Medical Monday: How We Treat Descending Thoracic Aortic Aneurysms

Welcome back to Medical Monday

Today, we're exploring how doctors treat descending aortic aneurysms. This life-threatening condition requires precise, highly specialized care.

When the descending thoracic aorta becomes enlarged and weak, it is referred to as a descending aortic aneurysm. The primary goal of treatment is to prevent rupture and restore safe blood flow. Currently, two main approaches are used for this condition: Thoracic Endovascular Aortic Repair (TEVAR) and Open Thoracoabdominal Aortic Replacement.

What Is a Descending Aortic Aneurysm?

Think of your aorta like the main highway pipeline that carries water from a powerful pumping station (your heart).

Over time, if one section of that pipeline becomes worn, thinner, or damaged, the water pressure pushes on that weak spot, making it bulge outward, like a bubble forming on a garden hose.

At first, the hose still works.

But that bubble is dangerous—if it keeps growing, it can suddenly burst, causing a catastrophic leak.

A descending aortic aneurysm is precisely that:

A weakened, ballooned-out area of the body's main artery.

Interventions like TEVAR and open thoracoabdominal surgery are ways of reinforcing or replacing that damaged part of the "hose" before it breaks.

How Do We Fix It? Two Main Interventions

1. TEVAR — Thoracic Endovascular Aortic Repair

Now, the standard of care at most centers for descending aortic aneurysms is thoracic endovascular aortic repair (TEVAR), a minimally invasive procedure to treat the aorta. TEVAR is like inserting a sturdy inner tube (a stent graft) into the pipe to reinforce the weak area, allowing water to flow safely without putting pressure on the damaged wall.

Why TEVAR is preferred:

• Faster recovery

• Less blood loss

• Lower short-term risk

• Excellent for older patients and those with other health issues

Cardiovascular and Interventional Radiological Society of Europe (CIRSE). Thoracic endovascular aortic repair (TEVAR) [Internet]. CIRSE; [cited 2025 Nov 23]. Available from: https://www.cirse.org/patients/general-information/ir-procedures/thoracic-endovascular-aortic-repair-tevar/

What happens during  TEVAR?

Since TEVAR is a minimally invasive procedure, it's performed through a small incision. Here are the steps.

1. Anesthesia is given to prevent pain and numb the body. 

2. A small incision is made by a surgeon in the groin area as well as the arm to get into the aorta. A thin tube (catheter) called a sheath will be placed in the artery.

3. A stent graft will be placed at the end of the catheter. The stent graft is a tube made of a thin metal mesh (the stent), covered with a thin polyester fabric (the graft). 

4. Using X-rays as a guide, the stent will be placed and expanded.

5. The catheter will be removed, and the incision will be closed. 

2. Open Thoracoabdominal Aortic Replacement

While TEVAR is the standard at most centers, open thoracoabdominal aortic repair is still essential for specific patients—especially younger individuals, those with connective-tissue disorders, or people with very complex aneurysms that stent grafts cannot safely treat.

Think of this option as replacing the damaged section of the pipe rather than reinforcing it from the inside.

When is open surgery chosen?

Open repair is usually recommended when:

• The patient is young and needs a long-lasting repair

• There is a connective tissue disorder (Marfan, Loeys–Dietz, Ehlers-Danlos)

• The aneurysm is too complex or involves multiple branches

• TEVAR would not seal safely, or could increase the risk of complications

• These cases are typically treated at specialized high-volume centers with expertise in major aortic surgery

Hong JC, Coselli JS. Open repair for thoracoabdominal aortic aneurysms precipitated by chronic aortic dissection. Vessel Plus. 2022;6:4. doi:10.20517/2574-1209.2021.88.

🛠️ What Happens During Open Thoracoabdominal Repair?

Open repair is a major surgery, done under general anesthesia. Here's what it looks like in a simplified way:

1. Anesthesia and preparation

2. Surgical exposure

The surgeon makes an incision that may extend:

• From the chest

• Through the abdomen

• Along the flank

• This gives direct access to the diseased aorta.

3. Clamping and protecting organs

Since the aorta carries blood to the spinal cord, kidneys, liver, and intestines, the surgical team uses:

• Bypass or perfusion circuits to keep organs supplied

• Cooling techniques to protect tissues

• Careful clamping to control blood flow

4. Removing the diseased segment

The weakened or aneurysmal part of the aorta is removed, like cutting out the cracked portion of a pipe.

5. Sewing in a new graft

A strong synthetic graft (usually Dacron) is sewn into place to replace the removed section.

If the aneurysm involves major branches, each branch is individually reconnected to the graft.

6. Closing the incision

Once the graft is in place and organs are reperfused, the incision is closed, and the patient is taken to the ICU for recovery.

Conclusion

Descending thoracic aortic aneurysms can be life-threatening, but today we have powerful tools to treat them safely and effectively. TEVAR has become the standard of care at most centers because it offers fast recovery, lower short-term risk, and excellent outcomes for many patients — especially older adults or those with other health conditions.

However, open thoracoabdominal aortic replacement remains essential for younger patients, those with connective-tissue disorders, and complex aneurysms that simply cannot be repaired endovascularly. These surgeries are performed in specialized centers with deep expertise, ensuring the best possible long-term durability.

In the end, the “best” approach isn’t one-size-fits-all — it’s the one tailored to the patient’s anatomy, age, genetics, and overall health. Thanks to modern cardiotoracic surgery, most people with descending aortic aneurysms now have safe, effective treatment options and a real chance at long-term survival.

This is all we have for you today, folks. We hope this has been informative. Join us back here next Tuesday.y 

ATT 

ÁLVARO JOSÉ MARTÍNEZ SANTACRUZ 

References 

1. Cardiovascular and Interventional Radiological Society of Europe (CIRSE). Thoracic endovascular aortic repair (TEVAR) [Internet]. CIRSE; [cited 2025 Nov 23]. Available from: https://www.cirse.org/patients/general-information/ir-procedures/thoracic-endovascular-aortic-repair-tevar/

2. Hong JC, Coselli JS. Open repair remains the gold standard. JTCVS Tech. 2021;10:16-23. doi:10.1016/j.xjtc.2021.01.024.

3. Hong JC, Coselli JS. Open repair for thoracoabdominal aortic aneurysms precipitated by chronic aortic dissection. Vessel Plus. 2022;6:4. doi:10.20517/2574-1209.2021.88.

4. Tshomba Y, Sica S, Minelli F, Ferraresi M, de Waure C, Donati T, et al. Long-term results of complex abdominal aortic aneurysm open repair. J Pers Med. 2022;12(10):1630. doi:10.3390/jpm12101630.

5. Isselbacher EM. Thoracic and abdominal aortic aneurysms. Circulation. 2005;111(6):816-28. doi:10.1161/01.CIR.0000154569.08857.7A.

6. Cleveland Clinic. Endovascular repair of thoracic aortic aneurysm [Internet]. Cleveland Clinic; [cited 2025 Nov 23]. Available from: https://my.clevelandclinic.org/health/treatments/16962-endovascular-repair-of-thoracic-aortic-aneurysms

7. Melloni A, Kahlberg A, Rinaldi E, Bilman V, Favia N, Melissano G, et al. Open thoracoabdominal aortic procedures following endovascular intervention. Aorta (Stamford). 2022;10(4):162-8. doi:10.1055/s-0042-1750117.

8. Nation D, Wang G. TEVAR: Endovascular repair of the thoracic aorta. Semin Intervent Radiol. 2015;32(4):265-71. doi:10.1055/s-0035-1558824.