How long is ascending aorta

These cases tend to develop in younger people. Genetics: Certain inherited conditions are linked to a higher risk of ascending aortic aneurysms, including:. These are called connective tissue disorders, and they can lead to many complications in addition to aortic aneurysms.

Infection: Sometimes, certain infections can also weaken artery walls, including those in the aortic arch. These infections include syphilis and salmonella. An ascending aortic aneurysm is often found during a routine checkup or an examination ordered for another condition. For example, a chest X-ray can show a bulging aorta. Other imaging tests that can detect an aortic aneurysm include:. Once an aneurysm is discovered, the decision to treat it usually depends on its size or rate of growth.

Usually, surgical repair is necessary once an aneurysm reaches 5 centimeters cm in diameter. An aneurysm that is less than 5 cm may be monitored without surgery. If you and your doctor agree that a watch-and-wait approach is best, you may be placed on medications to help lower your blood pressure and cholesterol. Medications to bring down your blood pressure include beta blockers, which also slow your heart rate, and angiotensin receptor blockers ARBs. In this procedure, a surgeon opens up your chest and replaces the damaged portion of your aorta with a synthetic tube called a graft.

In some cases, they also replace the aortic valve with a synthetic valve. In this procedure, the weakened portion of the aorta remains in place. Your doctor inserts a tiny, flexible catheter into an artery in your leg and guides the tube up to your aorta. The catheter then deploys a graft that surrounds the vulnerable part of the aorta to strengthen it. Emergency surgery can sometimes be done to repair an aneurysm that ruptures, though it must be done fast.

Risk factors for atherosclerosis include high cholesterol and high blood pressure. Genetic disorders and inflammatory conditions are thought to contribute to aneurysm development in the thoracic region. Inflammatory conditions that may increase the risk of thoracic aortic aneurysms include giant cell arteritis and Takayasu arteritis. Untreated infection, such as salmonella poisoning, is a rare cause of an aneurysm in the aorta that is commonly known as a mycotic aneurysm.

People with problems of the aortic valve may be more likely to experience ascending aortic aneurysms. For example, those born with a bicuspid aortic valve — where there are just 2, rather than 3, cusps of the aortic valve — may experience more pressure on the artery walls. Aneurysms that develop in the chest area, above the diaphragm, are classed as thoracic aneurysms and may be subcategorized as either ascending or descending.

Descending aortic aneurysms occur in the back of the chest cavity. Aneurysms that develop in the lower part of the aorta are called abdominal aortic aneurysms. These are more common than thoracic aortic aneurysms, with abdominal aortic aneurysms comprising over 75 percent of aortic aneurysms.

An ascending aortic aneurysm is a serious health risk. It may rupture, causing internal bleeding that can be life-threatening. The larger the aneurysm, the greater the risk of rupture. Similarly, larger aneurysms can cause aortic dissection, a life-threatening medical emergency characterized by tearing of the aortic layers.

If a doctor suspects an aortic aneurysm, they may use one or more of the following tests to confirm the diagnosis:. Doctors usually treat small aneurysms with beta-blockers , a type of medication for high blood pressure.

The physiological effect of beta blockers on the natural history of the dilated ascending aorta is not clearly understood, and a combination of reduced wall stress and vascular remodeling has been proposed. As mentioned earlier, patients with mildly dilated ascending aorta are those who benefit the most from beta blockade as shown in a study by Haouzi et al.

In addition, many authors have shown interest in the effect of angiotensin converting enzyme inhibitors ACEIs on the rate of dilation of TAA. In one study, the addition of perindopril to beta-blockers significantly reduced the aortic diameter as well as the aortic stiffness in a small sample of 10 patients with Marfan syndrome [51].

This finding is also corroborated by another study, in which beta blockers are compared to the ACEI enalapril [52] , the latter showing slower rate of aortic growth, fewer adverse outcomes and decreased side effects in patients with Marfan syndrome. The effect of ACEIs is thought to be due to the decreased activity of the angiotensin II receptors which increase cystic medial degeneration. At the European Society of Cardiology Congress, authors of the COMPARE trial prospective randomized study which included patients with Marfan syndrome revealed that losartan slowed aortic root enlargement [53].

