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The aorta is the body’s largest blood vessel, carrying oxygen-rich blood from the heart to the rest of the body; it is about the width of a garden hose and runs from the chest into the abdomen, where it divides to supply the legs. This important artery can be affected by short-term triggers such as heavy weight lifting, injury, or drug use (for example, cocaine), as well as long-term conditions like high blood pressure and certain inherited disorders such as Marfan syndrome or abnormalities of the heart valve, all of which can weaken the aortic wall. Because the aorta is constantly exposed to high pressure with every heartbeat, even small areas of weakness can gradually worsen over time. In many cases, these changes develop silently without causing symptoms until the aorta becomes significantly enlarged. When a section of the aorta becomes stretched and enlarged due to weakness in the vessel wall, forming a balloon-like bulge, this is called an aneurysm. We classify an aorta measuring 4.0–4.4 cm as slightly enlarged (dilated), while a diameter of 4.5 cm or more is considered an aneurysm, as the risks begin to increase more significantly.
As the aorta enlarges, its wall becomes weaker, and factors such as high blood pressure can put additional strain on it, causing further expansion and increasing the risk of tearing or rupture, which can be life-threatening; therefore, regular monitoring and good blood pressure control are essential.
Thoracic aortic aneurysms usually develop slowly and often do not cause noticeable symptoms, making them difficult to detect and diagnose. Many are discovered incidentally when patients undergo imaging tests for other symptoms or conditions. These tests may include a chest X-ray, an echocardiogram (an ultrasound of the heart and part of the aorta), a computed tomography (CT) scan, or a magnetic resonance imaging (MRI) scan. Unless the aneurysm has become large or has started to leak or rupture, a physical examination is typically normal. As it enlarges, some people may experience symptoms such as chest or back pain, shortness of breath, cough, or a hoarse voice, although these are often non-specific. CT and MRI scans are particularly useful, as they show both the size of the aorta and the exact location of the aneurysm, helping guide monitoring and treatment decisions.
Approximately 10% of patients may have other family members who have aortic aneurysms. The principal causes of death due to thoracic aneurysmal disease are dissection and rupture.
The diameter of the thoracic aorta is a reliable indicator of the severity of aneurysmal degeneration. It is the most important criterion that we have identified to estimate the risk of the catastrophic complications, aortic rupture and dissection, and therefore to guide preemptive surgical correction, so as to protect patients from these devastating events. Current guidelines recommend prophylactic surgical intervention at an aortic diameter of 5.5 cm for asymptomatic patients (or 5.0 cm if the operation is to be performed by an expert aortic team), and between 4.5 and 5.0 cm for Marfan syndrome and other genetically-mediated thoracic aortic aneurysms.
Relative aortic size in relation to body height or body surface area may be more informative than absolute aortic diameter alone when assessing the risk of complications. Patients can be stratified into four risk categories using indexed measurements. In general, surgery is considered for patients in the higher-risk group, including those with an Aortic Height Index (AHI) of ≥3.21 cm/m, a Cross-sectional Aortic Area/Height Ratio of ≥10 cm²/m, or an Aortic Size Index (ASI) of ≥3.08 cm/m². Surgery may also be considered in selected moderate-risk patients when it can be performed safely by an experienced specialist aortic team. Rapid expansion in aortic diameter is also a surgical indication. Aneurysm growth averages 0.07 cm/year in the ascending aorta and 0.19 cm/year in the descending aorta. A growth rate of 1 cm/year or faster is an indication for surgical repair.
Positive family history of aortic dissection significantly increases the risk of developing a new dissection in unaffected family members. Patient within a decade of the age of dissection of their relative (or even earlier) should receive frequent monitoring of the size of their aorta and be should be strongly considered for a surgical intervention even at moderate aortic size.
There is evidence to show that specific gene mutations confer a specific increased risk for adverse outcomes, even at small or normal aortic sizes. It has been recognized that aortic dissection in Marfan syndrome patients can occur at smaller sizes, therefore we recommend early intervention at <5 cm for the ascending aorta and <6 cm for the descending aorta. Patients with Loeys-Dietz syndrome, Ehlers-Danlos syndrome (specially the vascular variety of it), Turner’s syndrome should also be offered prophylactic early intervention at <5 cm or even <4.5 cm, if the operation is to be performed by an expert aortic team. Women with heritable thoracic aortic disease have higher rates of peripartum vascular complications compared to women with sporadic cause of thoracic aortic disease, and therefor, aortic surveillance during and immediately after pregnancy is mandatory for this subgroup of patients.
