Life-threatening condition: what is a dissecting aneurysm and aortic dissection? Dissecting aortic aneurysm: diagnosis and treatment Aortic aneurysm of the heart diagnosis.

- pathological local expansion of the main artery, due to the weakness of its walls. Depending on the location, an aortic aneurysm may present with pain in the chest or abdomen, the presence of a pulsating tumor-like formation, symptoms of compression of neighboring organs: shortness of breath, cough, dysphonia, dysphagia, swelling and cyanosis of the face and neck. The basis for the diagnosis of aortic aneurysm is x-ray (chest x-ray and abdominal cavity, aortography) and ultrasound methods (USDG, ultrasound of the thoracic/abdominal aorta). Surgical treatment of an aneurysm involves its resection with aortic replacement or closed endoluminal aneurysm replacement with a special endoprosthesis.

General information

An aortic aneurysm is characterized by an irreversible expansion of the lumen of the arterial trunk in a limited area. The ratio of aortic aneurysms of different localization is approximately the following: abdominal aortic aneurysms account for 37% of cases, ascending aorta - 23%, aortic arch - 19%, descending aorta thoracic aorta- 19.5%. Thus, the share of thoracic aortic aneurysms in cardiology accounts for almost 2/3 of all pathology. Aneurysms thoracic aortas are often combined with other aortic defects - aortic insufficiency and aortic coarctation.

The reasons

According to etiology, all aortic aneurysms can be divided into congenital and acquired. The formation of congenital aneurysms is associated with hereditary diseases of the aortic wall:

Erdheim syndrome
hereditary deficiency of elastin, etc.

Acquired aortic aneurysms can have inflammatory and non-inflammatory etiologies:

Post-inflammatory aneurysms arise due to specific and nonspecific aortitis with fungal lesions of the aorta, syphilis, postoperative infections.
Non-inflammatory degenerative aneurysms due to atherosclerosis, defects in suture material and aortic prostheses.
Hemodynamic-poststenotic and traumatic aneurysms associated with mechanical damage to the aorta
Idiopathic aneurysms develop with median necrosis of the aorta.

Risk factors for the formation of aortic aneurysms are elderly age, male sex, arterial hypertension, smoking and alcohol abuse, hereditary burden.

Pathogenesis

In addition to the defectiveness of the aortic wall, mechanical and hemodynamic factors are involved in the formation of an aneurysm. Aneurysms often occur in functionally stressed areas experiencing increased stress due to high blood flow velocity, steepness of the pulse wave and its shape. Chronic traumatization of the aorta, as well as increased activity of proteolytic enzymes, cause destruction of the elastic framework and nonspecific degenerative changes in the vessel wall.

The formed aortic aneurysm progressively increases in size, since the stress on its walls increases in proportion to the expansion of the diameter. The blood flow in the aneurysmal sac slows down and becomes turbulent. Only about 45% of the blood from the volume in the aneurysm enters the distal arterial bed. This is due to the fact that, getting into the aneurysmal cavity, the blood rushes along the walls, and the central flow is restrained by the turbulence mechanism and the presence of thrombotic masses in the aneurysm. The presence of thrombi in the aneurysm cavity is a risk factor for thromboembolism of distal aortic branches.

Classification

ascending aortic aneurysm
aneurysm of combined localization - thoracoabdominal part of the aorta.

Evaluation of the morphological structure of aortic aneurysms allows us to subdivide them into true and false (pseudoaneurysms):

True aneurysm characterized by thinning and outward protrusion of all layers of the aorta. By etiology, true aortic aneurysms are usually atherosclerotic or syphilitic.
pseudoaneurysm. The wall of the false aneurysm is represented by a connective tissue formed as a result of the organization of a pulsating hematoma; own walls of the aorta are not involved in the formation of a false aneurysm. By origin, they are more often traumatic and postoperative.

Saccular and fusiform aortic aneurysms are found in shape: the former are characterized by local protrusion of the wall, the latter by diffuse expansion of the entire diameter of the aorta. Normally, in adults, the diameter of the ascending aorta is about 3 cm, the descending thoracic aorta is 2.5 cm, and the abdominal aorta is 2 cm. An aortic aneurysm is said to occur when the diameter of the vessel in a limited area increases by 2 or more times.

Taking into account clinical course There are uncomplicated, complicated, exfoliating aortic aneurysms. Specific complications of aortic aneurysms include rupture of the aneurysmal sac, accompanied by massive internal bleeding and hematoma formation; thrombosis of aneurysm and thromboembolism of arteries; phlegmon of surrounding tissues due to infection of the aneurysm.

A special type is a dissecting aortic aneurysm, when through a rupture of the inner membrane, blood penetrates between the layers of the artery wall and spreads under pressure along the course of the vessel, gradually exfoliating it.

Symptoms of an aortic aneurysm

Clinical manifestations of aortic aneurysms are variable and are determined by the location, size of the aneurysmal sac, its length, and the etiology of the disease. Aneurysms may be asymptomatic or be accompanied by scanty symptoms and be detected on preventive examinations. The leading manifestation is pain caused by damage to the aortic wall, its stretching or compression syndrome.

Aneurysm of the abdominal aorta

The clinic of an aneurysm of the abdominal aorta is manifested by transient or persistent diffuse pains, discomfort in the abdomen, belching, heaviness in the epigastrium, a feeling of fullness in the stomach, nausea, vomiting, intestinal dysfunction, and weight loss. Symptoms may be associated with compression of the cardia of the stomach, duodenum, involvement of visceral arteries. Often patients independently determine the presence of increased pulsation in the abdomen. On palpation, a tense, dense, painful pulsating formation is determined.

Thoracic aortic aneurysm

For an aneurysm of the ascending aorta, pain in the region of the heart or behind the sternum is typical, due to compression or stenosis of the coronary arteries. Patients with aortic insufficiency are concerned about shortness of breath, tachycardia, dizziness. Large aneurysms cause the development of the syndrome of the superior vena cava with headaches, swelling of the face and upper half of the body.

Aortic arch aneurysm leads to compression of the esophagus with dysphagia; in case of compression of the recurrent nerve, hoarseness of voice (dysphonia), dry cough occurs; interest vagus nerve accompanied by bradycardia and salivation. With compression of the trachea and bronchi, shortness of breath and stridor breathing develop; with compression of the root of the lung - congestion and frequent pneumonia.