However, the study did not show a reduced rate of events in the treatment group. While the use of Statin has been soaring in the past decade for the treatment of abdominal aortic aneurysms AAA , no study has found a beneficial effect on the outcomes associated with TAA. Most studies have examined the effect of long-term medical therapy on the progression of idiopathic aortic dilation in patients with Marfan syndrome.

However, there are very few studies on patients with other etiologies. Thus, it is unclear whether extrapolation of the results of patients with Marfan syndrome can be done. Nevertheless, it is very important to encourage cardiovascular risk factor reduction in patients with TAA especially hypertension and dyslipidemia. As has been already mentioned, surgery and ideally prophylactic surgery remain the cornerstone of the treatment of the pathologically dilated ascending aorta. Different surgical procedures can be performed depending on the site of aortic dilation and the function of the aortic valve.

Dilation without implication of the Valsalva sinuses can be managed by tube graft replacement, however when the sinuses of Valsalva are involved, the Bentall procedure composite valve graft replacement with re-implantation of the coronary arteries or the valve sparing procedure can be performed [55].

The valve sparing procedure can be done following the David technique aortic valve reimplantation or the Yacoub technique aortic valve remodeling. The David technique is the one used preferentially [56]. In some cases, the Ross procedure can also be performed, if the native aortic valve is diseased and cannot be reimplanted. In general, all three procedures are associated with lower mortality and morbidity if performed electively.

Choice of procedure depends on many factors, but, in general, most studies show an early and late mortality and morbidity advantage associated with the valve sparing surgery at the expense of a slightly higher re-operation rate. As Table 9 , Table 10 show, there is decreased day and 5 years mortality in patients who undergo the valve sparing procedure.

As previously stated, freedom from re-operation for aortic insufficiency is slightly lower in patients who undergo the valve sparing procedure VSP. While some retrospective single center studies found that the VSP shows superiority in survival and morbidity, there seems to be a tendency towards higher rates of re-operation and re-exploration therapy [58].

In a meta-analysis analyzing data from patients, there was a statistically significant difference in reintervention rates in patients undergoing VRP [59]. In addition, some authors have reported that patients with Marfan syndrome might not be ideal candidates for VSP because they believe that these patients have innate structural disorders of the aortic valve requiring replacement later in life.

There have been many cases reported about ascending aorta dilatation during pregnancy and the increased rate of complications during this period. While this subject is not very well studied, pregnancy seems to predispose to arterial wall degeneration by the excess release of estrogen and progesterone [60].

In select women, this process is aggravated by the very well known cardiovascular changes during pregnancy increased circulating volume, increased stroke volume and increased heart rate. In addition, women with predisposing conditions such as those mentioned in Table 3 Marfan syndrome, BAV, etc.

While there were no official guideline and no prospective study to confirm it, most experts agree that women who wish to become pregnant should get prophylactic surgery at earlier stages of their disease. For example, patients with Marfan syndrome should get prophylactic repair when the ascending aorta reaches 4. As noted above, the natural history of TAA is that of progressive expansion.

Patients with aortic root or ascending aortic dilation that has not yet exceeded the threshold for surgical intervention require serial evaluations. The size of the aortic root and ascending aorta should be evaluated annually or biannually, although more frequent studies are warranted 3—6 months when the aorta exceeds 4. Patient who is newly diagnosed of TAA needs to have another imaging in 6 months to determine the growth rate.

If patient is a fast grower, imaging assessment needs to be every 3—6 months. Otherwise if TAA is stable, imaging will be annually. Patients who already had their TAA repair still require medical attention. These patients could develop aneurysm in other segments of aorta, particularly in patients with chronic dissection at the distal anastomosis of tube graft.

Annual imaging assessment of the entire aorta is recommended. According to ACC guidelines, all patients with Marfan syndrome and Loeys—Dietz syndrome should receive screening for ascending TAA when diagnosed with this disease and 6 months thereafter to determine the rate of growth. Afterwards, annual imaging is recommended to document the progression of the dilation. If the aorta reaches 4. As mentioned earlier, familial thoracic aneurysm disease can occur in different patterns.

