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Thoracic aortic aneurysm

Overview

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 rupture.

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.

Symptoms

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. Aneurysms can occur anywhere in the thoracic aorta, including the ascending aorta near the heart, the aortic arch in the curve of the thoracic aorta and the descending aorta in the lower part of the thoracic aorta.

Aneurysms that form in the lower part of your aorta — called abdominal aortic aneurysms — are more common than thoracic aortic aneurysms. An aneurysm can also 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.

Causes

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. This is more common in older people.
  • Genetic conditions. Younger people with an ascending aortic aneurysm often have a genetic cause. 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 related disorders, 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 arteritis, may cause thoracic aortic aneurysms.
  • Problems with your heart's aortic valve. 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 mainly true for people who were born with a bicuspid aortic valve, meaning the aortic valve has only two cusps instead of three.
  • Untreated infection. Though it is a rare cause of thoracic aortic aneurysm, it's possible to develop this condition if you've had an untreated infection, such as syphilis or salmonella.
  • Traumatic injury. Rarely, some people who are injured in falls or motor vehicle crashes develop thoracic aortic aneurysms.

Aortic emergencies

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. It's important to treat an aortic aneurysm before dissection occurs. If dissection occurs, people can still be treated with surgery and treatments, but they will have a higher risk of complications.

Risk factors

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.
  • 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. This is a more common risk in older people.
  • 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. This is a primary risk factor in younger people.
  • Marfan syndrome and related disorders. If you have Marfan syndrome or related disorders such as Loeys-Dietz syndrome or Ehlers-Danlos syndrome, you have a significantly higher risk of a thoracic aortic aneurysm.

Complications

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
  • Trouble swallowing
  • 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.

Diagnosis

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.

Tests

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 suspect you have a thoracic aortic aneurysm by looking at chest X-ray images. 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 uses sound waves to capture real-time images of your heart and the ascending aorta.

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, and it can detect the size and shape of an aneurysm. During a CT scan, you lie on a table inside a doughnut-shaped machine. CT scanning generates X-rays to produce cross-sectional images of the body. Doctors may inject a dye into your blood vessels that helps your arteries to be more visible on the CT pictures (CT angiography).

One downside of the use of CT in detecting and following aortic aneurysms is the exposure to radiation, particularly for people who require frequent monitoring, such as those with Marfan syndrome. However, newer CT scan techniques may be used to reduce your radiation exposure at some medical centers.

Magnetic resonance angiography (MRA)

An MRA is a painless imaging test that may be used to diagnose an aneurysm and determine its size and location. In this test, you lie on a movable table that slides into the tunnel. An MRI uses a magnetic field and pulses of radio wave energy to make pictures of the body. Doctors may inject a dye into your blood vessels to help your blood vessels to be more visible on images (magnetic resonance angiography).

This test may be an alternative to CT scans for people who need frequent monitoring, to reduce their exposure to radiation.

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. You may also want to consider genetic counseling before starting a family.

Treatment

The goal of treatment is to prevent your aneurysm from rupturing. Generally, your treatment options are medical monitoring or surgery. Your doctor's 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. Your doctor will also ask you about any signs or symptoms you may be experiencing that could be related to the aneurysm.

It's likely your doctor will order regular imaging tests to check on the size of your aneurysm. Expect to have an echocardiogram, CT scan or magnetic resonance angiography (MRA) at least six months after your aneurysm is diagnosed, and at regular follow-up exams and imaging tests after the first imaging test. The frequency of your imaging tests depends on whether the aneurysm is growing, and how fast it's growing.

Medications

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. For people with Marfan syndrome, beta blockers may reduce how fast the aorta is dilating. 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, Hyzaar), 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 (Altoprev), simvastatin (Zocor) and others.

The blood pressure goal is less than 140/90 millimeters of mercury.

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 (about 5 to 6 centimeters) and larger. If you have Marfan syndrome, another connective tissue disease, a bicuspid aortic valve 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.

Most people with a thoracic aortic aneurysm have open chest surgery, but in some select cases your doctor may determine you're a candidate for endovascular surgery. 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.

    If you have Marfan syndrome or other related conditions, you may have surgery to treat a section of the aorta that lies close to the junction of the aorta and the heart (aortic root). In aortic root replacement, your surgeon removes a section of your aorta and your aortic valve and replaces the section of the aorta with an artificial tube (graft). The aortic valve is replaced with a mechanical or biological valve.

    Alternatively, you may have valve-sparing aortic root repair, in which your surgeon replaces the enlarged section of the aorta with a graft, and the aortic valve remains in place.

  • 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 chest surgery, but endovascular surgery can't be done on everyone. Discuss with your doctor whether you're a candidate for this procedure. 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.

After surgery, your doctor may recommend regular monitoring of your condition.

Emergency surgery

Although it's possible to repair a ruptured aortic aneurysm with emergency surgery, the risk is much higher and there is a higher chance of complications. Because of this, doctors prefer to identify and treat thoracic aortic aneurysms before they rupture, and to follow through with lifelong monitoring and appropriate preventive surgery.

Preparing for an appointment

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 to discuss, 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.
  • Send imaging reports and bring records. It's helpful if you can send imaging reports to your doctor in advance and bring your reports and medical records.
  • Write down a list of 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.

Lifestyle and home remedies

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. Moderate physical activity is generally beneficial for you.

Stress can 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 most appropriate approach to prevent an aortic aneurysm or keep an aneurysm from worsening is to keep your blood vessels as healthy as possible. This means taking certain steps, including these:

  • 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.

Coping and support

Living with a thoracic aortic aneurysm can be stressful. Try to avoid stressful situations and strong emotions such as anger, as these can increase your blood pressure.

If you have a genetic condition such as Marfan syndrome, you may feel fear, anxiety or depression. Talk to your doctor if you experience these emotions; he or she may refer you to a doctor trained in mental health conditions (psychologist).

You may find it helpful to join a support group with people who have similar conditions. Talk to your doctor about support groups in your area.

Last updated: August 16th, 2017

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