When the aneurysm of the descending aorta stimulates the periaortic sympathetic plexus, pain occurs in the left arm and shoulder blade. If the intercostal arteries are involved, spinal cord ischemia, paraparesis, and paraplegia may develop. Compression of the vertebrae is accompanied by their usuration, degeneration and displacement with the formation of kyphosis. Compression of blood vessels and nerves is clinically manifested by radicular and intercostal neuralgia.

Complications

Aortic aneurysms can be complicated by rupture with massive bleeding, collapse, shock, and acute heart failure. Aneurysm rupture can occur in the system of the superior vena cava, the pericardial and pleural cavities, the esophagus, and the abdominal cavity. At the same time, severe, sometimes fatal conditions develop - superior vena cava syndrome, hemopericardium, cardiac tamponade, hemothorax, pulmonary, gastrointestinal or intra-abdominal bleeding.

With the separation of thrombotic masses from the aneurysmal cavity, a picture of acute occlusion of the vessels of the extremities develops: cyanosis and soreness of the toes, livedo on the skin of the extremities, intermittent claudication. Thrombosis of the renal arteries results in renovascular arterial hypertension and kidney failure; with damage to the cerebral arteries - stroke.

Diagnostics

Diagnostic search for aortic aneurysm includes an assessment of subjective and objective data, X-ray, ultrasound and tomography studies. Auscultatory sign of an aneurysm is the presence of systolic murmur in the projection of aortic expansion. Abdominal aortic aneurysms are detected by palpation of the abdomen in the form of a tumor-like pulsating mass. Instrumental diagnostics:

Radiography. The radiological examination plan for patients with an aneurysm of the thoracic or abdominal aorta includes fluoroscopy and chest radiography, plain radiography of the abdominal cavity, radiography of the esophagus and stomach. neighboring anatomical structures.
ultrasound. Echocardiography is used in recognizing ascending aortic aneurysms; in other cases, ultrasound (USDS) of the thoracic/abdominal aorta is performed.
CT scan. CT (MSCT) of the thoracic/abdominal aorta allows you to accurately and clearly present the aneurysmal expansion, identify the presence of dissection and thrombotic masses, para-aortic hematoma, and foci of calcification.

Based on the results of a comprehensive instrumental examination decision is made on indications for surgical treatment. Thoracic aortic aneurysm should be differentiated from lung and mediastinal tumors; aneurysm of the abdominal aorta - from volumetric formations of the abdominal cavity, lesions of the lymph nodes of the mesentery, retroperitoneal tumors.

Treatment of an aortic aneurysm

With asymptomatic non-progressive course of aortic aneurysm, they are limited to dynamic observation by a vascular surgeon and radiological control. To reduce risk possible complications antihypertensive and anticoagulant therapy, lowering cholesterol levels are carried out.

Surgical intervention is indicated for aneurysms of the abdominal aorta with a diameter of more than 4 cm; thoracic aortic aneurysms with a diameter of 5.5-6.0 cm or with an increase in smaller aneurysms by more than 0.5 cm in six months. When an aortic aneurysm ruptures, the indications for emergency surgical intervention are absolute.

In hemodynamically significant aortic insufficiency, resection of the ascending thoracic aorta is combined with aortic valve replacement. An alternative to open vascular intervention is endovascular aortic aneurysm repair with stent placement.

Forecast and prevention

The prognosis of an aortic aneurysm is mainly determined by its size and concomitant atherosclerotic lesion. of cardio-vascular system. In general, the natural course of an aneurysm is unfavorable and is associated with a high risk of death from aortic rupture or thromboembolic complications. The probability of rupture of an aortic aneurysm with a diameter of 6 cm or more is 50% per year, with a smaller diameter - 20% per year. Early detection and planned surgical treatment of aortic aneurysms is justified by low intraoperative (5%) mortality and good long-term results.

Preventive recommendations include blood pressure control, the organization of a proper lifestyle, regular monitoring by a cardiologist and an angiosurgeon, drug therapy for comorbidities. Individuals at risk for developing an aortic aneurysm should undergo a screening ultrasound examination.

Chest pain is one of the most common causes seeking medical help. The cause of chest pain may be clear, but is often atypical. Cases where patients complain of chest pain are the most difficult to diagnose.

The differential diagnostic range in such cases is extremely wide and includes, among other things, diseases that pose an immediate threat to life, such as myocardial infarction with and without ST segment elevation, unstable angina, thromboembolism pulmonary artery and dissecting aortic aneurysm.

Dissecting aortic aneurysm (RAA) is a rather difficult problem in terms of primary diagnosis. The reason for this is both the low frequency of this pathology and the high variability of clinical manifestations.

Without the use of cardiac surgical methods in early dates diseases, the prognosis is extremely unfavorable, and the two-week survival rate does not exceed 20%, therefore timely diagnosis RAA is the most important task.

The term "dissecting aortic aneurysm" refers to the sudden formation due to various reasons aortic intima defect with subsequent penetration of blood through this defect into the degeneratively changed median membrane, the formation of a hematoma and longitudinal dissection of the aortic wall.

Dissection (dissection) occurs mainly in the distal, less often in the proximal section. A hematoma can develop along the course of the aorta and block one of its branches, starting from the branches of the aortic arch and ending with the intestinal arteries.

Retrograde dissection may involve the coronary arteries. The right coronary artery is most commonly involved. Retrograde dissection can lead to weakening of one or more leaflets of the aortic valve and its insufficiency.

The false channel is located in the outer half of the middle shell of the aorta. Its outer wall is only a quarter of the original thickness of the aortic wall. This is the reason for frequent aortic ruptures in patients with dissecting aneurysms.

Rupture of an aneurysm of the aortic arch occurs most often in the mediastinal cavity, rupture of the descending aorta - in the left pleural cavity, abdominal aorta - in the retroperitoneal tissue. Since the parietal pericardium attaches to the ascending aorta just proximal to the origin of the brachiocephalic trunk, rupture of any part of the ascending aorta can lead to pericardial tamponade.

Classifications of dissecting aortic aneurysms

Classifications of dissecting aortic aneurysms are usually based on the location of the proximal rupture of the aortic intima and the extent of the dissection of the aortic wall. Since the rupture of the inner lining of the aorta can theoretically occur in any segment and be multiple, the variants of aortic dissection are very diverse.