Genetic testing is recommended for individuals with TAD/family history of TAD (especially <65 years of age), syndromic features, and/or early age of disease onset. Positive genetic testing should trigger gene-based management and cascade testing of at-risk relatives. When testing is negative or reveals variants of unknown significance, first-degree relatives should undergo screening aortic imaging.Thoracic aortic imaging is recommended for first-degree relatives of all patients with thoracic aortic dissection, to detect asymptomatic aneurysms.
Aortitis is the all-encompassing term that describes inflammation of the aorta. The most common causes of aortitis are the large-vessel vasculitides giant cell arteritis (GCA) and Takayasu arteritis, although it also is associated with several other rheumatologic diseases and rare infectious aortitis. In some cases, aortitis is an incidental finding after surgery for aortic aneurysm. Once the diagnosis of aortitis has been established, the approach to management depends on the underlying cause. The goals of therapy include both the immediate treatment of aortic inflammation, or infection in rare cases, and the surveillance and management of aortic and arterial complications. In addition to immunosuppressive therapy, patients with aortitis must be closely monitored for the development of aortic aneurysm. Prophylactic surgery is generally considered the standard treatment for aortic aneurysms associated with aortitis. Surgical intervention may also be required to treat serious complications of aortitis, including aortic dissection, aortic valve damage, narrowing of the coronary artery origins, limb ischaemia, stroke, and heart failure. Endovascular interventions may be used either alone or in combination with conventional surgical procedures, depending on the nature and extent of the disease.
The decision to operate on an aortic aneurysm hinges on a careful balance between the risk of aneurysm rupture or dissection and the risks associated with surgery. Over time, surgical outcomes have improved significantly, particularly when procedures are performed by specialist aortic surgeons within dedicated centres of excellence. In these settings, multidisciplinary aortic teams can deliver highly coordinated and efficient care — such as the specialist aortic service we provide at Oxford.
Patients with symptoms should undergo repair of their aneurysm regardless of size. Acutely symptomatic patients require emergency operation.
Bicuspid aortic valve disease is a condition present from birth in which the aortic valve has two leaflets instead of the usual three. It is the most common congenital heart condition, affecting around 1–2% of the population. This condition can run in families, with approximately 9–15% of first-degree relatives (such as parents, siblings, or children) also affected, and for this reason screening with an echocardiogram is recommended for close family members. In addition to affecting the valve, it is also associated with weakness of the aortic wall, meaning the aorta may gradually enlarge over time (an aneurysm), which occurs in up to 40% of patients. This enlargement most commonly involves the ascending aorta (around 60–70% of cases), but it can also affect the aortic root, the early part of the aortic arch, or a combination of these areas.
Bicuspid aortic valve related aortopathy refers to early weakening and structural changes in the wall of the aorta, seen in around half of patients who undergo surgery for this condition. These changes arise from a combination of factors. Many people with a bicuspid aortic valve have an underlying genetic tendency that affects the strength and structure of the aortic wall, making it more prone to weakening and enlargement, even without significant valve problems. These inherited differences can alter the normal composition of the aortic tissue, making it less resilient over time and leading some patients to develop aortic enlargement at a younger age. In addition, the way blood flows through a valve with two “doors” creates uneven stress on different parts of the aorta. This effect becomes more pronounced if the valve is narrowed (stenotic) or leaky (regurgitant), where blood flow becomes more forceful and turbulent with each heartbeat, placing extra strain on the aortic wall. Together, these genetic and flow-related factors result in a wide range of presentations, with some patients experiencing faster progression than others, highlighting the importance of regular monitoring and individualised care.
