Thoracic Aortic Aneurisms

How Can They Be Treated?

When we talk about treating thoracic aortic aneurisms we could have a number of things in mind. We might mean that we have a developing aneurism and are wondering what can be done to reduce the risk of further expansion or rupture. If this is what we mean then there are a number of lifestyle modifications that we can make. More on this in a moment.

However, if by treatment we mean that we have a large aortic aneurism in danger of imminent rupture and we are wondering what can be done, the answer is much more limited. In short, the answer is surgery. To date there is no medication that can cause an aortic aneurism to dissipate. Surgery is the only solution.

There are, however, a couple of options within this solution.

When Does Surgery Become Necessary For Aortic Aneurisms?

The determination to perform surgical repair varies with the types of thoracic aortic aneurisms. In the case of ascending aortic aneurisms - aneurisms on the section of the aorta immediately above the heart - elective repair is recommended when the diameter of the aneurism exceeds 5.5 cm. 

If the patient also suffers from Marfan’s syndrome, surgery should be performed when the aneurism reaches 5.0 cm. This is because people inflicted with Marfan’s syndrome often suffer from aortic valve leakage and have a higher risk of aneurism rupture.

If the aneurism is below the aortic arch then elective repair is recommended when the diameter is greater than 6.5 cm. In the case of Marfan’s syndrome the aneurism should not be allowed to exceed 6.0 cm.

Some doctors are more conservative in their application of surgical repair and would rather operate before the aneurism reaches the sizes listed above. If an aneurism shows a growth rate that exceeds 0.4 cm - some would say 1.0 cm - in any one year many would recommend surgery.

Surgery, of course, has its risks. But at hospitals specializing in the repair of aortic aneurisms, mortality rates can be as low as 2.3%, particularly in the repair of ascending aortic aneurisms. The mortality rate for surgical repair of aortic arch aneurisms and descending thoracic aneurisms is just over 5%. However the risk of death from a ruptured aneurism is vastly higher.

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Traditional Surgery For Aortic Aneurisms

When surgical repair is necessary what does it involve?

For ascending aortic aneurisms or arch aneurisms this typically requires dividing the breastbone and opening the dilated portion of the aorta. Some surgical treatments only require partially dividing the upper part of the sternum. This allows for less blood loss and quicker patient recovery. A Dacron patch or tube is then inserted into the opening and sewn in place. The aneurismal portion of the aorta is then closed around the tube.

Surgical treatment for descending thoracic aneurisms is similar. Typically it involves removing the diseased portion of the aorta through an incision made between the ribs. The aorta is then fitted with a Dacron patch.

Percutaneous Stenting

Often patients suffer from coexisting diseases (co-morbid conditions) making surgical treatments much more risky. For such cases a more recent treatment may be invoked. It involves applying a stent (artificial tube) through the skin to the affected area.

This is called percutaneous stenting. When applicable this procedure has a much lower morbidity rate sometimes making aneurism treatment possible when surgery is too hazardous.

Newer treatments for aortic aneurisms, involving endovascular aortic repair, are being applied to descending thoracic aneurisms. This involves making small incisions in both femoral arteries. A specially designed graft supported with metal stents is then introduced into the aneurism through both femoral arteries.

Once in position this endograft effectively diverts the flow of blood away from the aneurism wall, thus excluding the aneurism from circulation. This procedure does not remove the aneurism but allows it to shrink over a period of time. For more detail on this procedure see Endovascular Coiling under abdominal aortic aneurism treatments.

Endovascular Surgery

Endovascular coiling is a less invasive method of surgical repair. Because of this it is gaining in popularity in recent years.

This procedure eliminates the aneurism without the trauma of open surgery. It is especially useful in the treatment of abdominal aortic aneurisms and thoracic aortic aneurisms, in part, because of their proximity to the insertion point.

Endovascular surgery results in…

  • less blood loss
  • less trauma to the aorta
  • a reduction of time required for recovery

Average recovery time is reduced from the average of six weeks for the open method down to one or two weeks. This is good news for any patient but especially those who are at high risk because of other factors such as age or pre-existing medical conditions. 

This is not to imply that endovascular surgery is a good choice for everyone. This procedure is relatively new. The decision to treat aortic aneurisms by this method as opposed to the traditional "open" method depends on many factors and should be determined by a medical team and the patient. Endovascular surgery should be performed by cardiac and vascular surgeons - those who specialize in blood vessel surgery.

In the procedure a small insertion is made in the femoral artery - in the groin. A special stent consisting of a tube inside a metal cylinder is attached to the end of a catheter. The catheter (thin tube) is then inserted into the femoral artery and guided to the infected area of the aorta using X-ray imaging.

Once the stent has reached the aortic aneurism and set in place it is secured to the inner aortic wall by devices at each end. It is expanded like a balloon or spring until it fits tightly against the aorta wall. The blood then flows through the stent-graft instead of putting pressure on the stressed aortic wall that has become the aneurism. The aortic aneurism is completely cut off from the flow of blood and is no longer at risk from rupture. The pressure being relieved, the aneurism will normally shrink and disappear.

The success rate of this type of surgery has risen to around 90%. But it does carry risks such as leakage and infection. Since this technique is a recent development the long-term results are not yet known.

Non-Surgical Treatments for Thoracic Aortic Aneurisms

Non-surgical aneurism treatments focus on reducing coexisting conditions that tend to increase the likelihood of aneurism expansion and rupture. Surgery is the only cure to date. However, for certain patients, non-surgical methods are preferable. These include patients with small aneurisms that have a low likelihood of rupture. These aneurisms are generally smaller than 4 cm. (1.6 in.).

Patients with medium sized aortic aneurisms (4 to 6 cm., or 1.6 to 2.4 in.) who also have a limited life expectancy due to other factors such as old age or other illnesses are more likely to receive non-surgical treatments. And patients who are at high risk of death in the event of surgery would receive alternate aneurism treatments.

So far, no medication has been proven in a prospective scientific experiment to reduce the growth rate of aortic aneurisms in people, although propranolol - a beta-blocker - has been shown to reduce the incidence of ruptured aneurisms in turkeys and to delay the growth of aneurisms in mice. 

Currently the primary focus for non-surgical aneurism treatments is to help the patient stop smoking and control blood pressure. Hypertension is a known risk factor for aneurism rupture because it increases the pressure on the aneurism. Doctors will often treat hypertension with beta-blockers.

There are also lifestyle adjustments that can help reduce the risk of rupture, and the development of new aneurisms. Whether you are trying to reduce the risk of an existing aneurism or are hoping to prevent the development of a new one, there are a few things that you should do.

Cholesterol imbalance, increased atherosclerosis, and high blood pressure are all important factors in aneurism development and rupture. To help prevent aneurisms and their potential rupture these three factors should be monitored closely.

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