However, in practice, the rupture of the inner membrane most often occurs in the anterior wall of the ascending aorta at the border of the proximal and middle thirds, as well as in the initial segment of the descending aorta distal to the bed of the left subclavian artery.

It is on this principle that the simple and widespread Stanford classification, according to which there are several types of bundle:

type A- intimal rupture is in the ascending aorta with or without damage to the arch or descending aorta;
type B- the tear is located in the descending aorta, while the dissection extends proximally and distally.

To determine the prognosis of the disease and develop conservative and operative tactics in the clinic, a modification is used. M. DeBakey classification:

type I- the rupture of the inner membrane is localized in the ascending part of the aorta, and the dissection of its walls extends to the abdominal part of the aorta;
type II- rupture of the inner membrane is localized in the ascending part of the aorta, the dissection ends with a blind sac proximal to the brachiocephalic trunk;
type III- rupture of the inner lining of the aorta is localized in primary department descending thoracic aorta distal to the orifice of the left subclavian artery.

Classification of dissecting aortic aneurysm

According to another classification, there are five classes of aortic dissection.

The 1st class includes the classic aortic dissection with the formation of false and true moves without the formation of a message between them,
to the 2nd - intramural hematoma or hemorrhage,
to the 3rd - a penetrating manifestation of an atherosclerotic plaque in the aortic wall due to tearing of its capsule,
to the 4th - small limited or partial dissections of the aorta with the formation of a protrusion of its wall
to the 5th - iatrogenic or post-traumatic aortic dissections (for example, aortic dissection with a catheter inserted into it for cardiac catheterization).

Intimal rupture, which is the beginning of a dissecting aneurysm, is found in the ascending aorta in about 70% of cases. In 10% of cases, it is found in the arch, in 20% - in the descending part of the thoracic aorta. In rare cases, there is a tear in the intima of the abdominal aorta.

Dissection (dissection) of the aorta can be acute (up to 2 weeks) and chronic (more than 2 weeks).

Prevalence RAA is estimated on average as 1 in 10,000 hospitalized (however, a significant proportion of patients die on prehospital stage). This pathology is the cause of 1.1% of sudden deaths and 3-4% of all sudden deaths from cardiovascular disease; detected in 1 case per 400 autopsies.

To predisposing factors Aortic dissections include diseases and conditions accompanied by cystic degeneration of the media:

long-term arterial hypertension,
congenital connective tissue defects (Marfan, Ehlers-Danlos, Turner syndromes),
polycystic kidney disease,
old age (60-70 years);
congenital heart defects (coarctation of the aorta, bicuspid or unicuspid valve);
atherosclerosis of the aorta;
pregnancy;
chest trauma,
severe physical and emotional stress;
systemic vasculitis (especially often granulomatous, giant cell arteritis);
chemical and toxic effects (drugs, such as cocaine);
iatrogenic causes.

Clinical picture

Most frequent symptoms with RAA, there are a sudden onset of pain with a lightning-fast achievement of maximum intensity, localization of pain in the chest, and back pain. The pain is described by patients as very intense or unbearable, the worst pain they have ever experienced, the pain is sharp or tearing.

A significant proportion of patients may experience one or another change in the ST segment or T wave.

With the proximal type of dissection, an aortic regurgitation murmur may be heard.

Both with the proximal and distal types of dissection, asymmetry of the pulse (decrease in its filling or absence) can be determined and blood pressure on the upper or lower limbs.

In some patients, certain neurological disorders may be detected.

Relatively rare secondary (most often posterior-inferior) myocardial infarction associated with the spread of dissection at the mouth coronary artery.

For diseases similar to RAA clinical picture, relate:

acute coronary syndrome;
aortic insufficiency without dissection (dissection);
aortic aneurysm without dissection (dissection);
musculoskeletal;
pericarditis;
mediastinal tumor;
pleurisy;
pulmonary embolism;
cholecystitis.

The presence of RAA can be suspected if the patient has pain; pain associated with fainting (syncope); pain in combination with symptoms of heart failure; pain in combination with symptoms of CNS damage (stroke); heart failure without pain; symptoms of CNS damage (stroke) without pain; changes on a chest x-ray without pain; no pulse without pain.

As recommended working group European Society of Cardiology, to confirm the diagnosis, clarify the type of dissection (localization, extent), diagnose and clarify the severity of aortic insufficiency and diagnosis of extravasation (periaortic or mediastinal hematoma, pleural or pericardial effusion), preference should be given to transthoracic echocardiography followed by transesophageal echocardiography and intravascular ultrasound, multispiral computed tomography or magnetic resonance imaging.

Angiography may be performed to determine the anatomical substrate for planned percutaneous intervention in hemodynamically stable and unstable patients, but not routinely. Chest X-ray does not provide additional information.

Therapeutic measures

The following are the initial diagnostic and treatment measures that should be carried out if AAA is suspected, in accordance with the recommendations of the European Society of Cardiology Expert Group.

Collection of a detailed anamnesis and a complete examination (if possible).

Provision of venous access, blood tests (KLA, CPK, troponin I (T), D-dimer, hematocrit, lipids).

ECG in 12 leads.

Monitoring of blood pressure and ECG.

Pain relief (morphine).

Decrease in systolic blood pressure, preferably β-blockers (propranolol, metoprolol, esmolol), with contraindications - calcium antagonists.

Transportation to the ICU.

In severe arterial hypertension additional vasodilators.

Transthoracic (transesophageal) echocardiography.

All patients with dissecting aortic aneurysms are treated surgically.

Clinical example

We present a clinical example of in vivo diagnosis of AAA based on the characteristics of the course of the disease and the clinical picture.

Patient A., 59 years old. No complaints at the time of admission. Previously, she did not suffer from cardiovascular diseases.

For the first time 3 days before going to the hospital, there was a stabbing, piercing pain of moderate intensity in the region of the heart and between the shoulder blades without connection with physical activity and movement, aggravated by palpation, persisted for several hours after self-administration of analgesics. A repeated similar attack developed on the eve of admission to the hospital.

Consulted by a neurologist, vertebrogenic thoracalgia was suggested. An ECG was performed, changes were detected (negative T waves in leads III and aVF), for which the patient was referred to the hospital with a diagnosis of IHD. Posterior diaphragmatic myocardial infarction.

