Patient education: Thoracic aortic aneurysm (The Basics)

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What is a thoracic aortic aneurysm? — A "thoracic aortic aneurysm" is a problem in the aorta, the main blood vessel that comes out of the heart. Blood flows through the aorta to the rest of the body. The "thoracic aorta" is the upper part of the aorta. In people with a thoracic aortic aneurysm, also known as a "TAA," a part of the thoracic aorta balloons out or bulges.

A TAA can happen in different parts of the aorta (figure 1):

●The "ascending" thoracic aorta – This is the part that comes out of the heart and leads up toward the neck.

●The "descending" thoracic aorta – This is the part that leads down toward the belly.

If a TAA bursts, it is very dangerous. A burst aorta causes lots of internal bleeding.

What are the symptoms of a TAA? — Most people with TAAs have no symptoms. Some people have pain in the chest, back, or belly.

Other symptoms are less common. They depend on how big the TAA is and which part of the thoracic aorta is affected. TAA in the ascending aorta can cause heart problems.

If the TAA presses against other parts inside the body, symptoms might include:

●Cough, wheezing, or trouble breathing

●A hoarse voice

●Trouble swallowing

●Swelling of the face, neck, or arms

TAAs can burst with no warning. This can cause severe chest or back pain.

Who is most likely to get a TAA? — Your risks go up if you:

●Are male

●Smoke

●Have high blood pressure

●Have high cholesterol

●Have family members who have had the condition

●Have an "abdominal aortic aneurysm," which is a weakness or bulge in the lower part of the aorta

●Have a problem with the aortic valve, which is the valve that lets blood flow from the heart through the aorta

TAAs are more common in people with certain genetic conditions affecting the connective tissues. (Connective tissues make up and support the skin, bones, blood vessels, and other organs.) If you have one of these conditions, your doctor or nurse will talk to you about your risk of having a TAA. They will also decide if you should have regular testing.

People who have had certain other problems with their aorta are also at higher risk. For example, an "aortic dissection" that was not repaired right away can lead to a TAA. An aortic dissection is a tear in the inner wall of the aorta. People with a TAA are also more likely to get an aortic dissection.

Is there a test for TAAs? — Yes. If a doctor thinks you might have a TAA, they will do an imaging test to look at your thoracic aorta. Imaging tests create pictures of the inside of the body. The most common tests for TAA are CT and MRI scans. They can show if you have a TAA, where it is, and how big it is.

Depending on your situation, you might need other tests, too. For example, if you have a TAA in the ascending aorta, your doctor will want to check how well your heart is working. In some cases, doctors find a TAA when a person gets an imaging test, such as a chest X-ray, for another reason.

How are TAAs treated? — It depends. If your TAA is small and you are not having any symptoms, you might not need treatment right away.

If you have another condition related to your TAA, your doctor will decide if it needs treatment or tests.

What should I do if I have a TAA but don't need surgery? — You will need to:

●Get regular imaging tests – TAAs get bigger over time. These tests will show how fast yours is getting bigger. You will get tests every 3 months to 1 year, depending on how big your TAA is.

●Take medicine to control your heart rate and blood pressure

●Call your doctor if you start having pain in your chest, back, or belly. Pain can be a sign that the aneurysm is bursting.

People who have a TAA, even a small one, are at increased risk for heart disease. Your doctor can talk to you about ways to help lower your risk. This might include improving your diet, exercising more, and quitting smoking if you smoke.

When should TAAs be repaired? — Repair is the best treatment if your TAA is at risk of bursting. Your doctor can help you understand your risk based on:

●How large your TAA is

●How fast your TAA is getting bigger

●Your other conditions or health problems

How are TAAs repaired? — It depends on where your TAA is, and how big it is. It also depends on your age, health, and other medical conditions.

The ways to fix a TAA are:

●Traditional "open" surgery – If your TAA is in the ascending thoracic aorta (the part closest to the heart), it will need to be repaired with open surgery. For open surgery, the doctor cuts open your chest to get to your aorta. They might cut into your belly if the abdominal aorta is affected.

Before the surgery, you will get medicines (called anesthesia) to help you relax and then to make you unconscious. The doctor will place clamps on the aorta to stop blood from flowing through. Then they will replace the bulging part of the aorta with a tube called a "graft" (figure 2). The graft is made from a special fabric, and is sewn into place. After the clamps are removed, blood can flow normally through it. If there are problems with other parts of the aorta, its branches, or the heart valves, these can also be fixed during open surgery.

To do open surgery, the doctor might need to stop your heart for a short time. If this happens, a machine called the "heart-lung machine" will take over the work of your heart while the aorta is being fixed. The machine will keep blood flowing throughout your body. After the graft is in place, the doctor can restart your heart and take you off the heart-lung machine.

●Endovascular stent graft – If your TAA is in the descending thoracic aorta (the part that goes toward the belly), you might be able to have an endovascular repair.

To fix the aorta this way, the doctor makes a cut in a blood vessel at the top of the thigh and inserts a folded graft. Then the doctor threads the graft up to the bulging part of the aorta and unfolds it (figure 3). This type of graft does not need to be sewn into place. Blood flows through the graft.

●A combination (or "hybrid") repair – This involves open surgery followed by an endovascular graft. It might be an option in some situations.

What will happen after my TAA repair? — It depends on what kind of repair you had, as well as your age and health.

●If you had open surgery or hybrid repair, you will need to stay in the hospital, probably for at least a week or so. Your doctor will watch you for problems, such as internal bleeding. Other problems that can sometimes happen include stroke, spinal cord injury, and kidney failure. Your doctor can tell you how serious your risks for these might be. The risks depend on the type of aneurysm you had and how it was repaired.

Your body will need time to recover after major surgery. Most people don't feel back to normal for at least a couple of months, often longer.

●If you had only an endovascular repair, you will stay in the hospital for a few days. Recovery is much faster with this type of repair than with open surgery. But your doctor will still watch you for problems. In some cases, the endovascular stent graft can leak or slip out of place.

After repair, you will get imaging tests. For endovascular repairs, it's important to get these tests regularly. This is so your doctor can make sure the stent graft stays in place.

Can TAAs be prevented? — No. But you can greatly reduce your risk by not smoking. If you have high blood pressure, it is also important to control your blood pressure.