Although only a small proportion of people with bicuspid aortic valve disease (around 5% or less over a lifetime) develop an aortic dissection, it remains an important cause of this serious condition, particularly because patients tend to present at a younger age. The risk is higher in those who also have valve problems, such as narrowing (stenosis) or leakage (regurgitation). In particular, bicuspid valves associated with leakage appear to behave more aggressively than those with narrowing, with a significantly higher risk of aortic complications. Because of this, treatment decisions aim to provide the best long-term outcome. In patients who have both valve disease and enlargement of the ascending aorta (around 4.5–5.0 cm), surgery to treat both the valve and the aorta at the same time is often recommended—especially in lower-risk patients—rather than treating the valve alone with keyhole procedures such as transfemoral aortic valve implantation – TAVI. This is particularly important when additional risk factors are present, such as a family history of aortic disease, certain patterns of aortic enlargement, or evidence that the aorta is growing more quickly, and where prophylactic aortic repair is recommended to prevent catastrophic aortic complications, particularly aortic dissection and rupture
An aortic aneurysm can often be treated before it becomes dangerous, especially when it is identified early and carefully monitored. The main treatment is surgery, which involves replacing the weakened section of the aorta with a strong artificial tube called a graft. This graft is designed to take over the job of the damaged part of the blood vessel, allowing blood to flow normally while preventing the aneurysm from enlarging further or rupturing.
The decision to operate depends on the size and location of the aneurysm, as well as your overall health. Aneurysms in the upper part of the chest (the ascending aorta) are usually treated more urgently because they carry a higher risk of serious complications. In contrast, aneurysms in the lower chest or abdomen are often monitored closely over time. If they grow beyond about 4–5 cm (depending on your height and individual risk factors), increase in size quickly, or start causing symptoms, surgery is usually recommended to prevent rupture.
There are different types of surgery depending on the location of the aneurysm and the patient’s overall health. In some cases, traditional open surgery is performed, where the chest or abdomen is opened to directly repair the aorta. In other cases, a less invasive approach called endovascular repair may be possible, where the graft is inserted through blood vessels in the groin and guided into place using imaging.The goal of treatment is to reduce the risk of rupture, which can be life-threatening, while balancing the risks of surgery itself.
Aortic aneurysms can affect the aortic arch, which is a particularly complex area of the body. Surgery to repair the aortic arch may involve replacing the entire arch and reconnecting the three main blood vessels that supply blood to the brain and both arms. This is a highly specialised operation and should only be performed by cardiac surgeons with specific expertise in aortic surgery, supported by a team experienced in advanced techniques to protect the brain. During the procedure, the body is often cooled to very low temperatures (below 28°C), a method known as deep hypothermia, which helps protect the brain. In addition, controlled blood flow is maintained to vital organs using specialised perfusion techniques. In selected patients, some aortic arch operations can be performed without the need for deep cooling and this approach has been used with excellent results at our centre in Oxford, in carefully chosen cases. As with any major surgery, there are risks. One recognised complication is injury to the nerve that controls the vocal cords, which may result in hoarseness of the voice.
Aortic arch aneurysms often extend beyond the arch into the descending thoracic aorta (the part of the aorta that runs down through the chest). Because of this, surgery is frequently planned to treat both areas together rather than addressing them separately.One commonly used approach is the “Elephant Trunk” technique, which allows surgeons to repair the aortic arch while also preparing the descending aorta for future treatment if needed. This technique provides flexibility and is particularly useful when a second-stage procedure to the descending aorta is anticipated, either through open surgery or a minimally invasive (endovascular) stent procedure. When a stent-based (intravascular) treatment is planned, a modified version called the “Frozen Elephant Trunk (FET)” technique is often used (Thoraflex Hybrid – Terumo Aortic – Features & Benefits) This combines open surgery with placement of a stent graft in the descending aorta during the same operation. Devices such as the Thoraflex Hybrid graft are commonly used for this purpose, helping to stabilise the aorta and reduce the need for more extensive surgery later on. These operations are highly complex and usually involve advanced methods to protect vital organs. This often includes cooling the body to very low temperatures (deep hypothermia), as well as specialised techniques to maintain blood flow to the brain, spinal cord, and other organs during the procedure. For this reason, they are typically performed by cardiac surgeons with specialist expertise in aortic surgery, supported by an experienced multidisciplinary team, like the one we have at Oxford. In some cases, further treatment may still be required at a later stage. This could involve extending the stent graft using a minimally invasive procedure, or performing a second open operation to repair the remaining part of the descending thoracic aorta, sometimes in combination with the abdominal aorta. Your surgical team will plan this carefully and discuss the staged approach with you if needed.