During an objective examination, a moderately intense diastolic murmur was heard over the aorta and along the right edge of the sternum.

Taking into account the acute nature and duration of chest pain in combination with the identified signs of aortic insufficiency, presumably acute (there was no information about a pre-existing heart disease, the heart borders were within the normal range, there were no signs of chronic heart failure), it was suggested that there was RAA ascending section of the aorta.

The patient was admitted to the ICU, where it was planned to start an esmolol infusion, conduct transthoracic and, if necessary, transesophageal echocardiography.

10 minutes after admission, the patient suddenly lost consciousness, cessation of blood circulation (electromechanical dissociation) was diagnosed. Resuscitation measures are unsuccessful.

Diagnosis: Dissecting aneurysm of the ascending aorta. Hemopericardium. Cardiac tamponade.

Pathological anatomical examination revealed a non-extended dissection of the ascending aorta with a supravalvular rupture and hemorrhage into the pericardial cavity.

P. V. Dolotovskaya, I. V. Graifer, S. V. Efremov, N. V. Furman

The basis for the diagnosis of aortic aneurysm is radiological (radiography of the chest and abdominal cavity, aortography) and ultrasound methods (USDG, ultrasound of the thoracic/abdominal aorta). Surgical treatment of an aneurysm involves its resection with aortic replacement or closed endoluminal aneurysm replacement with a special endoprosthesis.

aortic aneurysm

An aortic aneurysm is characterized by an irreversible expansion of the lumen of the arterial trunk in a limited area. The ratio of aortic aneurysms of different localization is approximately the following: abdominal aortic aneurysms account for 37% of cases, ascending aorta - 23%, aortic arch - 19%, descending thoracic aorta - 19.5%. Thus, the share of thoracic aortic aneurysms in cardiology accounts for almost 2/3 of all pathology. Thoracic aortic aneurysms are often combined with other aortic malformations - aortic insufficiency and aortic coarctation.

Classification of aortic aneurysms

In vascular surgery, several classifications of aortic aneurysms have been proposed, taking into account their localization by segments, shape, wall structure, and etiology. In accordance with the segmental classification, there are: sinus of Valsalva aneurysm, ascending aortic aneurysm, aortic arch aneurysm, descending aortic aneurysm, abdominal aortic aneurysm, aneurysm of combined localization - thoracoabdominal aorta.

Evaluation of the morphological structure of aortic aneurysms allows us to subdivide them into true and false (pseudoaneurysms). A true aneurysm is characterized by thinning and outward protrusion of all layers of the aorta. By etiology, true aortic aneurysms are usually atherosclerotic or syphilitic. The wall of the false aneurysm is represented by a connective tissue formed as a result of the organization of a pulsating hematoma; own walls of the aorta are not involved in the formation of a false aneurysm. Pseudoaneurysms by origin are more often traumatic and postoperative.

Taking into account the clinical course, uncomplicated, complicated, exfoliating aortic aneurysms are distinguished. Specific complications of aortic aneurysms include rupture of the aneurysmal sac, accompanied by massive internal bleeding and hematoma formation; thrombosis of aneurysm and thromboembolism of arteries; phlegmon of surrounding tissues due to infection of the aneurysm. A special type is a dissecting aortic aneurysm, when, through a rupture of the inner membrane, blood penetrates between the layers of the artery wall and spreads under pressure along the course of the vessel, gradually exfoliating it.

The etiological classification of aortic aneurysms is detailed when considering the causes of the disease.

Causes of an aortic aneurysm

According to etiology, all aortic aneurysms can be divided into congenital and acquired. The formation of congenital aneurysms is associated with hereditary diseases of the aortic wall - Marfan's syndrome, fibrous dysplasia, Ehlers-Danlos syndrome, Erdheim's syndrome, hereditary elastin deficiency, etc.

Acquired aortic aneurysms of inflammatory etiology occur as a result of specific and nonspecific aortitis with fungal lesions of the aorta, syphilis, and postoperative infections. Non-inflammatory or degenerative aortic aneurysms include cases of disease caused by atherosclerosis, defects in suture material and prostheses. Mechanical damage to the aorta leads to the formation of hemodynamic-poststenotic and traumatic aneurysms. Idiopathic aneurysms develop with median necrosis of the aorta.

Risk factors for the formation of aortic aneurysms are older age, male sex, arterial hypertension, smoking and alcohol abuse, hereditary burden.

The pathogenesis of aortic aneurysms

In addition to the defectiveness of the aortic wall, mechanical and hemodynamic factors are involved in the formation of an aneurysm. Aortic aneurysms often occur in functionally stressed areas experiencing increased stress due to high blood flow velocity, steepness of the pulse wave and its shape. Chronic traumatization of the aorta, as well as increased activity of proteolytic enzymes, cause destruction of the elastic framework and nonspecific degenerative changes in the vessel wall.

Symptoms of an aortic aneurysm

Clinical manifestations of aortic aneurysms are variable and are determined by the location, size of the aneurysmal sac, its length, and the etiology of the disease. Aortic aneurysms can be asymptomatic or be accompanied by scanty symptoms and be detected at routine examinations. The leading manifestation of an aortic aneurysm is pain caused by damage to the aortic wall, its stretching or compression syndrome.

Aortic arch aneurysm leads to compression of the esophagus with dysphagia; in case of compression of the recurrent nerve, hoarseness of voice (dysphonia), dry cough occurs; the interest of the vagus nerve is accompanied by bradycardia and salivation. With compression of the trachea and bronchi, shortness of breath and stridor breathing develop; with compression of the root of the lung - congestion and frequent pneumonia.

When the aneurysm of the descending aorta stimulates the periaortic sympathetic plexus, pain occurs in the left arm and shoulder blade. If the intercostal arteries are involved, ischemia may develop. spinal cord, paraparesis and paraplegia. The compression of the vertebrae is accompanied by their usuration, degeneration and displacement with the formation of kyphosis; compression of blood vessels and nerves is clinically manifested by radicular and intercostal neuralgia.

Complications of an aortic aneurysm

Aortic aneurysms can be complicated by rupture with the development of massive bleeding, collapse, shock, and acute heart failure. Aneurysm rupture can occur in the system of the superior vena cava, the pericardial and pleural cavities, the esophagus, and the abdominal cavity. At the same time, severe, sometimes fatal conditions develop - superior vena cava syndrome, hemopericardium, cardiac tamponade, hemothorax, pulmonary, gastrointestinal or intra-abdominal bleeding.