It is therefore reasonable to recommend screening for first degree relatives of affected people. Family members of these patients should be screened for BAV. Screening of first-degree relatives is considered warranted for many of these conditions; however, at what age the investigation should be started, how often the imaging should be repeated and how long the screening should last are still debatable at the present time as well as the cost effectiveness of the methods.

Patients with aorthopathy associated with Marfan syndrome should avoid isometric exercise because of sustained elevation of blood pressure and wall stress applied on aortic wall during exertion [61]. Isometric exercises include weight lifting, sit-ups, and push-ups. Patients are encouraged to perform aerobic exercise with moderation.

These recommendations should be given to all patients with other aortopathies since the shear stress needs to be kept minimal once aorta becomes aneurysmal. Ascending aortic aneurysm is a lethal disease. Lower threshold of aortic diameter for surgery should be considered for patients with aortopathy related to congenital etiologies. Medical treatment as well as lifestyle changes and risk factor control, and serial imaging assessment of aortic aneurysm constitute the second part of the management of these patients.

National Center for Biotechnology Information , U. Int J Cardiol Heart Vasc. Published online Jan Author information Article notes Copyright and License information Disclaimer. Emile Saliba: ac. Published by Elsevier Ireland Ltd. Abstract Background Thoracic ascending aorta aneurysms TAA are an important cause of mortality in adults but are a relatively less studied subject compared to abdominal aortic aneurysms AAA.

Methodology Literature was obtained through online health related search engines PubMed, MEDLINE by including the following keywords: ascending aorta aneurysm, thoracic aneurysms, Marfan syndrome, bicuspid aortic valve, familial thoracic syndrome, aortic dissection, aorta imaging and aortic aneurysm guidelines.

Findings Literature revealed how lethal this disease can be and how simple steps such as follow-up and prophylactic surgery can significantly reduce morbidity and mortality. Conclusion TAA is a silent disease that needs to be recognized early in its course and followed closely in order to recommend appropriate preventive and prophylactic therapy in a timely manner.

Introduction The dilation of the ascending aorta is a common incidental finding on transthoracic echocardiography performed for unrelated indications. Anatomy The aorta is divided into two main segments: thoracic and abdominal. Definition of aortic aneurysm Published data on arteries diameter in healthy population are often scant or variable because of different imaging modalities used for measurement.

Pathophysiology The aorta is an elastic vessel composed of three main layers: the tunica intima, the tunica media and the tunica adventitia. Etiologies The process of cystic medial degeneration can be either due to an innate defect or an acquired one. Table 1 Etiologies of ascending aortic dilatation. Open in a separate window. Risk factors Different studies have shown that the ascending aorta diameter significantly correlates with age, waist circumference, smoking history and hypertension; the latter being the most prevalent risk factor for acute aortic dissection [15].

Diagnosis 2. Presentation Dilatation of the ascending aorta is a very indolent process as it takes many years to develop and it is asymptomatic initially. Table 2. Mean age at presentation years Source Hypertensive Mean size at complications mm a Source Hypertensive 60 Davies, Kaple et al. Imaging As can be seen in Table 3 , many imaging modalities can be used to image the ascending aorta. Table 3 Advantages and disadvantages of different imaging modalities a.

Chest X-ray TAA produces a widening of the mediastinum characterized by a width on AP film of greater than 8 cm at the T4 or carinal level. Echocardiography Transthoracic echocardiography TTE provides a simple non-invasive technique to evaluate the aortic root, proximal ascending aorta, aortic valve and left ventricular morphology and function in the vast majority of patients. CT scan Since the introduction of CT scanning in the 80s, it has become the preferred imaging technique to define aortic anatomy and its side branch vessels because of its easy accessibility and of its rapid results.

MRI MR angiography is an imaging modality that provides accurate measurement and definition of the entire aorta anatomy. Natural history Normal aorta grows slowly with age. Hypertension related ascending thoracic aortic aneurysms Nearly all studies found that hypertension increases ascending aorta dilatation in pre-existing TAAs and predisposes to the formation of TAA. Marfan syndrome Marfan syndrome, first described by Antoine Marfan in , is a connective tissue disorder with manifestations mainly involving the cardiovascular, respiratory, skeletal and ocular systems.

