Size of aneurysm determines surgery

DEAR DR ROACH »

My husband will be 83 in September and was recently diagnosed with an ascending thoracic aortic aneurysm measuring 4.8 cm.

Five centimeters is when they do something. After hearing about the survival rate based on your recent column, along with your comment that “most people do not survive a rupture of the aorta,” I’m scared. Why do they wait until 5.0 or rupture? Doctor says to test again in six months and just keep his blood pressure down. Shouldn’t he be careful about strenuous activities until repair? We can only wait at this point, it seems.

— C.G.

DEAR READER » The aorta, the largest blood vessel in the body, comes directly off the heart, ascends to form an arch, then descends through the chest and into the abdomen. The aorta is then considered in three divisions: the ascending thoracic aorta; the descending thoracic aorta; and the abdominal aorta. Aneurysms can occur in each of these areas, and each has slightly different criteria for when to intervene.

In my most recent column, that was an abdominal aortic aneurysm. Most adults with an ascending TAA are recommended for surgical repair at a diameter of 5.5 cm. However, if the aneurysm is rapidly expanding, surgery may be considered earlier. If a person has a medical illness, making surgery very risky, surgeons may wait until the size exceeds 6 cm.

The decision on when to do surgery requires judgement from an experienced surgeon and cardiologist.

This is a major surgery with potential for harm, including death, and it’s not to be undertaken unless the benefits clearly outweigh the risks. Rupture is unlikely at less than 6 cm.

Keeping the blood pressure down (below 120 systolic) is a good idea. Beta blockers are most commonly used for that, based on studies in people with genetic risk for TAA, such as Marfan syndrome.

Side note: Testing for genetic syndromes should be considered in all people with thoracic aortic aneurysms.

Statin drugs are often used, as there is evidence to suggest they slow down expansion of the aneurysm.

Strenuous activities like heavy lifting and contact sports should be avoided, but regular exercise is probably beneficial.