Ascending Aortic Aneurysm

Ascending Aorta Aneurysm

An aneurysm of the ascending aorta can be a silent and life-threatening condition. It begins with an abnormal widening (dilatation) of the aorta that often features no symptoms or warning signs. Many people live with an ascending aortic aneurysm without knowing it, until a sudden complication occurs, like an aortic rupture.

That’s why early detection is so crucial. Elective surgery offers a safer alternative when the aneurysm is found in time. At the Keyhole Heart Clinic, our specialists carefully assess each case. When appropriate, they can offer keyhole surgical procedures to replace the weakened section of the aorta before it becomes critical.

Read our resources on ascending aortic aneurysm, including the causes and the minimally invasive surgical repair available to you.   

What Is the Ascending Aorta?

The aorta is the body’s largest artery. It has two main sections: the thoracic aorta (in your chest) and the abdominal aorta (in your belly). The thoracic portion consists of three parts: the ascending, arch, and descending parts.

The ascending aorta begins right after the aortic valve and coronary arteries. It’s about 5 centimetres long and goes straight up until it hits the first major branch, which is the innominate artery.

This ascending portion has two distinct areas:

• The aortic root forms the lower section and includes specialised structures called the sinuses of Valsalva, along with an area called the sinotubular junction where the aorta begins to narrow slightly.
• The tubular ascending aorta makes up the upper section, extending from the sinotubular junction up to where the aortic arch begins.

When doctors talk about thoracic aortic aneurysms (TAA), they’re most commonly referring to problems in this ascending section. More than half of all thoracic aneurysms occur in this region. The aneurysm may develop in either the aortic root area or the tubular section above it.

Causes Of Ascending Aortic Aneurysm

Certain lifestyle factors and medical conditions can increase the risk of ascending aortic aneurysms, making early detection vital. It’s also called an ascending thoracic aortic aneurysm (ATAA), and it grows slowly without causing symptoms you’d likely notice.

It begins when the wall of your aorta becomes weak and starts to stretch. If left untreated, this can eventually become a serious health issue.

Several elements can cause an ascending aortic aneurysm:

1. Age & High Blood Pressure

As you get older, the elastic fibres in your aorta naturally break down. High blood pressure puts extra stress on the aortic wall, which speeds up this breakdown and causes abnormal widening.

2. Genetic Conditions

Some people inherit disorders that affect their connective tissue, making their aortic wall weaker. These conditions mess with your body’s ability to create strong, stretchy tissue that keeps your aorta healthy.

Connective tissue disorders include:

• Marfan syndrome
• Loeys-Dietz syndrome
• Ehlers-Danlos syndrome (vascular type)

These conditions can cause problems with your aortic layer structure, making it likely to stretch out even when you’re young.

3. Bicuspid Aortic Valve

A bicuspid aortic valve is a congenital heart defect where the aortic valve has two leaflets instead of three. It alters blood flow and is strongly linked with ascending aortic aneurysm, even when no other risk factors are present.

4. Family History

Even without a defined genetic syndrome, having a first-degree relative with an aortic aneurysm increases your risk. Some cases are associated with familial thoracic aortic aneurysm syndromes inherited in an autosomal dominant pattern.

5. Inflammation or Prior Surgery

Previous surgery involving the aorta and an inflammatory condition can also contribute to weakening of the vessel wall.

Being aware of your risk can help with early intervention. If you have a family history or a related condition, arrange your heart screening appointment without delay.

Ascending Aortic Aneurysm Symptoms

Chronic aneurysms of the ascending aorta don’t cause specific symptoms. This means you typically won’t experience any noticeable warning signs from the aneurysm itself as it develops over time.

When to Seek Emergency Care

If you have any of these sudden symptoms, get medical help right away, as they could be signs of an acute aortic dissection (tear in the aorta):

• Sudden onset of severe pain in the chest & back
• Syncope (fainting)
• Stroke symptoms
• Acute heart failure

Keep in mind that these symptoms don’t usually happen with a regular long-term aneurysm. If you experience these symptoms, it means something concerning is happening and you need to get medical help right away.

Risk Factors

Several factors contribute to the rapid growth of the ascending aorta, which in turn increases the risk of complications.

Primary risk factors:

• Age: This is the most crucial predictor of aortic dilatation. Research examining autopsy cases has confirmed that advancing age correlates with an increasing diameter of the ascending aorta.
• Hypertension: High blood pressure is the most prevalent risk factor for acute aortic dissection. Clinical studies show a strong link between hypertension and ascending aorta diameter.
• Smoking History: Smoking damages your blood vessel walls and breaks down the proteins that keep your arteries strong and flexible. Even if you’ve quit, your smoking history still adds to your risk.

