Medical Monday: When Do We Replace an Ascending Aortic Aneurysm?

Today we’re focusing on a serious—but, critically, a very treatable—cardiovascular condition: ascending aortic aneurysms.

These aneurysms represent a localized dilation or bulge in the wall of the aorta, specifically the section that arises from the left ventricle of the heart and travels upward, known as the ascending aorta. Because the aorta is the body's largest artery and carries oxygenated blood under high pressure to the rest of the circulatory system, a weakening or expansion in this region poses a significant risk.

🔍 What Is an Ascending Aortic Aneurysm?

The ascending aorta is the first part of your body’s main artery, located right after the heart. An aneurysm is when this section becomes enlarged or “ballooned,” making it weaker and more likely to tear or rupture. 

The primary concern with an ascending aortic aneurysm is the risk of catastrophic complications: aortic dissection (a tear in the inner layer of the aorta) or aortic rupture (a complete burst of the aortic wall). Both events are medical emergencies with very high mortality rates. 

This is a life-threatening situation—but surgery can prevent it.

Roland, J. (2017, August 29). Ascending aortic aneurysm. Healthline; Healthline Media. https://www.healthline.com/health/ascending-aortic-aneurysm

❗ What are the symptoms?

Most ascending aortic aneurysms cause no symptoms and are found by accident.

However, if symptoms do appear, they may include:

• Chest pain or upper back pain

• Shortness of breath

• Hoarseness

• Coughing or wheezing

• Difficulty swallowing

These symptoms often occur because the enlarged aorta presses on nearby structures.

🩻 Diagnosis and Tests

Since most AAAs are silent, they’re often discovered during imaging done for other reasons. If an aneurysm is suspected, your healthcare provider may order:

✅ Chest X-ray

Can show an enlarged aorta, but not detailed enough to detect smaller aneurysms.

✅ Transthoracic Echocardiogram (TTE)

Uses sound waves to evaluate the aortic root, ascending aorta, and heart valves.

✅ Chest CT Scan

Provides highly detailed 3D images of the aorta. With IV contrast, it can detect even small aneurysms or dissections.

✅ MR Angiography (MRA)

An MRI focused on the chest and aorta that shows blood flow, valve function, and heart performance without radiation.

📏 When Is Surgery Recommended?

Surgeons use the size of the aneurysm to decide the right time to operate.

✅ 5.5 cm — Universally agreed size where surgery is recommended for most people.

✅ 5.0 cm — Recommended earlier in:

• High-volume aortic centers

• Patients with genetic conditions (Marfan, Loeys-Dietz)

• People with a family history of aortic dissection

• Those with rapid growth (≥0.5 cm in 1 year)

Think of it like a growing weak spot in a tire—the larger it gets, the higher the risk of it bursting.

✅ If surgery is not needed yet

Your provider may recommend:

• Blood pressure medications (beta blockers, ARBs)

  • ARBs are routinely given to people with Marfan syndrome

• Statins to lower cholesterol

• Follow-up imaging every 6 months, then spaced out if stable

• Lifestyle changes

  • No smoking

  • Healthy diet

  • Avoid heavy lifting

  • Safe, low-impact exercise

🏥 Treatment Options

1. Watch-and-Wait (Medical Management)

Used for smaller aneurysms. Focuses on controlling risk factors and close monitoring.

2. Open Surgical Repair

The standard treatment for ascending aortic aneurysms.

• The surgeon opens the chest

• Removes the weakened portion of the aorta

• Replaces it with a durable synthetic graft

• Sometimes replaces the aortic valve if needed

✅ This surgery requires cardiopulmonary bypass (heart–lung machine) because the heart must be stopped safely during the repair.

3. Endovascular Repair (TEVAR)

Performed through a small incision in the leg, delivering a stent-graft to reinforce the aorta.

⚠️ Important:Endovascular repair for the ascending aorta is still in early trials and not widely available. The anatomy near the heart is complex, so open surgery remains the gold standard.

4. Emergency Surgery

Required if the aneurysm ruptures or causes an acute aortic dissection.This surgery must be done immediately, but even with surgery, the risk of complications remains high.

💬 Final Thoughts

Replacing an ascending aortic aneurysm is a major operation, but when done at the right time, it prevents rupture, dissection, and saves lives. Knowing the size thresholds and understanding why CPB is required helps demystify the process.

Your aorta is one of the most important vessels in your body—taking care of it is taking care of your life.

That’s all for today’s Medical Monday! Hope this was informative (and maybe saved you from a risky ride). See you next week!

ALVARO JOSE MARTINEZ SANTACRUZ

References

1. Ascending aortic aneurysm. (2021, October 27). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/21949-ascending-aortic-aneurysm

2. Faiza, Z., & Sharman, T. (2025). Thoracic aorta aneurysm. In StatPearls. StatPearls Publishing.

3. Isselbacher, E. M., Preventza, O., Hamilton Black, J., 3rd, Augoustides, J. G., Beck, A. W., Bolen, M. A., Braverman, A. C., Bray, B. E., Brown-Zimmerman, M. M., Chen, E. P., Collins, T. J., DeAnda, A., Jr, Fanola, C. L., Girardi, L. N., Hicks, C. W., Hui, D. S., Schuyler Jones, W., Kalahasti, V., Kim, K. M., … Peer Review Committee Members. (2022). 2022 ACC/AHA guideline for the diagnosis and management of Aortic Disease: A report of the American heart association/American college of cardiology joint committee on clinical practice guidelines. Circulation, 146(24), e334–e482. https://doi.org/10.1161/CIR.0000000000001106

4. Repair of an ascending aortic aneurysm. (2024, March 18). Hopkinsmedicine.org. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/repair-of-an-ascending-aortic-aneurysm

5. Roland, J. (2017, August 29). Ascending aortic aneurysm. Healthline; Healthline Media. https://www.healthline.com/health/ascending-aortic-aneurysm