A thoracic aortic aneurysm is a weakened area in the upper part of the aorta. The aorta is the major blood vessel that feeds blood to the body.

A thoracic aortic aneurysm may also be called thoracic aneurysm and aortic dissection (TAAD) because an aneurysm can lead to a tear in the artery wall (dissection) that can cause life-threatening bleeding. Small and slow-growing thoracic aortic aneurysms may not ever rupture, but large, fast-growing aneurysms may.

Depending on the size and growth rate of your thoracic aortic aneurysm, treatment may vary from watchful waiting to emergency surgery. Ideally, surgery for a thoracic aortic aneurysm can be planned if necessary.

Thoracic aortic aneurysms often grow slowly and usually without symptoms, making them difficult to detect. Some aneurysms will never rupture. Many start small and stay small, although many expand over time. How quickly an aortic aneurysm may grow is difficult to predict.

As a thoracic aortic aneurysm grows, some people may notice:

  • Tenderness or pain in the chest
  • Back pain
  • Hoarseness
  • Cough
  • Shortness of breath

Aneurysms can develop anywhere along the aorta, which runs from your heart through your abdomen. When they occur in the upper part of the aorta, they are called thoracic aortic aneurysms. More commonly, aneurysms form in the lower part of your aorta and are called abdominal aortic aneurysms. Less commonly, an aneurysm can occur in between the upper and lower parts of your aorta. This type of aneurysm is called a thoracoabdominal aneurysm.

When to see a doctor

Most people with aortic aneurysms do not have symptoms unless a tear (dissection) or rupture has occurred. A rupture or dissection is a medical emergency. Call 911 or your local emergency number for immediate assistance.

If an aneurysm ruptures or one or more layers of the artery wall splits (dissection), you may feel:

  • Sharp, sudden pain in the upper back that radiates downward
  • Pain in your chest, jaw, neck or arms
  • Difficulty breathing

If you have a family history of aortic aneurysm, Marfan syndrome or other connective tissue disease, or bicuspid aortic valve, your doctor may recommend regular ultrasound exams to screen for aortic aneurysm.

The exact causes of thoracic aortic aneurysms are unknown, but factors that can contribute to an aneurysm's development include:

  • Hardening of the arteries (atherosclerosis). As plaque builds up on your artery walls, they become less flexible, and the additional pressure can cause them to weaken and bulge. High blood pressure and high cholesterol are risk factors for hardening of the arteries.
  • Connective tissue diseases. People who are born with Marfan syndrome, a genetic condition that affects the connective tissue in the body, are particularly at risk of a thoracic aortic aneurysm. Those with Marfan syndrome may have a weakness in the aortic wall that makes them more susceptible to aneurysm. People with Marfan syndrome often have distinct physical traits, including tall stature, very long arms, a deformed breastbone and eye problems.

    Besides Marfan syndrome, other connective tissue diseases, such as Ehlers-Danlos and Loeys-Dietz syndromes, can contribute to a thoracic aortic aneurysm. Ehlers-Danlos syndrome causes your skin, joints and connective tissue to be fragile and makes your skin stretch easily.

  • Other medical conditions. Inflammatory conditions, such as giant cell arteritis and Takayasu's arteritis, may cause thoracic aortic aneurysms.
  • Problems with your heart's valves. Sometimes people who have problems with the valve that blood flows through as it leaves your heart (aortic valve), have an increased risk of thoracic aortic aneurysm. This is especially true for people who have a bicuspid aortic valve, meaning their aortic valve has only two leaflets instead of three.
  • Untreated infections. Though not a common cause of thoracic aortic aneurysm, you're more likely to develop this condition if you've had an untreated infection, such as syphilis or salmonella.
  • Traumatic injury. Some people who are injured in falls or motor vehicle crashes develop thoracic aortic aneurysms.

An aortic aneurysm is different from an aortic dissection. Aortic dissection can occur in the same place many aneurysms occur. In aortic dissection, a tear occurs in the wall of the aorta. This causes bleeding into and along the aortic wall and, in some cases, completely outside the aorta (rupture). Aortic dissection is a life-threatening emergency.