With the separation of thrombotic masses from the aneurysmal cavity, a picture of acute occlusion of the vessels of the extremities develops: cyanosis and soreness of the toes, livedo on the skin of the extremities, intermittent claudication. With thrombosis of the renal arteries, renovascular arterial hypertension occurs and kidney failure; with damage to the cerebral arteries - a stroke.

Diagnosis of an aortic aneurysm

The radiographic examination plan for patients with thoracic or abdominal aortic aneurysm includes fluoroscopy and chest radiography, plain abdominal radiography, and radiography of the esophagus and stomach. When recognizing aneurysms of the ascending aorta, echocardiography is used; in other cases, ultrasound (USDS) of the thoracic/abdominal aorta is performed.

Computed tomography (MSCT) of the thoracic/abdominal aorta makes it possible to accurately and visually present the aneurysmal expansion, identify the presence of dissection and thrombotic masses, para-aortic hematoma, and foci of calcification. At the final stage of the examination, aortography is performed, according to which the localization, size, length of the aortic aneurysm and its relationship to neighboring anatomical structures are specified. Based on the results of a comprehensive instrumental examination, a decision is made on the indications for surgical treatment of aortic aneurysm.

Thoracic aortic aneurysm should be differentiated from lung and mediastinal tumors; aneurysm of the abdominal aorta - from volumetric formations of the abdominal cavity, lesions of the lymph nodes of the mesentery, retroperitoneal tumors.

Treatment of an aortic aneurysm

With asymptomatic non-progressive course of aortic aneurysm, they are limited to dynamic observation by a vascular surgeon and radiological control. To reduce the risk of possible complications, antihypertensive and anticoagulant therapy, lowering cholesterol levels are carried out.

Surgical treatment of aortic aneurysm consists in excision of the aneurysmically altered portion of the vessel, suturing the defect or replacing it with a vascular prosthesis. Taking into account the anatomical localization, resection of the aneurysm of the abdominal aorta, thoracic aorta, aortic arch, thoracoabdominal part of the aorta, subrenal aorta is performed.

Prediction and prevention of aortic aneurysm

The prognosis of an aortic aneurysm is mainly determined by its size and concomitant atherosclerotic lesions of the cardiovascular system. In general, the natural course of an aneurysm is unfavorable and is associated with a high risk of death from aortic rupture or thromboembolic complications. The probability of rupture of an aortic aneurysm with a diameter of 6 cm or more is 50% per year, with a smaller diameter - 20% per year. Early detection and planned surgical treatment of aortic aneurysms is justified by low intraoperative (5%) mortality and good long-term results.

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Aortic aneurysm. Complications, diagnosis and treatment

Complications of an aortic aneurysm

Thrombus formation. In the cavity of an aneurysm, whether it is fusiform or saccular, normal blood flow is disrupted. Swirls form in it, which can lead to the formation of blood clots. The thrombus in this case will be sticky platelets. Being in the cavity of the aneurysm, the thrombus does not particularly interfere with the blood flow. However, after leaving the aneurysm, the thrombus can get stuck in vessels of smaller diameter. Predicting exactly where thrombosis will occur is almost impossible. The cerebral artery (with a picture of ischemic stroke), the arteries of the kidney, liver, and extremities may be blocked. Thrombosis stops the flow of arterial blood to the corresponding organ, which leads to rapid tissue death. Often, thrombosis ends in the death of the patient. The problem is that an aneurysm may not manifest itself in any way, and the patient does not suspect that he has a disease. At the same time, blood flow disorders already exist, and a stroke, for example, will be the first (and often the last) manifestation of the disease.
Pneumonia. Pneumonia may be the result of an aneurysm of the thoracic aorta, if the latter compresses the bronchi or presses on the trachea. Normally, the epithelium of the airways secretes a certain amount of mucus, which clears the bronchi and humidifies the air. Compression also leads to the fact that mucus accumulates in a certain section of the lung. Here are created favorable conditions for the development of infection. If it gets in, then pneumonia develops.
Clamping of the bile ducts. Aneurysms in the upper part of the abdominal aorta coexist with many different organs. A large aneurysm can, for example, occlude the bile ducts that run from the gallbladder to duodenum. In this case, firstly, the outflow of bile from the gallbladder is disturbed, and, secondly, the digestion process worsens. The risk of cholecystitis, pancreatitis increases, and the patient may suffer from diarrhea, constipation, flatulence.
Risk of heart disease. An aneurysm of the thoracic aorta of considerable size can compress the nerve plexuses that regulate the work of the heart. Because of this, patients sometimes experience persistent bradycardia or tachycardia. In addition, pressure often increases in the thoracic aorta itself, which creates an additional load on the left ventricle. As a result, irreversible changes can occur in the aortic valve of the heart or in the heart muscle. Even after removal of the aneurysm and normalization of pressure, disturbances in the work of the heart may remain.
Ischemia lower extremities. Ischemia is called oxygen starvation fabrics. In the lower limbs arterial blood may be ingested in smaller amounts due to an infrarenal aortic aneurysm (located below the origin of the renal arteries). Lack of oxygen leads to poor cell renewal. Increased risk of frostbite trophic ulcers(due to lack of nutrition) and other soft tissue injuries. Aneurysm in this case will play the role of a provoking factor.

Ruptured aortic aneurysm

injuries and falls;

taking certain medications (especially those that increase blood pressure);

psychoemotional stress.

Dissecting aortic aneurysms rupture most often and quickly, since their wall is less durable. However, even such formations rarely rupture at rest.

sudden weakness;
loss of consciousness;
noise in ears;
sudden pain;
rapid blanching of the skin;
the appearance of a dark spot on the skin of the abdomen (with the accumulation of a large amount of blood in the abdominal or retroperitoneal cavity).

A patient with a ruptured aortic aneurysm needs urgent surgical intervention to eliminate bleeding and resuscitation to maintain vital processes.

