week.

Taking control of your blood pressure and keeping it in a healthy range will help reduce the need for future surgery. You will, however, likely require lifelong monitoring of the diameter of your aorta even after an operation to be sure problems don’t develop in other areas. Keeping regular appointments with a heart specialist will help you monitor your aorta and reduce the chances of future problems.

Reviewed by: Emily A. Farkas, MD
June 2016