Thoracic aortic aneurysm risk factors include:

  • Age. Thoracic aortic aneurysms occur most often in people age 65 and older.
  • Tobacco use. Tobacco use is a strong risk factor for the development of an aortic aneurysm. The longer you've smoked or chewed tobacco, the greater your risk.
  • High blood pressure. Increased blood pressure damages the blood vessels in the body, raising your chances of developing an aneurysm.
  • Buildup of plaques in your arteries (atherosclerosis). The buildup of fat and other substances that can damage the lining of a blood vessel (atherosclerosis) increases your risk of an aneurysm.
  • Family history. People who have a family history of aortic aneurysm are at increased risk of having one. People who have a family history of aneurysms tend to develop aneurysms at a younger age and are at higher risk of rupture.
  • Connective tissue disorders. If you have a connective tissue disorder, such as Marfan syndrome or Ehlers-Danlos syndrome, you have a significantly higher risk of a thoracic aortic aneurysm.

Tears in the wall of the aorta (dissection) and rupture of the aorta are the main complications of thoracic aortic aneurysm. A ruptured aortic aneurysm can lead to life-threatening internal bleeding. In general, the larger the aneurysm, the greater the risk of rupture.

Signs and symptoms that your thoracic aortic aneurysm has burst include:

  • Sudden, intense and persistent chest or back pain
  • Pain that radiates to your back
  • Trouble breathing
  • Low blood pressure
  • Loss of consciousness
  • Shortness of breath
  • Weakness or paralysis of one side of the body, difficulty speaking, or other signs of stroke

Blood clot risk

Another complication of aortic aneurysms is the risk of blood clots. Small blood clots can develop in the area of the aortic aneurysm. If a blood clot breaks loose from the inside wall of an aneurysm, it can block a blood vessel elsewhere in your body, possibly causing serious complications.

If you think you may have a thoracic aortic aneurysm or are worried about your aneurysm risk because of a strong family history, make an appointment with your family doctor. If an aneurysm is found early, your treatment may be easier and more effective.

Because many thoracic aortic aneurysms are found during a routine physical exam or while your doctor is looking for another condition, there are no special preparations necessary. If you're being screened for an aortic aneurysm, your doctor will likely ask if anyone in your family has ever had an aortic aneurysm, so have that information ready.

Because appointments can be brief and there's often a lot of ground to cover, it's a good idea to be prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

  • Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet. For an ultrasound or echocardiogram, for example, you may need to fast for a period of time beforehand.
  • Write down any symptoms you're experiencing, including any that may seem unrelated to a thoracic aortic aneurysm.
  • Write down key personal information, including a family history of heart disease, aneurysms or connective tissue disease.
  • Make a list of all medications, vitamins or supplements that you take.
  • Take a family member or friend along, if possible. Sometimes it can be difficult to recall all of the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Be prepared to discuss your diet, exercise habits and tobacco use. If you don't already follow a diet or exercise routine, be ready to talk to your doctor about any challenges you might face in getting started. Be sure to tell your doctor if you're a current or former smoker.
  • Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out. For an aortic aneurysm, some basic questions to ask your doctor include:

  • What's the most likely cause of my symptoms?
  • What kinds of tests will I need to confirm a thoracic aortic aneurysm?
  • What treatments are available, and which do you recommend for me?
  • What's an appropriate level of physical activity?
  • Do I need to change my diet?
  • How often should I be screened for an aneurysm?
  • Should I tell other family members to be screened for an aneurysm?
  • I have other health conditions. How can I best manage these conditions together?
  • Is there a generic alternative to the medicine you're prescribing me?
  • Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting for more information?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask additional questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

  • When did you first begin experiencing symptoms?
  • Do your symptoms come and go, or do you have them all the time?
  • How severe are your symptoms?
  • Do you have a family history of aneurysms or other hereditary diseases, such as Marfan syndrome?
  • Have you ever smoked?
  • Have you ever been told you have high blood pressure?
  • Does anything seem to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?

