When we think about heart health, most of us immediately picture heart disease. But there are other important parts of our vascular system—like the veins and arteries—that can also be at risk. Conditions such as abdominal aortic aneurysms and thoracic aortic aneurysms may not be as well known, but they can be just as serious.
These types of aneurysms are often called “silent killers” because they usually develop without symptoms and are difficult to detect—until a life-threatening event like a rupture occurs. Payam Salehi, MD, Chief of Vascular Surgery and Shivani Kumar, MD, vascular surgeon at Tufts Medical Center break down the risks, symptoms and advances in treatments.
What is an aortic aneurysm + how is it diagnosed?
An aortic aneurysm is a bulge in a weakened aorta, the body’s largest artery. The aorta carries all of the blood leaving the heart across the chest and the abdomen. Aortic aneurysms can be very difficult to detect through physical examination and may go undetected for years unless specific tests are performed. Most patients do not notice anything is wrong unless the aortic aneurysm begins to dissect (tear) or rupture, which can lead to massive, life-threatening bleeding.
What are the different types of aortic aneurysms: Abdominal, thoracic and thoracoabdominal?
The most common and deadly aneurysm is aortic. Two-thirds of aortic aneurysms are abdominal (AAA), and a third is thoracic (occurring in the chest cavity). When the aneurysm occurs in both areas, it is called thoracoabdominal.
How serious are aortic aneurysms + what are the risks?
According to the Centers for Disease Control and Prevention, 9,904 Americans died of aortic aneurysms in 2019 (the last year for which data is available). About 59% of deaths due to aortic aneurysm or aortic dissection happen among men. Left untreated, dissections and ruptures can be fatal. With proper treatment and monitoring, however, most patients with these conditions will survive with improved quality of life.
What causes aortic aneurysms + what are the symptoms?
In thin patients or those with very large abdominal aneurysms, a pulsing mass may be felt in the middle of the abdomen. Most people, however, feel no pain or other symptoms associated with aortic aneurysms unless they rupture or rapidly expand. Most aortic aneurysms are found on imaging studies such as X-rays, CT scans, MRIs, ultrasound and echocardiograms. Often, the finding of an aortic aneurysm is a surprise from a study done for other reasons.
Several well-known factors increase an individual’s risk of developing an aneurysm, including:
- A family history of aneurysms
- Arteriosclerosis (hardening of the arteries)
- High blood pressure
- Lung disease (like COPD)
- Other known aneurysms
- Smoking
Additionally, several rare genetic disorders affect connective tissue strength and greatly increase the risk of aneurysm formation. The most common of these are Marfan's and Ehlers-Danlos syndrome.
How are aortic aneurysms treated? Surgery, stents + new technology
Since the risk of complications from aneurysms is related to their size and location, and since growth over time is normal, a key to aneurysm disease management is early detection. Most small aneurysms have low likelihood of near-term complications and can be monitored with serial ultrasound or CT scans. This imaging helps determine whether treatment should include medical management alone (i.e., blood pressure and cholesterol medications) or repair of the aneurysm. Options to repair the aneurysm include:
- Endovascular aneurysm repair and thoracic endovascular aortic repair (EVAR): These minimally invasive procedures are typically achieved through small punctures in the groin through which a graft is inserted and covers the inside of the aorta, thereby preventing the blood flow from touching the weakened aortic wall. These procedures performed from within the aorta are called endovascular repairs and are referred to EVAR (endovascular aneurysm repair) when done to abdominal aneurysms, or TEVR (thoracic endovascular aortic repair) when done in the chest.
- ZFEN (Zenith Fenestrated Endovascular Graft): A type of stent used to treat abdominal aortic aneurysms near the kidney arteries. It has small openings to keep blood flowing to the kidneys while supporting the weakened part of the aorta.