Diagnosis of an aortic aneurysm

Physical examination for aortic aneurysm

visual inspection. Visually, with aortic aneurysms, very little information can be obtained. Any changes in the shape of the chest are extremely rare and only in cases where the patient has lived with a large aneurysm of the thoracic aorta for at least a few years. With an aneurysm of the abdominal aorta of large size, one can sometimes observe a pulsation that is transmitted to the anterior abdominal wall. In addition, when an aneurysm ruptures, purple spots can sometimes be observed on the abdominal wall - a sign of massive internal bleeding. However, this symptom almost never appears on the anterior abdominal wall (usually on the side), since the aorta is located retroperitoneally (separated from the intestines, stomach and other organs by the posterior peritoneum), and hemorrhage occurs primarily in the retroperitoneal space.
Percussion. Percussion is the percussion of body cavities to determine the boundaries of different organs by ear. With an aneurysm of the abdominal aorta, the approximate size and location of the formation can be determined in this way. Often the area of percussion sound dullness coincides with the "vascular bundle" zone. Then, according to percussion, this zone will be expanded. In addition, with a large aneurysm of the thoracic aorta, the borders of the heart or mediastinum may be slightly shifted. With an aneurysm of the abdominal aorta, percussion is less informative, since the vessel passes along the posterior wall of the abdominal cavity. Palpation in this case will be more informative.
Palpation. Palpation of the chest cavity is almost impossible due to the rib cage, so palpation is almost never used in the diagnosis of thoracic aortic aneurysm. With an aneurysm of the abdominal cavity, it is often possible to detect a formation pulsating in time with the heart. This eloquently speaks precisely of the presence of an aneurysm, since such formations do not occur in other diseases. In addition, the detection of a pulse can be attributed to palpation. If the heart rate or heart rate varies by different hands or on the carotid arteries, this may indicate the presence of an aortic arch aneurysm. Weakened or absent pulsation on the femoral arteries (or different frequency on different legs) may indicate an infrarenal aneurysm.
Auscultation. Listening with a stethophonendoscope (listener) is a very common and valuable diagnostic method. With an aneurysm of the abdominal aorta, by applying a stethoscope to the projection site of the aneurysm, you can hear an increased noise of blood flow. With thoracic aortic aneurysm pathological changes may be different - a metallic accent of the second tone over the aorta, systolic murmur at the Botkin point, etc.
Pressure measurement. Most often, patients with an aneurysm are found to have hypertension (increased pressure). With aneurysms of the aortic arch of large sizes, the pressure on different arms may be different (the difference is more than 10 mm Hg).

Upon detection characteristic symptoms During the physical examination, the doctor prescribes other diagnostic measures to confirm the diagnosis.

X-ray for aortic aneurysm

Ultrasound for aortic aneurysm

relatively low cost;
painless and safe for the patient examination;
immediate results;
the duration of the study is only 10 - 15 minutes;
the ability to determine the shape and size of the aneurysm;
the possibility of detecting some complications of an aneurysm;
the possibility of assessing blood flow in the aorta and its branches;
the possibility of detecting emerging thrombi.

In general, ultrasonography is more common in diagnosing abdominal aortic aneurysms. abdominal wall thinner, and the picture that the doctor receives is more accurate. When examining an aneurysm of the thoracic aorta, a number of pathologies of the heart and lungs can also be detected, which is also important for treatment. The method of examining the organs of the chest cavity using ultrasound waves is called echocardiography (EchoCG).

MRI and CT for aortic aneurysm

ear implants and built-in hearing aids;
the presence of metal pins or plates after surgery;
the presence of a pacemaker;
some types of prosthetic heart valves.

An important advantage of MRI is that this procedure also allows you to evaluate the blood flow in individual vessels, and not just get an image of the aneurysm itself. Doctors are able to evaluate circulatory disorders and suspect a number of related disorders.

ECG for aortic aneurysm

Laboratory tests

Change in the level of leukocytes. It can be observed with some infections, which, in turn, are the cause of the development of an aneurysm. The level of leukocytes usually increases in acute infectious processes and decreases in chronic ones. In chronic cases, the proportion of non-segmented neutrophils in the leukocyte formula also increases.
Changes in blood clotting. The study of the level of platelets, clotting factors and a number of other indicators often changes if blood clots form in the cavity of the aneurysm.
Elevated cholesterol. Hypercholesterolemia is an increase in the level of cholesterol in the blood up to 5 mmol / l or more. Most often, this indicates an atherosclerotic lesion of the aorta. It also speaks indirectly elevated level triglycerides or low-density lipoproteins (even if total cholesterol is normal).
In the analysis of urine, in rare cases, blood impurities (microhematuria) can be detected, which are detected in a specific analysis.

However, all these changes are optional, not found at all stages of the disease and not in all patients.

Treatment of an aortic aneurysm

smoking cessation is perhaps the most important measure for both preventing the development of an aneurysm and delaying the increase in the diameter of an already existing thoracic aortic aneurysm;
normalization of blood pressure (including with the help of medications);
normalization of body weight, if necessary with the help of a nutritionist;
following a diet low in cholesterol to prevent atherosclerosis;
refusal of serious physical exertion;
prevention of psycho-emotional stress (up to taking sedatives).

Given that the causes of aortic aneurysm may vary, other preventive measures may be required. They are determined and explained to the patient by the attending physician after the examination.

Medications for aortic aneurysm

With a small diameter of the pathological area in the aorta (up to 5 cm) during the period of dynamic observation of a patient with a thoracic aortic aneurysm.
In severe concomitant diseases, when the risk of surgery exceeds the risk of rupture of the aneurysm itself. These conditions include acute disorders of the coronary circulation, acute disorders cerebral circulation, heart failure II - III degree.
In preparation for surgery.

For each patient, the attending physician selects his own treatment regimen, depending on the type and size of the formation, as well as depending on the symptoms and complaints of the patient. However, there are several groups of drugs that are prescribed most often.

drugs that reduce heart rate (heart rate);
drugs to lower blood pressure;
cholesterol-lowering drugs.

To reduce heart rate, beta-blockers are most often used, which affect the innervation of the heart. With contraindications to the use of beta-blockers, verapamil from the group of calcium channel blockers may be prescribed. It is necessary to slow down the heart rate to beats per minute. This significantly reduces the load on the walls of the aorta and reduces the likelihood of complications.

Composition and form of release

Dosage and regimen

Tablets 10 mg, 40 mg

Initial dose 20 mg, average dose per day.

Tablets 25 mg, 50 mg, 100 mg

50 or 100 mg per day.

Tablets 2.5 mg, 5 mg, 10 mg

The daily dose is from 2.5 to 10 mg at a time.