For certain cases of aortic dissection that involve extensive areas of the aorta, we use the Artivion AMDS device as part of the surgical repair. This specially designed implant helps support the damaged section of the aorta, improve blood flow, and promote healing of the vessel wall. These operations are highly specialised and may involve cooling the body to low temperatures and using techniques to protect the brain and other organs during surgery. They are performed by specialist aortic surgeons working within an experienced multidisciplinary team, like the one we have at Oxford. In some cases, further treatment or follow-up procedures may still be needed in the future.
Thoracoabdominal aortic aneurysm surgery is a major operation to repair a weakened and enlarged section of the aorta that extends from the chest into the abdomen. The aim is to replace the diseased part of the aorta with a durable artificial graft, preventing rupture and protecting blood flow to vital organs such as the kidneys, liver, bowel and spinal cord. Because this part of the aorta supplies many important branches, these vessels must be carefully preserved or reconnected during the procedure. Treatment can be performed using fully open surgical techniques, or in some cases a combined (hybrid) approach, which uses a mix of endovascular (keyhole) methods and more limited open surgery. The best option depends on the patient’s overall health and the exact shape and extent of the aneurysm. These procedures are complex and are carried out by highly specialised teams using advanced techniques to improve safety and recovery. Although recovery can take time, the operation is often life-saving, and patients are closely monitored and supported throughout their hospital stay and during long-term follow-up.
A straightforward repair of an ascending aortic aneurysm is performed under general anaesthesia, meaning you will be fully asleep during the operation, and typically requires a hospital stay of around 5–7 days. However, your recovery, including time in the intensive care unit (ICU), may be longer depending on how complex the surgery is, particularly if the procedure also involves the aortic arch or other parts of the aorta. During the operation, the surgeon makes an incision down the centre of your chest (usually about 25 cm) and opens the breastbone to access the heart and aorta. Your heart is temporarily stopped using medication, and your blood is diverted to a heart-lung machine, which takes over the function of your heart and lungs by circulating and oxygenating your blood. The weakened section of the aorta is then removed and replaced with a durable synthetic tube (graft). If the aneurysm extends into the vessels supplying the head and neck, your body temperature may be lowered (typically between 15–27°C) to help protect the brain, and blood flow may be briefly paused or carefully controlled using specialised techniques. Once the repair is complete, blood flow is restored, your heart is restarted, and the breastbone is closed using wires, with the skin closed using dissolvable stitches or staples. The operation usually takes between 4 and 8 hours, although more complex procedures involving multiple parts of the aorta, especially the aortic arch, can take 12 hours or longer.
Aortic dissection is a serious condition in which a tear develops in the inner layer of the aorta (the main blood vessel from the heart). This allows blood to flow between the layers of the aortic wall, forcing them apart. It is a life-threatening medical emergency that can lead to death very quickly, even with prompt treatment. If the tear extends through all layers of the aorta, it can cause sudden rupture and severe internal bleeding. Overall, aortic dissection carries a very high risk; >50% of cases involving rupture are fatal, and up to half of patients may die before reaching hospital. In the UK, it affects around 4,000 people each year, but only about 1,200 patients survive long enough to reach hospital. Overall, aortic dissection causes more deaths annually than road traffic accidents in the UK, highlighting how serious and under-recognised this condition is.
Aortic dissection is most commonly associated with high blood pressure, which is present in around 70–80% of patients. It is also linked to conditions that weaken the aortic wall, including connective tissue disorders and inflammatory diseases (vasculitis), as well as chest trauma. It most often occurs in people aged 50 to 70 years and is about twice as common in men as in women. In younger women, particularly those under 40, it can rarely occur during pregnancy, usually in the later stages or shortly after delivery. Certain inherited conditions significantly increase the risk. These include Marfan syndrome, Loeys-Dietz syndrome, Ehlers-Danlos syndrome, Turner syndrome, and bicuspid aortic valve. These conditions can weaken the structure of the aorta and make dissections more likely, often at a younger age. Ascending aortic size at Type-A dissection varies by sex and geographic origin, with most acute aortic dissections occurring below current surgical thresholds, challenging the universality of fixed diameter cut-offs. In some cases, aortic dissection can occur following injury to the chest, such as in car accidents (blunt trauma), or as a complication of medical procedures involving the heart and blood vessels, including cardiac catheterisation or the use of devices like an intra-aortic balloon pump. It can also develop as a late complication after previous heart surgery, with >10% of patients having a history of prior open-heart procedures.
