Ascending Aortic Aneurysm Repair

Overview

How is an ascending aortic aneurysm repaired?

An ascending aortic aneurysm is repaired through traditional open surgery. Your surgeon removes the weakened part of your ascending aorta and replaces it with a graft (synthetic fabric tube). This graft functions as a new lining for your artery so blood can pass through.

A cardiac surgeon performs this procedure in a hospital surgical suite.

Who needs ascending aortic aneurysm repair?

If you have a ruptured or dissected aneurysm in your ascending aorta, you have what’s called Type A dissection, and you need surgery. It’s an emergency surgery that can save your life.

You might also need surgery if you have an aneurysm that’s at risk of rupture or dissection. Your provider will check your aneurysm once or twice a year using imaging tests. Sometimes an aneurysm that’s very small or stable in size doesn’t need treatment for a while. But if the aneurysm is large or shows signs of rapid growth, you’ll need surgery to prevent rupture or dissection.

Your provider will recommend surgery if the risks of delaying treatment outweigh the risks of surgery.

Most thoracic aortic aneurysms (six out of 10) occur in the ascending aorta. Less often, they occur in the descending aorta or aortic arch.

When should an ascending aortic aneurysm be repaired?

The best timing for ascending aortic aneurysm repair depends on many factors. The most important is whether you have symptoms. Others include the aneurysm’s size and how fast it’s growing. Your body size and your particular medical conditions also play a role.

Symptoms of rupture or dissection

If you have chest pain, you might need emergency surgery. This could signal the aneurysm is about to rupture.

Call 911 if you have the following symptoms:

  • Sudden, severe pain in your chest or upper back. It may feel like something is tearing or ripping inside you.
  • Chest pain of any kind.
  • Clammy, sweaty skin.
  • Coughing, feeling hoarse or having trouble breathing.
  • Dizziness.
  • Fainting.
  • Fast heartbeat.
  • Nausea and vomiting.
  • Shortness of breath.

Aneurysm size

Aneurysm size is one of the key factors that determine when you need elective (planned) surgery. You may need surgery when the aneurysm diameter reaches:

  • In general, 5.5 centimeters.
  • For people with Marfan syndrome, 4.5 centimeters.
  • For people with Loeys-Dietz syndrome, 4.0 centimeters.

Aneurysm growth rate

You’ll need surgery soon if your aneurysm is growing quickly. That’s true even if the aneurysm is considered smaller (below 5.5 centimeters). You need surgery if:

  • The aneurysm is growing 1 centimeter per year or 0.5 centimeters per six months (in general).
  • The aneurysm is growing 0.5 centimeters per year for people with certain conditions. These include some connective tissue disorders, bicuspid aortic valve or chronic dissection.

Individual factors

Your provider will also take into account individual factors like your body size and medical conditions. For example, someone with a smaller body size may need surgery sooner. Your provider will use a formula to calculate the risk of rupture based on your body size and aneurysm size. This can lead to surgeries for aneurysms below 5 centimeters in diameter.

If you need another type of heart surgery, your provider may advise aneurysm repair at the same time. In that case, the aneurysm diameter could be as small as 4 centimeters. It’s wise to fix it sooner to prevent future problems and avoid multiple surgeries.

Your provider will talk with you about your unique needs. Your age, family history and underlying medical conditions can impact how you respond to the surgery. So, your provider will weigh the risks and benefits of having surgery sooner rather than later. Ask your provider if you have questions or concerns at any point.

Can endovascular methods be used to repair an ascending aortic aneurysm?

Thoracic endovascular aortic repair (TEVAR) repairs aneurysms in your descending thoracic aorta. That’s the part of your aorta that extends from the aortic arch down to the diaphragm. But TEVAR is rarely used for your ascending aorta (the first part that comes out of your heart). These two parts of your aorta (ascending and descending) have differences in anatomy and blood pressure. TEVAR was designed for the descending aorta.

However, in rare emergency situations, TEVAR has been used for the ascending aorta. It can save people who had a dissection but are too medically fragile to survive traditional surgery.

Researchers are developing new devices specifically for the ascending aorta. This exciting research shows much promise. In the future, endovascular methods could repair ascending aortic aneurysms. For now, though, traditional open surgery remains the preferred method.

Procedure Details

What happens before ascending aortic aneurysm repair?

You’ll have a physical exam several weeks before your surgery. Your provider will run tests and also talk with you about your health. Preoperative tests may include:

  • Blood work to check your kidney function.
  • CT orHeart MRI to check all parts of your aorta. Sometimes other problems with your aorta, like aortic valve disease, can be treated during the same surgery. Your provider will discuss this option with you.
  • Coronary angiography to check for atherosclerosis.
  • Duplex ultrasound to check the health of your carotid arteries. Untreated problems with your carotid arteries can raise your risk of a stroke during surgery. People over age 65 and people with peripheral artery disease or other risk factors need this test.

