What is Thoracic Aorta Aneurysm?

The thoracic aorta is a large artery in the chest that is made up of the aortic root, the part of the aorta that rises upwards (ascending aorta), the aortic arch (which is shaped like a curve), and the section of the aorta that goes downwards (descending aorta). An aneurysm is when the size of the artery increases by 50%, often due to a weakness in the wall of the artery.

Thoracic aortic aneurysms (TAA), which are aneurysms occurring in this large chest artery, usually don’t have noticeable symptoms, and about 95% of patients don’t experience any symptoms. Despite this, these aneurysms can lead to serious and life-threatening problems like aortic dissection (a tear in the lining of the aorta) or rupture (bursting). That’s why they are sometimes referred to as “silent killers.”

About 22% of people suffering from an aneurysm complication die before they even reach the hospital. The majority of these aneurysms occur in the root or the ascending aorta, followed by the descending aorta. They rarely occur in the aortic arch.

What Causes Thoracic Aorta Aneurysm?

Being a man, growing older, having conditions like high blood pressure, chronic obstructive pulmonary disease (COPD), heart disease, smoking, and a previous case of aortic dissection all increase the risk of Thoracic Aortic Aneurysm (TAA). The reason for different types of aortic aneurysms is linked to a structure in the body known as the ligamentum arteriosum. Above this structure, wear and tear on the elastic tissue in the aorta can lead to aneurysms; below it, the typical cause is a buildup of fatty deposits, known as atherosclerosis.

These differences are thought to be related to the various origins of the muscle cells in these two areas during development in the womb. A history of TAA in the family is a strong risk factor; about 20% of TAA cases can be traced back to inherited conditions. However, only 5% of those affected have genetic syndromes like Marfan syndrome, Loeys-Deitz syndrome, and Ehlers-Danlos syndrome.

About 21% of patients with a family history of TAA do not have an accompanying syndrome – these cases are called “nonsyndromic familial aortic aneurysms”. In these instances, the aneurysms occur without any other related conditions. In some rare cases, an inflammation of the heart valve (endocarditis) on the left side can lead to the dilation (enlargement) of the aortic root.

Before the discovery of antibiotics, syphilis was a leading cause of aortic aneurysms. Other inflammatory diseases, like Takayasu, Behçet, giant cell, lupus, sarcoidosis, rheumatoid arthritis, and ankylosing spondylitis can, in some rare instances, affect the aorta and result in an aneurysm. Other rare causes can include a two-leaflet aortic valve (bicuspid aortic valve) and an isolated enlargement of the area of the aorta connected to the heart.

Additionally, having TAA has been associated with other conditions and abnormalities such as an abdominal aortic aneurysm, brain aneurysm, kidney cysts, and a specific type of aortic arch, known as bovine aortic arch.

Risk Factors and Frequency for Thoracic Aorta Aneurysm

In the US, around 13,000 people die from aortic disease every year, with thoracic aortic aneurysms (TAA) being the 18th most common cause of death. The occurrence of TAA is about 10 cases per 100,000 patient years, and the existing rate ranges from 0.16% to 0.34%. The number of TAA cases is increasing due to improved imaging techniques for diagnosis and longer overall lifespan. Those with inherited TAA usually show symptoms around the age of 56.8 years, while those with TAA from other causes typically show symptoms around the age of 64.3 years. TAA is more common in men, but women usually experience more severe health issues and have a higher risk of the aorta rupturing.

  • Each year, about 13,000 people in the US die from aortic disease, with TAA being the 18th most common cause of death.
  • The occurrence of TAA is approximately 10 cases per 100,000 patient years, and the existing rate is between 0.16% to 0.34%.
  • The number of TAA cases is rising due to improved medical imaging and increased lifespan.
  • People with inherited TAA usually start showing symptoms around the age of 56.8 years, while those with TAA from other causes typically start around 64.3 years.
  • Men are more likely to develop TAA, but the condition usually causes more severe health problems in women, including a higher risk of aorta rupture.