Additional risk elements:

• Body size: Taller people tend to have larger aortic dimensions
• Waist circumference: Abdominal obesity may contribute to aortic enlargement
• Gender: Men are generally at higher risk than women

• Carotid artery thickness: Thickening of the carotid artery walls in your neck
• Epicardial fat: Excess fat tissue around the heart
• Severe atherosclerosis: Extensive hardening and narrowing of arteries throughout the body

Diagnosing an Ascending Thoracic Aortic Aneurysm

As the ascending thoracic aortic aneurysm is often asymptomatic, it is sometimes only discovered by chance during the examination of other conditions.

There are various technologies available for obtaining imaging for diagnosis. Each imaging modality offers different advantages in assessing the size, location, growth and potential complications.

• Chest X-ray: A TAA may appear as a widened mediastinum (space between the lungs) over 8 cm or loss of retrosternal space (area behind the breastbone). But chest X-rays can miss it, with up to 20% of cases appearing normal.
• CT scan: A CT scan is a fast and highly accurate diagnostic tool for detecting various aneurysms, including thoracoabdominal aortic aneurysms, dissections, and related conditions. 3D images help measure aortic size. It uses radiation and contrast dye, which can affect the kidneys, so it’s not used for regular screening. But it’s ideal for diagnosis and surgery planning.
• Echocardiography: Transthoracic echocardiography (TTE) is a non-invasive ultrasound technique that assesses the aortic root and surrounding structures. It’s the first choice for screening and follow-up.
• MRI: Magnetic resonance angiography (MRA) provides detailed imaging of the entire aorta and heart function without radiation exposure. It uses contrast dye (gadolinium), which can be risky in patients with artificial implants or kidney disease, limiting its use.

Ascending Aorta Aneurysm Treatment

Treatment decisions for ascending aortic aneurysms depend on the growth rate, size and underlying risk factors of the aneurysm.

Elective surgery is the primary treatment to prevent life-threatening complications like aneurysm rupture or dissection. Surgical intervention is generally recommended once the aorta reaches a diameter of 5.5 cm, as the risks then outweigh the benefits. Endovascular aneurysm repair (EVAR) is a minimally invasive option for some cases, depending on the aneurysm’s size and location.

Certain conditions require earlier intervention. Patients with Marfan syndrome, bicuspid aortic valve, family history of aortic disease, or rapid aneurysm growth may need surgery at smaller sizes (4.5–5.0 cm). This is because these factors increase the risk of serious complications even at smaller diameters.

In patients without these risk factors, monitoring includes regular imaging (every 6–12 months) and blood pressure control. Medications such as beta blockers and Angiotensin-converting-enzyme (ACE) inhibitors help reduce stress on the aorta and slow the growth of an aneurysm.

Keyhole Ascending Aortic Aneurysm Surgery

While elective procedures are ideal, emergency surgery has increased risks and is typically performed when complications like dissection or rupture occur.

If you need surgery for an ascending aortic aneurysm, it may not require complete open surgery. In many cases, aneurysm repair can be performed through a minimally invasive keyhole approach. At the Keyhole Heart Clinic, our specialists have over two decades of experience in minimally invasive cardiovascular surgery.

This involves a smaller incision through the upper breastbone, known as a mini-sternotomy. When performed by an experienced team, it offers an effective alternative to traditional open surgery.

Keyhole aneurysm repair or replacement surgery may be an option if:

• The aneurysm is limited to the ascending aorta
• You require aortic valve repair or replacement at the same time
• You need a root replacement, where both the valve and ascending aorta are involved
• You are eligible for a valve-sparing procedure, preserving your natural aortic valve

This minimally invasive method may result in a quicker recovery and a shorter hospital stay. However, it’s not suitable for everyone. Your surgical team will assess the size and location of your aneurysm, your valve function, and your overall health to recommend the best approach.

Schedule your appointment with world-renowned surgeon, Mr Birdi, and explore your personalised options for safe and effective ascending aortic aneurysm repair.

The Keyhole Heart Clinic: Changing Hearts & Saving Lives.

We combine innovation and care to support your heart health at The Keyhole Heart Clinic. Our clinical lead and director, Mr. Inderpaul Birdi, is a cardiothoracic surgeon and consultant with over 20 years of experience helping patients through complex heart procedures.

Our team specialises in keyhole cardiovascular surgery, such as:

• Keyhole coronary bypass surgery (from single to quadruple bypass)
• Keyhole mitral valve repair or replacement surgery
• Keyhole tricuspid valve replacement
• Keyhole aortic valve replacement
• Keyhole atrial fibrillation ablation
• Keyhole atrial septal defect closure

Our patients have shared over 100 five-star reviews, reflecting our commitment to combining surgical excellence with compassionate care.

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