Aortic aneurysm - thoracic

About thoracic aortic aneurysm

The aorta is the largest blood vessel in your body and carries all the blood that is pumped out of your heart and distributes it, via its many branches, to all the organs in your body. The aorta passes upwards from your heart before it curves backwards and downwards, and travels through your chest (the thoracic aorta) and into your abdomen (the abdominal aorta).

The aorta is usually 2 to 3cm (about one inch) in diameter. A weak spot in the aorta can cause it to bulge outwards and this is called an aneurysm. If the bulge occurs in the aorta as it goes through your chest, it's called a thoracic aortic aneurysm. If it occurs in the aorta as it goes through your abdomen, it's called an abdominal aortic aneurysm. Abdominal aortic aneurysms are more common than thoracic aneurysms. You can have more than one aneurysm at the same time.

Most people who get a thoracic aneurysm are over 50 and they’re three times more common in men than in women.

Symptoms of thoracic aortic aneurysm

You may not have any symptoms of a thoracic aortic aneurysm. However, if it starts to expand and push on surrounding tissue or nerves in your chest, it can cause:

  • chest pain (as the aneurysm widens the pain may spread into your upper back or neck)
  • back pain
  • difficulty breathing
  • coughing
  • wheezing
  • hoarseness
  • difficulty swallowing

These symptoms aren't always caused by a thoracic aortic aneurysm but if you have them, see your GP.

Complications of thoracic aortic aneurysm

If the aneurysm ruptures it will cause severe internal bleeding. This will be fatal without emergency surgery to repair it. The chance of an aneurysm rupturing depends on its size. If your aneurysm is greater than 5.5cm wide, the chances of rupture are high – and the risk increases with increasing size.

If your thoracic aneurysm ruptures you will get severe pain in your chest. If you have this symptom, you must seek urgent medical attention.

Complications of a thoracic aortic aneurysm can include the following.

  • Heart failure – if the aneurysm happens near your heart it may cause the aortic valve to leak. This can cause blood to flow back into your heart (called aortic regurgitation) and stop your heart pumping effectively and cause heart failure.
  • Aortic dissection – very rarely, the inner lining of your aorta can tear and blood will enter into the wall of the aorta. If this happens, you may feel sudden and excruciating chest and back pain.

Causes of thoracic aortic aneurysm

A thoracic aneurysm develops when the wall of your aorta weakens, which causes it to bulge. The exact reasons why your aorta weakens aren't fully understood at present.

Many people with a thoracic aneurysm also have atherosclerosis. This is a process in which fatty deposits build up on the inside of your arteries and weaken the artery walls.

You’re more likely to develop an aneurysm if you:

  • smoke
  • have a family history of aneurysms or atherosclerosis
  • have high blood pressure
  • do little physical activity
  • have high cholesterol
  • are overweight
  • have Marfan syndrome or any other connective tissue disorder
  • have chronic obstructive pulmonary disease (COPD)

Diagnosis of thoracic aortic aneurysm

You may not have any symptoms of a thoracic aortic aneurysm, unless it’s large or is expanding quickly. Your GP will ask about your symptoms, if you have any, and examine you.

If your GP suspects that you have a thoracic aortic aneurysm, you may have other tests in hospital, which may include the following.

  • A CT or MRI scan can provide images of your thoracic aorta. They are very useful for determining the exact position of the aneurysm.
  • A chest X-ray may show a widening of your aorta.
  • A transthoracic echocardiography is a test in which an ultrasound sensor is placed over your chest. This can show an image of your heart and thoracic aorta.
  • A transoesophageal echocardiography test involves passing a small ultrasound sensor into your oesophagus or gullet (the food pipe that goes from your mouth to your stomach) with sedation or general anaesthesia.

Screening

At present there is no national screening programme in the UK to detect thoracic aortic aneurysms, only abdominal aortic aneurysms. However, ultrasound scans to screen for the condition are available from private clinics and hospitals.

Treatment of thoracic aortic aneurysm

Your treatment for a thoracic aortic aneurysm will depend on your symptoms and the size of your aneurysm.