Signs and Symptoms of Thoracic Aorta Aneurysm

Thoracic aortic aneurysms often don’t show symptoms in most patients. However, in some cases, patients might experience symptoms like chest pain that extends to the back, signs of severe low blood pressure, or even signs of a tear in the aorta. Symptoms can also occur due to the pressure exerted by the aneurysm on surrounding structures. This might lead to difficulty in breathing because of pressure on the airway or symptoms of superior vena cava syndrome, which is when blood flow is blocked to the vein carrying blood from the upper body to the heart. Some people may develop hoarseness of voice because of the pressure on the recurrent laryngeal nerve. In rare cases, ascending or root aneurysms might show signs of heart failure due to a rupture in the right atrium or superior vena cava, or blood-streaked spit due to bleeding in the lung. It’s essential to ask patients if there’s a family history of sudden cardiac death.

  • Chest pain that extends to the back.
  • Severe low blood pressure, possibly indicating a tear in the aorta.
  • Difficulty breathing due to pressure on the airway.
  • Signs of superior vena cava syndrome.
  • Hoarseness of voice due to pressure on the recurrent laryngeal nerve.
  • Signs of heart failure due to a rupture in the right atrium or superior vena cava (in rare cases).
  • Blood-streaked spit due to bleeding in the lung (in rare cases).
  • Family history of sudden cardiac death.

During a physical exam, most aneurysms don’t reveal any signs. However, in people with aortic regurgitation, a heart condition where the aortic valve doesn’t close tightly, doctors may hear a specific type of heart murmur and notice a broad gap between systolic and diastolic blood pressure. Doctors should also check for physical signs of Marfan and Loeys Dietz syndromes, conditions that increase the risk of aortic aneurysms.

Testing for Thoracic Aorta Aneurysm

To diagnose thoracic aortic aneurysms (which are abnormal bulges in the wall of the aorta, the largest blood vessel in your body), doctors often use a method known as a contrast-enhanced CT scan. This type of scan is much in demand as it allows doctors to rapidly assess the size, location, and extent of the aneurysm. It also lets them clearly visualize calcifications, dissections, and mural thrombus (blood clots) within the aorta. If any previous CT scans are available, then the current one should be compared with the first one and not the most recent scan.

Magnetic Resonance Imaging (MRI) is another method employed by doctors. It provides a detailed 3D image of the ascending aorta. A special kind of MRI known as Contrast-enhanced MR angiography with gadolinium allows for a more precise measurement of the aorta and its branches.

Doctors also use a technique known as Transesophageal echocardiography (TEE) for diagnosing aortic aneurysms. It is a reliable way to accurately measure different parts of the aorta. Transthoracic echocardiography (TTE), on the other hand, is a reliable test to check the root of the aorta and the severity of aortic regurgitation (leakage of blood through the aortic valve).

Ascending aortography is an imaging technique that provides clear images of the shape of the aorta. However, it can’t measure the size of the aorta.

PET scans, a relatively new method, highlight areas with increased metabolic activity, a sign of inflammation suggesting a potential rupture.

A chest x-ray can show signs of an aortic aneurysm. If an ascending aortic aneurysm is present, there’d be no retrosternal airspace in the lateral views of the chest x-ray.

An Electrocardiogram (EKG) shows changes related to aortic insufficiency (leakiness of the aortic valve), signs of strain, and left ventricular hypertrophy (enlargement of the heart’s left pumping chamber). It can also show changes associated with coronary artery disease.

Lastly, genetic testing can now be used to assess for the presence of thoracic aortic aneurysms. Techniques like whole-exome and genome sequencing allow for effective examination of genes associated with this condition. Doctors can diagnose patients with high-risk genotypes, such as MYLK, ACTA2, and MYH11 mutations efficiently.

Treatment Options for Thoracic Aorta Aneurysm

The main goal of non-surgical treatment for thoracic aortic aneurysms (TAA) is to lower the stress on the aorta. This can slow down the growth of the aneurysm. Medications like beta-blockers – which lower blood pressure – are often used first. Other medications such as angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors, which can lower proteins related to aneurysm growth, are also beneficial, especially for patients with Marfan syndrome. Lipid-lowering drugs like statins may also be used as they can reduce the risk of rupture. However, fluoroquinolones should be avoided as they can increase wall degeneration. For patients without symptoms, doctors will regularly monitor the aneurysm’s growth. Advice on lifestyle changes such as quitting smoking and controlling blood pressure through diet is also key.