What you can do in the meantime

It's never too early to make healthy lifestyle changes, such as quitting smoking, eating healthy foods and becoming more physically active. These are primary lines of defense against thoracic aortic aneurysm and its complications.

If you're diagnosed with a thoracic aortic aneurysm, you should ask about the size of your aneurysm, whether your doctor has noticed any changes and how frequently you should visit your doctor for follow-up appointments.

Thoracic aortic aneurysms are often found during routine medical tests, such as a chest X-ray or ultrasound of the heart or abdomen, sometimes ordered for a different reason.

If your doctor suspects that you have an aortic aneurysm, specialized tests can confirm it. These tests might include:

  • Chest X-ray. Your doctor may first notice you have a thoracic aortic aneurysm by looking at chest X-ray images. Your doctor may order a chest X-ray as a first test to check for problems with the upper part of your aorta, or your doctor may discover a thoracic aortic aneurysm on X-ray images ordered to check for another condition.
  • Echocardiogram. Thoracic aortic aneurysms may be diagnosed by echocardiogram, and this technique is often used to screen family members of those with thoracic aortic aneurysm. An echocardiogram is often used to check for aneurysms in someone with Marfan syndrome. An echocardiogram uses sound waves to capture real-time images of your heart in motion. Echocardiograms show how well your heart chambers and valves are working. Occasionally, to better see your aorta, your doctor may recommend a transesophageal echocardiogram — in which the sound waves are generated from within your body by a device threaded down your esophagus.
  • Computerized tomography (CT) scan. This painless test can provide your doctor with clear images of your aorta. During a CT scan, you lie on a table inside a doughnut-shaped machine. Detectors inside the gantry measure the radiation that has passed through your body and converts it into electrical signals. One downside of the use of CT in detecting and following aortic aneurysms is the exposure to radiation, particularly for patients who require frequent monitoring, such as those with Marfan syndrome.
  • Magnetic resonance angiography (MRA). MRA is another painless imaging test. Most MRA machines contain a large magnet shaped like a doughnut or tunnel. You lie on a movable table that slides into the tunnel. The magnet produces signals that vary according to the type of tissue the magnet scans. Your doctor can use the images produced by the signals to see if you have an aneurysm.

Screening for thoracic aortic aneurysms

Conditions that cause a thoracic aortic aneurysm may run in families. Because of this, your doctor may recommend you have tests to check for thoracic aortic conditions if a first-degree relative, such as a parent, sibling, son or daughter, has Marfan syndrome or another condition that could cause a thoracic aortic aneurysm. These tests may include:

  • Imaging tests. Your doctor may recommend that your first-degree relatives have an echocardiogram or another type of imaging test to check for Marfan syndrome or another thoracic aortic condition. If your doctor finds you have an enlarged aorta or an aneurysm, you'll likely need another imaging test within six months to make sure your aorta hasn't grown larger.
  • Genetic testing. If you have a family history of Marfan syndrome, or another genetic condition that raises your risk of thoracic aortic aneurysm, you may want to consider genetic testing and genetic counseling before starting a family.

The goal of treatment is to prevent your aneurysm from rupturing. Generally, your treatment options are medical monitoring or surgery. Your decision depends on the size of the aortic aneurysm and how fast it's growing.

Medical monitoring

If your thoracic aortic aneurysm is small, your doctor may recommend medical monitoring, which includes regular appointments to make sure your aneurysm isn't growing, and management of other medical conditions that could worsen your aneurysm.

It's likely your doctor will order regular imaging tests to check on the size of your aneurysm. Expect to have an echocardiogram at least six months after your aneurysm is diagnosed and regular exams and imaging tests after that.