You’ll talk with your provider about:

  • Medicines you’re taking. Your provider needs to know what drugs, supplements and herbs you’re using. These include prescription and over-the-counter medicines. Your provider may ask you to stop taking some medicines as you prepare for surgery.
  • Medical conditions. You’ll need to control conditions like high blood pressure before your surgery. You may need to take antibiotics if you have chronic bronchitis.
  • How you’re feeling. If you have a cold, flu, herpes breakout or any other illness, tell your provider. Being sick could impact how you respond to surgery.
  • Smoking or using tobacco products. You should not smoke for at least one month leading up to your surgery. Your provider can share resources to help you quit.

Your provider will give you detailed instructions for the day of your surgery. These may include:

  • Not drinking anything after midnight the night before your surgery. That includes water.
  • Taking certain drugs the morning of your surgery.
  • Planning for someone to drive you to the hospital and pick you up after recovery.

Be sure to ask your provider if you have any questions or if anything is unclear. Good preparation is essential for a successful surgery.

What happens during ascending aortic aneurysm repair?

Your surgeon will replace the weakened part of your aorta with a graft (synthetic fabric tube). If other parts of your aorta are damaged, like the aortic root or aortic arch, your surgeon can fix those parts at the same time. Your surgeon may also replace your aortic valve if needed. The extent of surgery depends on your aorta’s condition as well as your medical history and family history.

Once you’re moved to the operating room, your care team will help you feel comfortable and relaxed. You’ll be given general anesthesia that puts you to sleep during the surgery. During parts of your surgery, you’ll be on a heart-lung machine (cardiopulmonary bypass). Your care team may also use deep hypothermic circulatory arrest (DHCA) to stop your blood circulation.

Your surgery will include the following steps:

  1. Incision. Your surgeon will make an incision in the front of your chest (median sternotomy).
  2. Clamping. Your surgeon will use a tool called an aortic cross-clamp to pause blood flow through your ascending aorta.
  3. Graft insertion. Your surgeon will replace the bulging section of your ascending aorta with a tube called a graft. This graft functions as a new lining for your artery. Your surgeon will sew the graft in place with stitches.
  4. Closure. Your surgeon will close the incision in your chest with stitches or staples.

This surgery usually takes three to four hours. The time can vary based on how many issues need to be fixed.

What happens after ascending aortic aneurysm repair?

You’ll be moved to the intensive care unit (ICU). You’ll be closely watched for a few days before moving to a regular hospital room. Your total hospital stay will likely be four to 10 days.

While you’re in the hospital, you’ll receive:

  • A urinary catheter to help you pee.
  • A tube through your nose and stomach that drains fluids.
  • Blood-thinning medication (anticoagulants).
  • Compression socks that help prevent blood clots in your legs.
  • A breathing machine to help support your lungs.
  • Pain medication to ease your recovery.

You’ll slowly move around more to regain your strength. But it’s important to follow your provider’s guidance and take things slowly.

Make sure to find someone to drive you home from the hospital. You won’t be able to drive until your provider says it’s OK.

Risks / Benefits

What are the advantages of ascending aortic aneurysm repair?

As an elective surgery, ascending aortic aneurysm repair prevents a rupture or dissection. Open surgery is currently the standard treatment method. It helps you avoid a medical emergency so you can keep on living your life.

Emergency surgery to repair a dissected or ruptured ascending aortic aneurysm can save your life.

What are the risks and complications of ascending aortic aneurysm repair?

Ascending aortic aneurysm repair is major surgery. Like any major surgery, it carries risks and complications. These include:

Any open surgery is riskier for people with other serious health problems, including:

People over age 65 also face a higher risk of complications. Risks can vary based on the person. Talk with your provider about your individual risks and how to manage them.

Recovery and Outlook

What is the survival rate after ascending aortic aneurysm repair?

Aortic aneurysm surgery has good outcomes when performed before a rupture or dissection. About 95% to 98% of people survive elective surgery. But thoracic aortic aneurysm ruptures and dissections are often fatal. About 1 in 5 people who have a rupture or dissection don’t live long enough to have surgery. Those who have emergency surgery are less likely to survive than those undergoing elective surgery.

About 85% of people who have elective thoracic aortic aneurysm repair survive for at least five years. That number drops to 37% for people who have emergency surgery after a rupture or dissection.

What is the life expectancy for people who have ascending aortic aneurysm repair?

The life expectancy is normal for those who have elective surgery (before a rupture or dissection). One study shows that people who have elective ascending aortic aneurysm repair live just as long as the general population.

How long does it take to recover from ascending aortic aneurysm repair?

Most people stay in the hospital for up to 10 days. But you may need more time depending on your condition. You may also benefit from cardiac rehab after you leave the hospital. This helps you regain your strength and independence.

Full recovery usually takes four to six weeks. But some people need several months to fully get back to normal.