Type A aortic dissection is a life-threatening condition that requires urgent surgery. The operation involves removing and replacing the damaged section of the aorta, particularly where the tear has occurred, using a durable synthetic graft. In most cases, the ascending aorta is replaced, and the aortic valve is carefully assessed and repaired if necessary. The exact procedure is tailored to each patient, depending on the extent of the dissection and the structures involved. In some patients, the dissection extends beyond the ascending aorta into the aortic arch (which supplies blood to the brain and arms), the descending thoracic aorta, or even the abdominal aorta. It may also affect important branch vessels to the head and neck or the arteries supplying the legs. When this occurs, more complex surgery is required to restore safe blood flow and prevent further complications.
Advanced techniques such as the Frozen Elephant Trunk (FET) procedure may be used when the dissection involves both the upper and descending aorta. This approach allows treatment of multiple segments of the aorta in a single operation and can help stabilise the remaining aorta for the future. In some cases, treatment is performed in stages, with an initial life-saving operation followed by planned procedures to address other affected areas of the aorta at a later time.
It is not uncommon that some portions of the aorta, although affected by the dissection, are not treated during the initial emergency operation. These segments may remain stable for a period of time but can enlarge or cause problems later, and therefore may require further planned treatment in the future. For this reason, patients require long-term follow-up, typically for at least five years and often lifelong. This involves regular imaging scans and clinical review to monitor the remaining aorta and ensure any changes are detected early. Ongoing care is best provided in specialist centres with expertise in aortic disease, such as those the one we have in Oxford, where dedicated multidisciplinary teams can offer comprehensive monitoring and timely treatment when needed.
Surviver of aortic dissection and their families can find further information at Aortic Dissection: The Patient Guide. This Guide has been put together by patients, family and carers, for patients, family and carers and it contains everything that patients and their families wish to know about the disease and the post operative recovery. The THINK AORTA campaign aims to raise awareness and improve diagnosis of Aortic Dissection worldwide.The Aortic Dissection Charitable Trust made an animation describing the pathophysiology of acute Aortic Dissection.
Endovascular treatment is a minimally invasive way of repairing an aortic aneurysm without the need to open the chest. Instead, the procedure is performed from inside the blood vessel using long, thin tubes called catheters. A small incision is made in the groin, and a catheter is carefully guided through the femoral artery up to the affected part of the aorta. Using X-ray guidance, a stent-graft is then positioned precisely at the site of the aneurysm. The stent-graft itself is a fabric tube supported by a flexible metal framework (stent). Once in place, it expands to fit the aorta and acts like an internal lining or “sleeve.” By sealing securely above and below the weakened area, it allows blood to flow through the graft rather than putting pressure on the aneurysm, reducing the risk of rupture.
Because this approach avoids major open surgery, it is generally associated with less pain, smaller scars, and a lower risk of complications. Most patients recover more quickly, spend less time in hospital, and are able to return to normal activities sooner compared to traditional surgery. Endovascular treatment for thoracic aortic aneurysms can also be used as part of a staged approach to managing more complex and extensive disease involving the entire aorta. In these cases, treatment is carefully planned over time and may involve a combination of open surgery, hybrid procedures, and minimally invasive (endovascular) techniques, performed at different stages to achieve the safest and most effective outcome.
Our specialist aortic team in Oxford has extensive experience in endovascular (TEVAR – keyhole) aortic procedures and is recognised as a leading centre in the UK for the treatment of complex aortic disease. We perform a high volume of these procedures using the latest techniques and technology, with excellent outcomes and a strong focus on patient safety. Our multidisciplinary team, including surgeons, interventional specialists, anaesthetists and imaging experts, works closely together to tailor treatment to each individual. Patients can feel reassured that they are being cared for by a highly experienced team, with comprehensive support before, during and after treatment.
