A thoracic aortic aneurysm, an abnormal bulge in a weakened wall of the aorta in the chest area, can cause a variety of symptoms and often life-threatening complications. Due to the serious risks it presents, timely diagnosis and treatment of a thoracic aneurysm are critical.

Is a thoracic aortic aneurysm serious?
Thoracic aortic aneurysms affect about 15,000 people in the United States each year, and are the 13th leading cause of death. Research has shown that patients with untreated large thoracic aneurysms are more likely to die of complications associated with their aneurysms than from any other cause.

What is the best treatment for a thoracic aortic aneurysm?
The decision on how to best treat a thoracic aneurysm depends on its size and rate of its growth, location and your overall health. The risk of rupture increases when the aneurysm is larger than about twice the normal diameter of a healthy aorta blood vessel.

Medical Management
If a thoracic aneurysm is small and causes no symptoms, your physician may recommend “watchful waiting,” which includes:

• Close monitoring of the aneurysm with CT or MRI scans every 6 months
• Blood pressure medication to control high blood pressure, and decrease pressure on the weakened area of the aneurysm
• Restriction of some physical activities. Heavy lifting should be avoided due to increased pressure on the aorta, which may put an aneurysm at risk of rupture

The aorta To understand how surgery is used to treat a thoracic aneurysm, it is best to know where the aorta is located and how it functions. The aorta is shaped like an old-fashioned walking cane with the stem of the curved handle coming out of the heart and curling through the aortic arch, which supplies branches of vessels to the head and arms. Once the aorta descends through the chest cavity into the abdomen, it separates off to provide blood to the abdominal organs and both legs. Click here for larger view

Surgery
The decision to treat a thoracic aneurysm with surgery is determined by many factors, including:

• The presence of symptoms, including chest and back pain, and pain in the jaw, neck and upper back
• If the aneurysm is growing more than 1 centimeter (cm) per year
• Signs of an aortic dissection, including sudden, severe sharp tearing pain in the chest or back
• The age of the patient and the patient’s overall medical condition

New evidence has shown that the size of the aneurysm in addition to a patient’s height plays an important role in the decision for surgery. While 5 centimeters is the size most aneurysms are considered for surgery, Cleveland Clinic surgeons have compiled years of experience and published studies to find that a patient’s height and their aneurysm’s size strongly correlates with the need for surgery. For instance, a patient who is over 6 feet tall with a 5 centimeter aneurysm would be recommended for surgery. Yet, a patient who is 5 feet 7 inches with a thoracic aneurysm of 4.7 centimeters is a candidate for surgery due to their individual risk of rupture.

Due to highly individualized characteristics guiding the decision for surgery, it is best that a physician closely monitor your thoracic aneurysm on a regular basis.

How is a thoracic aortic aneurysm treated with surgery?
The current standard surgical treatment of a thoracic aortic aneurysm is the open-chest approach. The main purpose of open-chest surgery to treat a thoracic aneurysm is to replace the weakened portion of the aorta with a fabric tube, called a graft.

Repairing a thoracic aneurysm is surgically complicated and requires an experienced thoracic surgical team. However, neglecting the aneurysm presents a higher risk.

Cleveland Clinic surgeons have considerable experience in complex aortic operations, performing over 1,000 aortic procedures in 2005. Procedures include ascending aorta, aortic arch, descending aorta, thoracoabdominal repairs, and thoracic aorta endovascular stent graft procedures.

2005 Aortic Thoracic Procedures in Cleavlend clinic

Preoperative evaluation
To help ensure the best outcome of thoracic aneurysm surgery, you will undergo a thorough preoperative evaluation to check for atherosclerosis (a hardening of the arteries that damages the artery’s walls) in the body’s blood vessels.

Preoperative evaluation may also include:

• Screening of left ventricular (the heart’s left side) function and an assessment for the presence of coronary artery disease
• Ultrasound examination
• Pulmonary function testing with a spirometer to measure lung function

How is surgery for a thoracic aortic aneurysm completed?
Thoracic aneurysms occur above the diaphragm, including in the ascending aorta, the aorta arch and the descending thoracic aorta.