If you have high blood pressure or blockages in your arteries, it's likely that your doctor will prescribe medications to lower your blood pressure and reduce your cholesterol levels to reduce the risk of complications from your aneurysm. These medications could include:

  • Beta blockers. Beta blockers lower your blood pressure by slowing your heart rate. Examples of beta blockers include metoprolol (Lopressor, Toprol-XL), atenolol (Tenormin) and bisoprolol (Zebeta).
  • Angiotensin II receptor blockers. Your doctor may also prescribe these medications if beta blockers aren't enough to control your blood pressure or if you can't take beta blockers. These medications are recommended for people who have Marfan syndrome, even if they don't have high blood pressure. Examples of angiotensin II receptor blockers include losartan (Cozaar), valsartan (Diovan) and olmesartan (Benicar).
  • Statins. These medications can help lower your cholesterol, which can help reduce blockages in your arteries and reduce your risk of aneurysm complications. Examples of statins include atorvastatin (Lipitor), lovastatin (Mevacor), simvastatin (Zocor) and others.

Blood pressure should be less than 140/90 millimeters of mercury. The goal for cholesterol is to have low-density lipoprotein (LDL) cholesterol (the "bad" type of cholesterol) under 70 milligrams per deciliter.

If you smoke or chew tobacco, it's important that you quit. Using tobacco can worsen your aneurysm.

Surgery to prevent rupture

If you have a thoracic aortic aneurysm, surgery is generally recommended if your aneurysm is about 1.9 to 2.4 inches (5 to 6 centimeters) and larger. If you have Marfan syndrome, another connective tissue disease or a family history of aortic dissection, your doctor may recommend surgery for smaller aneurysms because you have a higher risk of having an aortic dissection.

Depending on your condition and the location of your thoracic aortic aneurysm, your doctor may recommend:

  • Open chest surgery. Open chest surgery to repair a thoracic aortic aneurysm involves removing the damaged section of the aorta and replacing it with a synthetic tube (graft), which is sewn into place. This procedure requires open abdominal or open chest surgery, and it will take you a month or more to fully recover.
  • Endovascular surgery. Doctors attach a synthetic graft to the end of a thin tube (catheter) that's inserted through an artery in your leg and threaded up into your aorta. The graft — a woven tube covered by a metal mesh support — is placed at the site of the aneurysm and fastened in place with small hooks or pins. The graft reinforces the weakened section of the aorta to prevent rupture of the aneurysm. Recovery time is generally faster with this procedure than with open surgery, but endovascular surgery can't be done on everyone. After endovascular surgery, you'll need to have regular follow-up imaging scans to ensure that the graft isn't leaking.
  • Other heart surgeries. If another condition is contributing to your aneurysm's development, such as a problem with your heart's valves, your doctor may recommend additional surgeries to repair or replace the damaged valves to stop your aneurysm from worsening.

Emergency surgery

Although it's possible to repair a ruptured aortic aneurysm with emergency surgery, the risk is much higher and there is less chance of survival.

If you've been diagnosed with a thoracic aortic aneurysm, your doctor will likely advise you to avoid heavy lifting and vigorous physical activity as these can increase blood pressure, putting additional pressure on your aneurysm. If you want to participate in a particular activity, ask your doctor if it would be possible to perform an exercise stress test to see how much exercise raises your blood pressure.

Stress can also raise your blood pressure, so try to avoid conflict and stressful situations as much as possible. If you're going through a particularly emotional time in your life, let your doctor know because your medications may need to be adjusted to keep your blood pressure levels from going too high.

There are no medications you can take to prevent an aortic aneurysm, although taking medications to control your blood pressure and cholesterol level may reduce your risk of having complications from a thoracic aortic aneurysm.

For now the best approach to prevent an aortic aneurysm or keep an aneurysm from worsening is to keep your blood vessels as healthy as possible. That means taking these steps:

  • Don't use tobacco products.
  • Keep your blood pressure under control.
  • Get regular exercise.
  • Reduce cholesterol and fat in your diet.

If you have some risk factors for aortic aneurysm, talk to your doctor. If you are at risk, your doctor may recommend additional measures, including medications to lower your blood pressure and relieve stress on weakened arteries. You may also want to consider screening echocardiograms every few years.

Mar. 22, 2013