Tablets 2.5 mg, 5 mg, 10 mg

2.5 mg, 5 mg or 10 mg 1 time per day.

Tablets 40 mg, 80 mg

mg 3 times a day.

Blood pressure must also be reduced to reduce stress in the aortic wall. For this purpose, calcium channel blockers, ACE inhibitors (angiotensin-converting enzyme inhibitors) are used. For each patient, the attending physician selects the drugs of the group that best suits him. In some cases, a combination of drugs is possible. The appointment depends on the causes that cause hypertension.

Composition and form of release

Dosage and regimen

Tablets 5 mg and 10 mg

The daily dose is 5 mg or 10 mg once.

Tablets 5 mg, 10 mg, 20 mg

5 mg, 10 mg, 20 mg 2 times a day.

Tablets 5 mg, 10 mg, 20 mg

5 mg, 10 mg, 20 mg once.

Tablets 2.5 mg, 5 mg, 10 mg

2.5 mg, 5 mg, 10 mg 1 time per day.

Tablets 2 mg, 4 mg, 8 mg, 10 mg

Pomg 1 time per day.

Atherosclerosis is a risk factor rapid growth aneurysms, contributing to the weakening of the vessel wall. Timely treatment can delay the progression of the process for a long time. Used drugs from the group of statins, fibrates, sequestrants bile acids. The drug for the treatment of a particular patient is chosen by the doctor, guided by the results of the tests.

Composition and form of release

Dosage and regimen

Tablets 10 mg, 20 mg, 40 mg

Pomg for 1 time, take once in the evening.

Tablets 10 mg, 20 mg, 40 mg

Pomg for 1 time in the evening.

Tablets 10 mg, 20 mg, 40 mg

Pomg 1 time in the evening.

Tablets 145 mg, 160 mg, 200 mg, 250 mg

mg 1 time per day.

g per day of intake.

For various complications of an aortic aneurysm or related disorders, the patient may need other drugs. For example, if an aortic aneurysm occurs as a result of a systemic infection, a course of treatment with antibiotics that are effective against the causative microbe is necessary. Various vitamin complexes, preparations for strengthening can also be prescribed. vascular wall, drugs against the formation of blood clots. However, there are no uniform treatment standards. The specialist is guided by the situation, based on the violations found in the patient. Self-medication with the above drugs without consulting a doctor is very dangerous. Incorrect dose selection can accelerate the rupture of the aneurysm or give an excessive load on other internal organs.

Surgical treatment of aortic aneurysm

acute circulatory disorders in the vessels of the heart;
circulatory failure II or III degree;
serious problems with blood circulation in the vessels of the brain (in the presence of relevant neurological problems);
the impossibility of adequate revascularization of at least the deep arteries of the thigh (after the operation there will be insufficient blood circulation).

Past myocardial infarction with a stable electrocardiogram for three months or a stroke six weeks ago (in the absence of neurological disorders) are not contraindicated. Such patients may undergo surgical removal of the aneurysm.

detailed examination of the condition respiratory system(spirography);
assessment of the state of the kidneys, in order to exclude latent renal failure;
it is mandatory to assess the condition of the blood vessels of the lower extremities, as well as the coronary arteries and arteries of the pulmonary circulation;
determination of sensitivity to antibiotics prescribed for staphylococci and coli(these microorganisms most often cause postoperative complications).

Regardless of the type of aneurysm, antibiotic therapy is prescribed in advance (usually 24 hours before surgery) as a prevention of postoperative complications. During the day, a sufficient concentration of the antibiotic appears in the blood to prevent the reproduction of pathogenic (pathogenic) bacteria.

Classic surgery. Classical intervention is understood as a large-scale abdominal operation with general anesthesia and wide tissue dissection. The goal is to remove the section of the aorta with an aneurysm and replace it (usually with a prosthesis). As a result, blood flow through the aorta is restored completely. The big disadvantage of this operation is its trauma. There is a high risk of complications during and after surgery. Even in the absence of complications, the patient, as a rule, recovers for a long time and loses his ability to work for a long time.
Endovascular surgery. Endovascular surgery is understood as a set of methods in which there is no large-scale tissue dissection. All necessary instruments are brought to the aneurysm through other vessels (often through femoral artery). Depending on the type and size of the aneurysm, there are several options for intervention. Sometimes a special reinforcing mesh is installed in the lumen of the vessel, which prevents the growth or delamination of the formation. With saccular aneurysms of small sizes, sometimes they resort to "filling" the mouth. Currently, there is a fairly wide range of manipulations through endovascular access. However, they are all performed, as a rule, for small saccular aneurysms, when there is no serious threat of rupture.

If it is a dissection of the aneurysm, rupture or other complications, or the risk of rupture, according to doctors, is very high, only conventional surgery is performed. It gives more extensive access to the aorta, allows you to more reliably fix the problem and better examine other weak areas of the vessel, if any. Also classical surgery is the only treatment option for large and giant fusiform aneurysms.

Alternative treatment of aortic aneurysm

Infusion of dill greens. Infuse one tablespoon of finely chopped dill in 400 ml of boiling water. Divide this portion into 3 parts and drink during the day.
Infusion of hawthorn. The fruits of the red hawthorn are well dried and chopped. To prepare the infusion, you need two tablespoons of the resulting powder. Pour the powder into 300 ml of boiling water and infuse for half an hour. Divide into three parts and consume 30 minutes before meals.
Infusion of levkoy jaundice. This infusion is prepared from two tablespoons of jaundice. 150 ml of boiled water is poured. Drink 15 ml 5 times a day. You can add sugar to the prepared infusion to improve the taste.
Elderberry decoction. To prepare this decoction, you need Siberian elderberry root. Boil 200 ml of water, add the crushed elderberry root, let it simmer over low heat for 15 minutes. Remove from heat and leave for another 30 minutes. Strain the resulting broth, pour into a glass dish. Drink one tablespoon 3 times a day.

It must be understood that none of the remedies recommended above will have the most important effect - slowing down the growth of the aneurysm. When using funds traditional medicine only temporary relief of symptoms of the disease, such as shortness of breath or swelling, is possible. Therefore, relying on phytorecepts is completely unacceptable. A complete cure can only be guaranteed by timely access to doctors and surgical treatment.