Surgery is often used to prevent the aneurysm from rupturing or splitting (dissecting). Patients showing signs of acute dissection, rupture, or internal bleeding from the aneurysm’s wall need immediate surgery. Surgery is also recommended when the diameter of the ascending aorta (the part connected to the heart) reaches 5.5 cm, and when the descending aorta (the part that leads down to the abdomen) reaches 6.5 cm. For people with Marfan syndrome, if the diameter of the ascending aorta reaches 5 cm, surgery is recommended. During surgery, the section of the aorta with the aneurysm is removed and replaced with a synthetic graft. The extent of the surgery depends on the location of the aneurysm. Some people may need the uppermost part of their aorta replaced, while others may require more extensive surgery involving the aortic root or arch. The surgical approach involves stopping and cooling the blood flow (deep hypothermic circulatory arrest) to protect the brain and other organs.

Various surgical techniques can be used to repair TAAs. A different kind of surgery, known as thoracic endovascular aortic repair (TEVAR), uses grafts inserted into the arteries to repair TAAs. Although TEVAR is a less invasive procedure, care must be taken to ensure it does not reduce blood flow to the spinal cord. In some situations, custom-made grafts may be used.

If you have a condition called aortic dissection, you’ll most likely feel a severe chest pain that feels like it’s tearing and radiates to your back. This condition can be a complication of another health problem called a Thoracic Aortic Aneurysm (TAA) as it can weaken the wall of your aorta and increase stress on it. The major sign of aortic dissection is the development of a tear in the inner layer of the aorta creating what doctors call true and false passageways. Additional symptoms may include low blood pressure, feeling sick to your stomach, struggling to breathe, and a notable difference in blood pressure between your right and left arm.

Medical imaging like a chest X-ray might show an enlarged silhouette of your heart area. A more detailed image from a CT scan can clearly display the layers and passageways in the aortic wall. If you are diagnosed with an aortic dissection, you will need emergency surgery to repair the tear.

There is another condition known as thoracic aortic pseudoaneurysm, which is basically a tear in the aorta that is covered by a thin layer. It can occur due to trauma or the erosion of a damaged and ulcerated plaque. People with this condition may experience chest pain or even functional impairments due to the clot breaking off and blocking blood flow. CT scans and angiograms can help visualize this condition. Again, a surgical operation is crucial to prevent a potential aortic rupture.

Aortic intramural hematoma is a condition where blood collects in the middle layer of the aorta. Usually, there are no tears in the inner layer. This can happen because of a penetrating ulcer resulting from hardened and narrow arteries or due to blockage of the false passageway after a dissection. Surgery is required to restore the normal structure of the aortic wall as the blood collection can also trigger aortic dissection.

What to expect with Thoracic Aorta Aneurysm

Every year, the swelling of the main blood vessel that carries blood from your heart for the rest of your body (the aorta) can grow in size — the ascending aortic aneurysm grows by 1 mm, while the descending aortic aneurysm grows up to 3 mm. When the aorta expands to a size of 6 cm, it loses its flexibility and takes on the characteristics of a rigid tube. This results in a scenario where increased blood pressure places extra stress on the aortic wall.

Surgery is recommended for all patients showing symptoms and those without, but have an aneurysm that’s growing too large. Data reveals that patients who had an elective operation have a five-year survival rate of 85%. Meanwhile, those who underwent emergency surgery have a five-year survival rate of 37%.

Possible Complications When Diagnosed with Thoracic Aorta Aneurysm

An aortic aneurysm can lead to aortic dissection (a tear in the body’s main artery) and rupture, which statistically occur at the same rate of 3.5 per 100,000 patient years. The risk of rupture increases to 34% when the aneurysm in the ascending aorta reaches 6 cm in size.
Situations that cause sudden emotional stress or intensive physical activity like weight lifting can increase blood pressure significantly, up to 300 mmHg, which can trigger an acute aortic dissection or rupture.
Interesting patterns have been noticed – aortic dissection is more common during the winter and morning hours, times when blood pressure usually peaks.

Surgery to address an aortic aneurysm can result in complications such as excessive bleeding, stroke, lung functions issues, heart problems, and a considerable risked of death during surgery. This risk of mortality is 28.6% in surgical repairs of the descending aorta and 23.4% in endovascular repairs.

Lastly, in a study looking at people who had sudden cardiac death, between 2 to 7.3% experienced complications from thoracic aortic aneurysm (TAA), such as aortic dissection and rupture.

