Thoracic Aortic Aneurysm | NYU Division of Cardiac Surgery

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Overview
Causes
Symptoms
Diagnosis
Treatment
Our Thoracic Aneurysm/Dissection Specialists

Overview

An aortic aneurysm is a dilatation (abnormal enlargement) in the wall of the aorta, the largest artery in the body. The dilatation typically occurs in a weakened portion of the artery’s wall, causing it to bulge outward. If left untreated, an aortic aneurysm may rupture, causing serious complications such as internal bleeding.

Approxminately 60,000 people in the U.S. develop aortic aneurysms each year. Roughly three-quarters of these occur in the abdominal aorta, the portion of the aorta that travels through the abdomen. These aneurysms are generally treated by vascular surgeons (see the NYU Division of Vascular Surgery.)

Aneurysms that appear in the portion of the aorta that travels through the chest, or thorax, are called thoracic aortic aneurysms. Each year, approximately 15,000 people in the U.S. develop thoracic aortic aneurysms. A thoracic aortic aneurysm is a serious, potentially fatal condition and requires the immediate attention of a skilled and experienced team. The NYU Division of Cardiac Surgery treats hundreds of patients with aneurysms each year.

Causes

Most thoracic aortic aneurysms are caused by atherosclerosis, a condition in which plaque (fatty deposits) build up on the inner walls of the arteries, causing them to harden and narrow. Over time, plaque can cause the aorta to stiffen and weaken, leaving it prone to bulges and ruptures. Aneurysms are also associated with a bicuspid aortic valve (in which there are two leaflets instead of the normal three), connective tissue disorders such as Marfan syndrome, and syphilis.

Symptoms

Many aneurysms, even large ones, do not cause symptoms and are first detected during a routine physical exam or x-ray evaluation for another disorder. Symptoms tend to appear when the aneurysm enlarges, pressing against nearby structures, such as the esophagus (which carries food to the stomach), trachea (windpipe), larynx (voice box), and heart.

Depending on the size and location of the aneurysm, symptoms may include:

Chest or back pain
Boring, gnawing, constant pain, developing over the course of several hours or days
Sudden severe stabbing pain
Coughing and shortness of breath
Coughing up blood
Hoarseness
Difficulty swallowing

Diagnosis

In addition to a physical exam, one or more tests are used to diagnose a thoracic aortic aneurysm. These include:

X-ray of the chest
CT scan of the chest
Aortography: x-ray procedure performed after injection of a contrast dye that outlines the aneurysm.
64-slice cardiac CT angiography: a noninvasive test that uses X-rays to build highly detailed three-dimension pictures of cardiac anatomy.
Cardiac Magnetic Resonance Imaging (MRI): scanning technology that employs noninvasive magnetic fields and radio waves (instead of x-rays) to obtain two- and three-dimensional images of the body.
Transesophageal Echocardiography (TEE): noninvasive test that uses high-frequency sound waves to visualize the heart.

Treatment

How a thoracic aortic aneurysm is treated depends on its size and location, as well as on the patient’s age, symptoms, and general health. Three treatment approaches are used, including “watchful waiting,” a conventional surgical approach called aneurysmectomy, and a minimally invasive approach called endovascular stent-graft repair.

Watchful Waiting. “Watching waiting” is commonly recommended for a patient whose aneurysm is small and asymptomatic. In such cases, the physician will keep a close watch on the patient’s condition with periodic CT or MRI scans. If the patient has hypertension, the physician may prescribe a blood pressure medication in order to reduce strain on the weakened portion of the aorta. A cholesterol-lowering medication such as a “statin” may also be prescribed.

Surgery. Larger thoracic aortic aneurysms may require a surgical repair known as an aneurysmectomy. This involves removing the portion of the aorta that contains the aneurysm and replacing it with a tube made of artificial material. An aneurysmectomy involves general anesthesia, open-chest surgery, and a hospital stay of five days or more. If the aneurysm involves important branches of the aorta, these vessels may be repaired or bypassed.

Endovascular Stent-Graft Repair. Most thoracic aortic aneurysms are now treated with a minimally invasive approach called endovascular stent-graft repair, instead of conventional surgery. In this approach, a catheter is used to insert and guide a stent-graft (a polyester tube covered by a tubular metal web) into the aorta to the site of the aneurysm. The procedure begins by making a small incision in the groin and inserting the stent-graft into the femoral artery (which descends directly from the aorta). Using fluoroscopy (a continuous x-ray technique) and transesophageal echocardiography (TEE), the stent-graft is guided through the aorta to the aneurysm. With the stent-graft in place, blood flows through the stent-graft instead of through the aneurysm, eliminating the risk of rupture. This procedure may not require general anesthesia, and patients may have only a two-day hospital stay.