Restrictions during recovery

Your provider will give you detailed recovery instructions. These may include restrictions like:

  • No driving until your provider says it’s OK. This is usually at least one to two weeks after your surgery when you’ve stopped taking pain medication.
  • No baths until your incision heals. You may take a shower, but be careful around your incision.
  • No swimming until your incision heals.
  • No heavy lifting (more than 10 pounds) for four to six weeks. This may be longer depending on how you’re healing. Follow your provider’s instructions.
  • No heavy exercise or activities that make you out of breath.

Dealing with pain

Take your prescription pain medication at the same time each day. This may help your medicine work most effectively.

Caring for your incision (surgical wound)

Your incision is the area on the front of your chest that was cut open for surgery. Now it’s closed, but it’s still a wound. It needs special care as you recover. Your provider will tell you how to care for it. You’ll likely need to change the dressing (bandages) every day. Only remove the dressing to take a shower if your provider says it’s OK.

Sneezing or coughing might feel uncomfortable as your incision heals. To ease any pain, hug a pillow against your incision when you sneeze or cough.

Changes in appetite and energy level

You may notice you’re not as hungry as usual. This is normal. It can take a few weeks for your appetite to return. Some people lose up to 20 pounds as they recover from aneurysm surgery.

You may also feel tired for several weeks. This is a normal part of healing. Talk with your provider about how you’re feeling and share any concerns you have.

What lifestyle changes should I make after my surgery?

It’s important to make lifestyle changes to reduce your risk of future heart problems. These include:

  • Eating a heart-healthy diet. Especially cut down on sodium (salt).
  • Exercise Ask your provider what’s safe and ideal for you.
  • If you smoke or use tobacco products, it’s time to quit. Smoking and tobacco products like vaping damage your arteries and causes many other health problems.
  • Manage high blood pressure, high cholesterol and diabetes.
  • Join a support group to share your experiences with others who are in your shoes.

When to Call the Doctor

When should I see my healthcare provider?

As you recover from your surgery, stay aware of your body and how you’re feeling. Call your provider if you notice any of these problems.

Incision (surgical wound) problems:

  • Redness, pain, warmth or swelling.
  • Blood or clear fluid soaking through your bandage.
  • Green or yellow drainage.
  • Edges of your incision coming apart.

Other problems:

  • Chest pain or shortness of breath even when you rest.
  • Swollen legs, or inability to move your legs.
  • Dizziness, fainting, or extreme fatigue.
  • Coughing up blood, or coughing up yellow or green mucus.
  • Chills or fever.
  • Blood in your poop.

These problems may signal a complication from surgery. Your provider will make sure you get the care and attention you need.

A note from Cleveland Clinic

If you’re planning to have ascending aortic aneurysm repair, it’s normal to have many questions. Your provider will talk with you about the risks and the benefits of this surgery. Like any major surgery, it involves some risks. But if your provider recommends surgery, that means it’s riskier to wait than to operate. Most people survive elective aneurysm repair surgeries and go on to live just as long as people without aneurysms. But ruptures and dissections are often fatal. With the right resources and care team, you’ll be on the road to recovery and feeling strong again in no time.

Last reviewed by a Cleveland Clinic medical professional on 04/01/2022.

References

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  • Borger MA, Fedak PWM, Stephens EH, et al. The American Association for Thoracic Surgery consensus guidelines on bicuspid aortic valve-related aortopathy. (https://www.jtcvs.org/article/S0022-5223(18%2931256-X/fulltext) J Thorac Cardiov Surg. 2018 Aug;156(2): E41-E74. Accessed 3/2/2022.
  • Hernandez-Vaquero D, Silva J, Escalera A, et al. Life expectancy after surgery for ascending aortic aneurysm. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141111/) J Clin Med. 2020 Mar;9(3):615. Accessed 3/2/2022.
  • Merck Manual. Thoracic Aortic Aneurysms. (https://www.merckmanuals.com/home/heart-and-blood-vessel-disorders/aneurysms-and-aortic-dissection/thoracic-aortic-aneurysms) Accessed 3/2/2022.
  • Preventza O, Huu AL, Olive J, Cekmecelioglu D, Coselli JS. Endovascular repair of the ascending aorta: The last frontier. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8807413/) Ann Cardiothorac Surg. 2022 Jan;11(1):26-30. Accessed 3/2/2022.
  • Society for Vascular Surgery. Repair of a Thoracic Aortic Aneurysm. (https://vascular.org/patients/vascular-treatments/repair-thoracic-aortic-aneurysm#whyitsdone) Accessed 3/2/2022.
  • StatPearls. Thoracic Aorta Aneurysm. (https://www.ncbi.nlm.nih.gov/books/NBK554567/) Accessed 3/2/2022.
  • U.S. Centers for Disease Control and Prevention. Aortic Aneurysm. (https://www.cdc.gov/heartdisease/aortic_aneurysm.htm) Accessed 3/2/2022.
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