    • Increased risk of aortic dissection or rupture in cases of elevated blood pressure.
    • The chance of rupture rises when the ascending aortic aneurysm increases to a size of 6 cm.
    • Highest incidences of aortic dissection occur in winter and morning hours due to higher blood pressure.
    • Several complications, including excessive bleeding, stroke, issues with lung and heart function, could occur during surgeries to repair aortic aneurysms
    • Risk of death during surgery is 28.6% for repairs of the descending aorta and 23.4% for endovascular repairs.
    • In cases of sudden cardiac death, 2 to 7.3% of patients were found to have complications from thoracic aortic aneurysms, such as aortic dissection and rupture.
  • Preventing Thoracic Aorta Aneurysm

    Your aorta is a large blood vessel that carries oxygen-enriched blood from your heart to your brain and the rest of your body. It has two main parts. The section that runs through your chest is known as the thoracic aorta, while the lower part in your abdomen is called the abdominal aorta.

    A thoracic aortic aneurysm occurs when part of this vessel expands or bulges out larger than it should be. The aneurysm can often occur at the point where your heart connects to the aorta (ascending aortic aneurysm), or in the part of the thoracic aorta closer to your legs (descending aortic aneurysm). Even though many people with this condition don’t have any symptoms, some may experience chest or back pain, a cough, or a hoarse voice.

    This is a serious condition that often doesn’t show initial symptoms but can lead to severe pain in the chest that continues to the back when the aorta’s layers start to tear. This is known as an aortic dissection. Similar pain can result when the aneurysm ruptures or bursts. These are the complications that we worry about most and can be life-threatening.

    Risk factors for developing these aneurysms include being male, smoking, having uncontrolled high blood pressure, and high cholesterol levels. Moreover, people with certain genetic diseases that affect connective tissues are more likely to develop an aneurysm in the ascending aorta.

    Those at risk should get regular checkups to measure the size of their aorta. If your doctor suspects you have a thoracic aneurysm, they may recommend a CT scan to get detailed images of your aorta. If an aneurysm is detected and it’s small, your doctor will monitor it regularly. They may also suggest lifestyle changes: avoid strenuous workouts or heavy lifting, maintain a calm demeanor to avoid sudden surges in your blood pressure, and quit smoking or avoid secondhand smoke exposure.

    If the aneurysm is larger or growing quickly, or if it’s causing symptoms, surgery may be needed. Those with a family history of sudden heart-related deaths and thoracic aortic aneurysms should get checked out. There’s also the option of genetic testing to see if other family members carry the same disease-causing genes.

    Frequently asked questions

    The prognosis for Thoracic Aorta Aneurysm depends on several factors, including the size of the aneurysm, the presence of symptoms, and the timing of surgery. However, data shows that patients who undergo elective surgery have a five-year survival rate of 85%, while those who require emergency surgery have a five-year survival rate of 37%. Therefore, early detection and timely surgical intervention are crucial for improving prognosis.

    Being a man, growing older, having conditions like high blood pressure, chronic obstructive pulmonary disease (COPD), heart disease, smoking, and a previous case of aortic dissection all increase the risk of Thoracic Aortic Aneurysm (TAA). The reason for different types of aortic aneurysms is linked to a structure in the body known as the ligamentum arteriosum. Above this structure, wear and tear on the elastic tissue in the aorta can lead to aneurysms; below it, the typical cause is a buildup of fatty deposits, known as atherosclerosis. These differences are thought to be related to the various origins of the muscle cells in these two areas during development in the womb. A history of TAA in the family is a strong risk factor; about 20% of TAA cases can be traced back to inherited conditions. However, only 5% of those affected have genetic syndromes like Marfan syndrome, Loeys-Deitz syndrome, and Ehlers-Danlos syndrome. About 21% of patients with a family history of TAA do not have an accompanying syndrome - these cases are called "nonsyndromic familial aortic aneurysms". In these instances, the aneurysms occur without any other related conditions. In some rare cases, an inflammation of the heart valve (endocarditis) on the left side can lead to the dilation (enlargement) of the aortic root. Before the discovery of antibiotics, syphilis was a leading cause of aortic aneurysms. Other inflammatory diseases, like Takayasu, Behçet, giant cell, lupus, sarcoidosis, rheumatoid arthritis, and ankylosing spondylitis can, in some rare instances, affect the aorta and result in an aneurysm. Other rare causes can include a two-leaflet aortic valve (bicuspid aortic valve) and an isolated enlargement of the area of the aorta connected to the heart. Additionally, having TAA has been associated with other conditions and abnormalities such as an abdominal aortic aneurysm, brain aneurysm, kidney cysts, and a specific type of aortic arch, known as bovine aortic arch.