Watchful waiting

If you have a small aneurysm, your doctor won’t usually advise you to have surgery but you will need regular ultrasound checks to see if your aneurysm is expanding. It's also important to manage your condition by changing your lifestyle and treating any condition that may be causing the aneurysm (such as high blood pressure).

Surgery

Your doctor will advise you to have elective (planned) surgery if your aneurysm is:

  • larger than 5.5cm, or 5cm if you have Marfan syndrome or have a family history of aneurysms
  • expanding by more than 1cm per year
  • causing pain or other symptoms, such as difficulty breathing

You will need to have emergency surgery if your aneurysm ruptures.

There are three main surgical options for a thoracic aortic aneurysm.

Open surgery
In open surgery for aortic aneurysm, your surgeon will open your chest to gain access to your aorta. He or she will insert a graft into the weak area of your aorta. The graft will be synthetic and made out of an elastic material. Blood will flow through the graft inside your aorta instead of going through the aneurysm and this will prevent the aneurysm getting bigger.

Keyhole surgery
In keyhole surgery, your surgeon will make two or three small cuts in your chest and will insert a tube-like telescopic camera, which will send pictures to a monitor so he or she can see the aneurysm. Your surgeon passes specially designed surgical instruments through the other cuts to put the graft into place. However, keyhole surgery isn't suitable for everybody – ask your doctor if it’s an option for you.

Endovascular stent graft replacement
In endovascular aneurysm repair (EVAR), your surgeon will feed a stent – a tube that is covered with synthetic graft material – through the femoral arteries in your groin, up through your aorta to the area of the aneurysm. Your surgeon will use X-ray images to guide the placement of the stent. The graft material will bond with the arterial wall and blood will flow through the stent instead of the weakened aneurysm. However, stents aren't suitable for everyone, it depends on the location of the aneurysm and other factors. Ask your doctor for more information.

Prevention of thoracic aortic aneurysm

There are several things you can do to reduce your chance of developing an aneurysm – and the associated risk factor of atherosclerosis – including:

  • not smoking
  • having your blood pressure and cholesterol checked regularly
  • exercising regularly
  • maintaining a healthy weight
  • eating a healthy diet

It’s important to have regular medical check-ups if you have a family history of arterial disease so that any problems can be detected early.

What is Marfan syndrome?

Answer

Marfan syndrome is a condition that affects the way in which your body produces fibres that make up the connective tissue in your body, such as between your joints and organs. These fibres provide the strength to the tissues of the body.

Explanation

People with Marfan syndrome have a defect in a gene that controls the production of elastic fibres in their body. The elastic fibres (connective tissue) hold your joints and organs in place and help control how your body grows. Because connective tissue is found throughout your body, the effects of Marfan syndrome can be widespread and involve your heart, lungs, skeleton, skin and eyes, for example. It can also affect your musculoskeletal system, such as your arm, fingers or toes.

About one in 5,000 people have Marfan syndrome. People can inherit the condition, meaning that they get it from a parent who also has it.

If you have Marfan syndrome, you're more at risk of getting an aortic aneurysm because the elastic tissue of your aorta isn't produced correctly. This makes your aorta weaker and so it can widen.

What are the risks of open surgery versus stenting for treating thoracic aortic aneurysm?

Answer

Endovascular aneurysm repair (EVAR), also known as stent grafting, may have fewer risks than open surgery, but it isn't suitable for everyone.

Explanation

Like all major surgical procedures, surgery to repair a thoracic aortic aneurysm carries some risks. These include a heart attack, bleeding, stroke or even death. The risk depends on your specific circumstances and how much of your aorta needs to be replaced.

EVAR substantially reduces the risk of complications, but not all patients can have this procedure. Talk to your doctor or surgeon for more advice.

How long does it take to recover from open surgery for thoracic aortic aneurysm?

Answer

You can expect to be in hospital for around a week. A full recovery usually takes at least six weeks.

Explanation

People respond to surgery differently. Many factors, including your age and general state of health, will affect how quickly you recover from the procedure. If you smoke, it will slow down your recovery. Talk to your surgeon for more information.