The location of a thoracic aneurysm determines many factors, including where the incision for surgery is made. If the aneurysm is close to the aortic valve, an incision in the front of the chest (median sternotomy) may be used. An aneurysm close to the aortic valve may also require the valve to be repaired or replaced.

If surgery is needed on the aortic arch, the procedure is approached from the front chest area. A standard incision for an aneurysm in the descending thoracic aorta is made on the left side of the chest (left thoracotomy).

Repairing a thoracic aneurysm
After making an incision in the chest, your thoracic surgeon will replace the weakened portion of the aorta with a graft. The graft is made of a material that is stronger than the weakened aorta, allowing blood to pass through the vessel without causing a bulge.

Total aorta repair can be done as one operation in some patients.

Many patients who have a thoracic aneurysm may also have heart valve disease, disease of the aorta next to the heart, or extensive aorta disease, leading into the abdomen or other major arteries. For those thoracic aneurysms that are extensive or more complex, heart surgery is sometimes performed at the same time as an open-chest aneurysm repair. In addition, thoracic surgeons may work along side vascular surgeons to complete a complex procedure involving the entire aorta or peripheral blood vessels.

The standard surgical treatment for thoracic aneurysms is open-chest aneurysm repair, but Cleveland Clinic surgeons are now able to treat some thoracic and thoracoabdominal aneurysms with a promising, newer procedure called an endovascular stent.

Endovascular means that surgery is performed inside your body using thin, long tubes called catheters. By entering through small incisions in the groin, the catheters guide a stent graft through the blood vessels to the site of the aneurysm. While endovascular stents are only used in limited cases, this type of repair is being evaluated for optimal use.

What are the risks of thoracic aortic aneurysm surgery?
The risks involved with repairing a thoracic aneurysm depend on the extent of the repair required, the length of surgery and on your overall general health. Your surgeon will talk with you about the possible risks and benefits of the procedure.

Complications after thoracic aneurysm surgery may include:

• Heart attack
• Irregular heartbeats
• Bleeding
• Stroke
• Paralysis due to injury of the spinal cord
• Graft infection
• Kidney damage

How long will it take to recover from thoracic aortic aneurysm surgery?
Your length of hospital stay following thoracic aneurysm surgery depends on your condition and the operation performed, but it is typically 7 days.

Most people need at least 4 to 6 weeks to recover from thoracic aneurysm surgery. If your aneurysm is extensive, involves intervention to repair other complications, or if you have other conditions such as heart, lung or kidney disease, recovery may take 2 to 3 months.

After you’ve had surgery to repair an aneurysm, it is recommended you adopt the same heart-healthy lifestyle led by other heart surgery patients. Your health care team can provide more information.

For More Information
To learn more about:

• Our Aorta Clinic and the physicians and surgeons who treat aortic aneurysms
• Aortic Disease, Marfan Syndrome, and Connective Tissue Disorders
• Aorta Surgery

If you need more information or would like to make an appointment, call the Heart and Vascular Institute Resource Nurses at: 216/445-9288 or toll free at 866/289-6911, Monday through Friday from 8:30 am to 4:00 pm, Eastern Standard Time, or use the contact us form.

Sources:

• The Society of Thoracic Surgeons. “Aortic Aneurysms.” (2006). (Accessed 18 May, 2006)
• Vascular Web, Society for Vascular Surgery. “Thoracic Aneurysm.” (2006). (Accessed 18 May, 2006).
• Medline Plus Medical Encyclopedia: Thoracic Aortic Aneurysm (Accessed 21 May, 2006)
• Griepp, RB, Ergin, MA, Lansman, SL, et al. The natural history of thoracic aortic aneurysms. Semin Thorac Cariovasc Surg 1991; 3:258.
• Woo, JY, Bavaria, JE, Mohler, III, ER. Management and outcome of thoracic aortic aneurysm. (December 2005) http://www.uptodate.com/