Table 4 Mean increase in aorta size in patients with Marfan syndrome. Familial thoracic syndromes Genetic predisposition other than Marfan syndrome appears to be linked with the development of ascending TAA.

Loeys—Dietz syndrome Loeys—Dietz syndrome is an autosomal dominant genetic disorder mainly associated with mutations of the genes responsible for the transforming growth factor B receptors 1 and 2. Ehlers—Danlos syndrome EDS Ehlers—Danlos regroups a multitude of connective tissue disorders characterized by laxity of the Joints and skin disorders.

Arterial tortuosity syndrome Arterial tortuosity syndrome is an autosomal recessive disorder characterized by tortuosity and aneurysm formation in the major arteries caused by a deficiency in glucose transporter GLUT 10 causing an upregulation of TGFBR1 signaling [11]. Aneurysms osteoarthritis syndrome Aneurysms osteoarthritis syndrome is an autosomal dominant syndromic characterized by thoracic aortic aneurysms and dissections associated with the presence of arterial aneurysms, early-onset osteoarthritis and cutaneous manifestations.

Management 4. When to intervene As has been previously mentioned, complications of ascending aorta aneurysms can be disastrous even if diagnosed promptly and properly managed. Table 5 Mortality rates for timing of surgical therapy. NEJM M a 1. J thorac Surg 4. Ann Thorac Surg 4. Circulation 1. Table 6 Comparison of national guidelines for the management of TAA in patients without any genetic predisposition. Faster growing aneurysms should be considered for intervention sooner than the usual operative threshold.

Table 7 Comparison of national guidelines for the management of TAA in patients with Marfan syndrome. Table 8 Comparison of national guidelines for the management of TAA in patients with bicuspid aortic valve. Medical management If diagnosed early, mild to moderate dilated ascending aortas can certainly benefit directly from medications such as beta blockers and ACE inhibitors. Surgical intervention As has been already mentioned, surgery and ideally prophylactic surgery remain the cornerstone of the treatment of the pathologically dilated ascending aorta.

Table 9 Mortality rates for surgical repair with valve replacement. Sample 30 days mortality 5 years mortality 10 years mortality Gott et al. NEJM Marfan patients [53] 3. J Thorac Cardiovasc Surg Marfan patients [52] 6.

Table 10 Mortality rates for surgical repair with valve sparing surgery. Sample Early mortality 5 years mortality 10 years mortality Gott et al. Ascending aortic dilatation and pregnancy There have been many cases reported about ascending aorta dilatation during pregnancy and the increased rate of complications during this period. Follow-up and screening As noted above, the natural history of TAA is that of progressive expansion. Exercise restriction Patients with aorthopathy associated with Marfan syndrome should avoid isometric exercise because of sustained elevation of blood pressure and wall stress applied on aortic wall during exertion [61].

Conclusion Ascending aortic aneurysm is a lethal disease. It is shaped like a walking cane with a curved handle. An ascending aortic aneurysm is an abnormal bulging and weakening in your aorta at the point before the curve. If an aortic aneurysm ruptures, it can cause life-threatening bleeding. An aneurysm at risk for rupture needs surgical repair. An aortic aneurysm repair is major surgery that needs anesthesia. This has brain and heart risks.

Major surgery also carries a risk for blood clots in the large veins of your legs during or after surgery. These clots can break free and travel to your lungs. This condition is called a pulmonary embolism. Other risks of aortic aneurysm repair include:. You may have other risks, based on your specific medical condition.

Be sure to talk with your healthcare provider about any concerns you have before this surgery. Ask your healthcare provider to tell you what you should do before your procedure. Below is a list of common steps that you may be asked to do. The operation may take 5 hours or longer.

You may need several surgical repairs over your lifetime. This depends on the health of the aortic valve and heart arteries. You may need to stay in the hospital for up to 10 days or so after surgery.