    Signs and symptoms of Thoracic Aortic Aneurysm include: - Chest pain that extends to the back - Severe low blood pressure, possibly indicating a tear in the aorta - Difficulty breathing due to pressure on the airway - Signs of superior vena cava syndrome, which is when blood flow is blocked to the vein carrying blood from the upper body to the heart - Hoarseness of voice due to pressure on the recurrent laryngeal nerve - Signs of heart failure due to a rupture in the right atrium or superior vena cava (in rare cases) - Blood-streaked spit due to bleeding in the lung (in rare cases) - Family history of sudden cardiac death During a physical exam, most aneurysms don't reveal any signs. However, in people with aortic regurgitation, a heart condition where the aortic valve doesn't close tightly, doctors may hear a specific type of heart murmur and notice a broad gap between systolic and diastolic blood pressure. Doctors should also check for physical signs of Marfan and Loeys Dietz syndromes, conditions that increase the risk of aortic aneurysms.

    The types of tests that are needed for Thoracic Aortic Aneurysm include: 1. Contrast-enhanced CT scan: This scan allows doctors to assess the size, location, and extent of the aneurysm. It also helps visualize calcifications, dissections, and blood clots within the aorta. 2. Magnetic Resonance Imaging (MRI): This provides a detailed 3D image of the ascending aorta. Contrast-enhanced MR angiography with gadolinium allows for a more precise measurement of the aorta and its branches. 3. Transesophageal echocardiography (TEE): This is a reliable way to accurately measure different parts of the aorta. 4. Transthoracic echocardiography (TTE): This is a reliable test to check the root of the aorta and the severity of aortic regurgitation. 5. Ascending aortography: This imaging technique provides clear images of the shape of the aorta. 6. PET scan: This relatively new method highlights areas with increased metabolic activity, indicating inflammation and a potential rupture. 7. Chest x-ray: This can show signs of an aortic aneurysm, such as the absence of retrosternal airspace in lateral views. 8. Electrocardiogram (EKG): This shows changes related to aortic insufficiency, signs of strain, left ventricular hypertrophy, and coronary artery disease. 9. Genetic testing: Techniques like whole-exome and genome sequencing can assess for the presence of thoracic aortic aneurysms and identify high-risk genotypes.

    The doctor needs to rule out the following conditions when diagnosing Thoracic Aortic Aneurysm: 1. Aortic dissection 2. Thoracic aortic pseudoaneurysm 3. Aortic intramural hematoma

    The side effects when treating Thoracic Aorta Aneurysm include: - Increased risk of aortic dissection or rupture in cases of elevated blood pressure. - The chance of rupture rises when the ascending aortic aneurysm increases to a size of 6 cm. - Highest incidences of aortic dissection occur in winter and morning hours due to higher blood pressure. - Several complications, including excessive bleeding, stroke, issues with lung and heart function, could occur during surgeries to repair aortic aneurysms. - Risk of death during surgery is 28.6% for repairs of the descending aorta and 23.4% for endovascular repairs. - In cases of sudden cardiac death, 2 to 7.3% of patients were found to have complications from thoracic aortic aneurysms, such as aortic dissection and rupture.

    A cardiovascular surgeon or a thoracic surgeon.

    The occurrence of TAA is approximately 10 cases per 100,000 patient years, and the existing rate is between 0.16% to 0.34%.

    The treatment for Thoracic Aortic Aneurysm (TAA) can be both non-surgical and surgical. Non-surgical treatment aims to lower the stress on the aorta and slow down the growth of the aneurysm. This can involve the use of medications such as beta-blockers, angiotensin receptor blockers (ARBs), angiotensin-converting enzyme (ACE) inhibitors, and lipid-lowering drugs like statins. Lifestyle changes such as quitting smoking and controlling blood pressure through diet are also important. Surgical treatment is often used to prevent rupture or dissection of the aneurysm. Surgery is recommended when the diameter of the ascending aorta reaches certain thresholds, and during surgery, the section of the aorta with the aneurysm is removed and replaced with a synthetic graft. Various surgical techniques can be used, including thoracic endovascular aortic repair (TEVAR) which is a less invasive procedure.

    Thoracic aortic aneurysm is when the size of the thoracic aorta, a large artery in the chest, increases by 50% due to a weakness in the artery wall. It can lead to serious and life-threatening problems like aortic dissection or rupture.

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