- Thoracoabdominal Branch Endoprosthesis (TAMBE): This exciting advancement is a medical device and procedure used to prevent rupture of thoracoabdominal aortic aneurysms. The device is a specially-made stent graft that is implanted inside the aorta to cut off blood flow to the aneurysm, prevent rupture and cause the bulge to shrink. The device is inserted around the aneurysm in the aorta through a blood vessel. Only 2 small incisions, in the chest and the groin, are needed. TAMBE requires less time in the operating room and a shorter hospital stay and it results in a faster recovery, fewer complications and overall better outcomes for the patient. Tufts Medical Center was the first to perform a TAMBE procedure since its FDA approval in 2025.
Some aneurysms, however, aren’t suitable for minimally invasive techniques and require open surgical repair, which replaces the diseased aorta with a graft that is sewn into the healthy portions of the aorta above and below the aneurysm. Though more traumatic initially, the open approach can be adapted to any anatomy and, in selected patients, may have better long-term outcomes. Minimally invasive procedures result in less pain and faster recovery, but every patient is different and customized treatment is critical.
Who needs screening for abdominal aortic aneurysm (AAA)?
If you have a known aneurysm or if your doctor feels an aneurysm, you should have a study for cause, not a screening. Screening studies are designed to identify problems that have not been previously discovered. As such, screening studies are recommended for diseases that pose a high risk if undiscovered and can be discovered with a low risk and effective test. While the rules vary between commercial insurance companies, Medicare (CMS) currently recommends and pays for a one-time screening ultrasound of the abdominal aorta for 1) anyone with a family history of an AAA or 2) for men 65-75 years old who have smoked over 100 cigarettes. These screening ultrasound studies, which typically take about 15 minutes, are safe and pain-free.
If you or someone you know fits in one of these categories and have not been screened, ask your primary care physician or vascular specialist to discuss if you need screening.
What does a vascular surgeon do + when should I see one?
Vascular surgeons are specialists who are highly trained to treat diseases of blood vessels and veins. These physicians should be experienced experts who can perform the required procedures—whether traditional or minimally invasive surgery—they also care for patients who may not require surgery and are treated with medication, monitoring and lifestyle adjustments such as diet and exercise.
What is recovery like after aortic aneurysm repair?
This depends on the details of your anatomy and the specific procedure. Less invasive endovascular procedures can be done with local anesthesia and sedation or general anesthesia. Most people spend a single night in the hospital and are discharged with mild pain and bruising in the groins. Overall recovery time is minimal baring complications. Open surgical procedures for aortic aneurysms require general and/or spinal anesthesia. Hospital stays are commonly 5-7 days and recovery sometimes involves rehab stays with a return to full activity taking weeks to months.
While recovery from open aortic surgery is much tougher than endovascular techniques and the near-term risk of complications is higher than endovascular repair, open surgery is more versatile, allowing for treatment of any aneurysm. Also, in the long term, the endovascular techniques have increased risk of developing “leaks.” Therefore, all patients receiving endovascular AAA repairs should have long-term, follow-up scans to detect and treat these possible leaks and accompanying aneurysm growth.
What’s new in aortic aneurysm treatment? Advances in endovascular repair and stent technology
Device development continues at a brisk pace, with several manufacturers that produce the devices used in aortic aneurysm repair. These manufacturers are now several generations into refinements. Today’s endovascular stent grafts are built on smaller and more flexible delivery systems that allow us to offer this treatment to patients with small or tortuous arteries. Devices are now made with branches and custom-made side holes to allow these grafts to extend into branch arteries leading to the arms, intestines, kidneys and pelvic arteries. These “branched and fenestrated” endografts are increasing the proportion of patients considered anatomically suitable for these minimally invasive, life-saving techniques. The vascular community closely tracks and studies the results of all treatment choices in aneurysm repair and continuously refines recommendations on factors that optimize patient outcomes in the near and long term. Since vascular surgeons perform both open and endovascular repairs, they can provide the most up-to-date recommendations on treatment options.
When should I talk to a doctor about an aortic aneurysm?
Talk with your primary care physician, meet with a vascular surgeon and get the recommended tests. Be informed and proactive.