Prognosis for aortic aneurysm

shape of the aneurysm. As a rule, dissecting aneurysms are the most dangerous. The best prognosis is most often for fusiform true aneurysms, the walls of which are more durable.
Reason for education. Aneurysms that appeared on the background of atherosclerosis grow more slowly. With syphilis, the prognosis is worse, since the disease that has reached the aortic wall is already at a late stage, and other organs may be affected. At congenital diseases connective tissue, the prognosis is generally poor, as there is no effective treatment.
size of the aneurysm. Larger aneurysms are more likely to cause more symptoms and have a tendency to rupture. Their prognosis will be worse.
Patient's age. Atherosclerotic aneurysms usually form in people over 40 years of age. At the same time, they may have various concomitant diseases - ischemic disease heart, kidney or liver problems, etc. All this can become a relative or even absolute contraindication to surgical treatment. The prognosis, of course, worsens.
Disease stage. Fresh aneurysms that have formed in recent weeks have a worse prognosis because it is harder for doctors to assess the risk of rupture. Subacute aneurysms have a better prognosis.
location of the aneurysm. It is difficult to say which aneurysms are more dangerous - the thoracic or abdominal aorta. In both cases, the rupture most often leads to the death of the patient. An important factor is which branches of the aorta are affected by the aneurysm. This largely determines the volume and complexity of surgical intervention (especially when it comes to prosthetics). The worst prognosis is for multiple aortic aneurysms located in both the thoracic and abdominal cavities.

In general, aortic aneurysm without surgical treatment is considered a disease with a poor prognosis. The very presence of an aneurysm indicates the possibility of its rupture with lethal internal bleeding. The possibilities of preventive methods and drug therapy are not limitless. If the patient was successfully treated surgically, then the prognosis is favorable. Re-formation of an aneurysm or other complications after surgery is possible, but they no longer pose such a serious danger. In this case, the prognosis will depend more on the patient himself (whether he will conscientiously follow the prescriptions of doctors).

Do aortic aneurysms give disability?

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It is possible in any part of the aorta, but more often at a distance of 5 cm from the aortic valve.

This is an emergency surgical or therapeutic pathology, the lethality from which without treatment in the first year exceeds 90%. The dissection begins with the formation of an intima rupture, the action of the blood flow dissects the middle membrane in the longitudinal direction at different lengths. Predisposing factors are summarized in this section below.

Classification

There are three classifications of the disease - DeBakey, Stanford and descriptive. Aneurysms involving the ascending aorta and/or arch of the aorta are classified as emergency only. surgical pathology, descending aortic dissection is treated with therapeutic agents.

Cause of dissecting aortic aneurysm

Atherosclerosis, Marfan's syndrome, heredity, hypertension, physical activity.

Pathogenesis. Rupture of the intima, dissection of the aortic wall, the formation of a false passage.

Classification. According to the DeBakey classification, dissecting aortic aneurysms are divided into three types.

Flow. Acute (85%) - hours, days; subacute - from several days to 2-4 weeks; chronic - up to several months.

Symptoms and signs of a dissecting aortic aneurysm

Pain in the sternum: classically with a sudden onset, very acute in nature, the most common pain in the front of the chest radiating to the interscapular region. Usually there is pain of a tearing nature, which, unlike MI, is most pronounced at the very beginning. Pain most felt in the anterior chest is associated with ascending aortic dissection, while pain in the interscapular region indicates the formation of an aneurysm. Patients often describe this pain as "tearing," "tearing," "sharp," "piercing," "like being stabbed with a knife."
Sudden death.
congestive insufficiency.
signs of occlusion. Examples include:

stroke or acute ischemia of the extremities - due to compression or stratification;
paraplegia with impaired sensitivity - due to occlusion of the spinal artery;
MI - usually the right coronary artery;
renal failure and renovascular hypertension;
stomach ache.

There is a painless formation of the disease.
Purposefully collect anamnesis of hypertension, previous heart murmurs, aortic valve disease, ask for previous chest x-rays for comparison.

Intense pain in the back, behind the sternum, in the interscapular and epigastric region.

Sudden death or shock, usually due to acute aortic regurgitation or cardiac tamponade.

Congestive heart failure due to acute aortic insufficiency and/or MI.

Signs of occlusion of one of the branches of the aorta: stroke, acute limb ischemia, MI, celiac trunk, kidney.

Aortic dissections are divided into proximal (ascending) and distal. It is characterized by sudden severe pain behind the sternum or in the region of the heart, radiating along the aorta or its main branches to the back, shoulder blades and along the spine.

Diagnosis of a dissecting aortic aneurysm

The ECG is often normal or there are nonspecific changes - anomalies of the ST segment and T wave.

A chest x-ray may be normal. Rear projection can detect expansion upper mediastinum, darkening or enlargement of the aortic bulb, uneven contour of the aorta, separation (more than 5 mm) of intima calcium from the outer outline of the aorta, displacement of the trachea to the left, expansion of the shadow of the heart (pericardial effusion).

Echocardiography helps to detect expansion of the aortic bulb, backflow of blood through the aortic valve, pericardial effusion (tamponade).

The "gold standard" in the diagnosis of dissecting aortic aneurysm is MRI angiography. It provides accurate data on the places of entry (exit) to a false move and the departure of branches. However, the presence of metal valves, pacemakers are considered contraindications for MRI. Monitoring patients in an unstable state while in a tomograph is difficult and unsafe.

A new test using monoclonal antibodies against myosin heavy chains of smooth muscle fibers allows you to accurately differentiate acute dissection from MI.

Diagnostic criteria

Sharp sudden pain in the chest.
Sharp pallor of the skin.
Expansion of the vascular bundle (determined by percussion).
The presence of signs of atherosclerosis.
History of arterial hypertension.

Differential diagnosis between myocardial infarction and aortic dissection is difficult due to the similarity of the clinical picture, the transience of manifestations and the similarity of the contingent (elderly people with atherosclerosis and arterial hypertension).

Differential diagnosis is aided by the following:

Pain with a heart attack increases gradually, with an aneurysm - a sudden attack of severe pain.
Irradiation of pain in a dissecting aneurysm is more often in the back, along the spine, which is not typical for a heart attack.
Aneurysm pain may be accompanied by anemia.
characteristic ECG signs and increased enzyme activity in myocardial infarction and their absence in aortic aneurysm.

It should be noted that with a complete rupture of the aorta, patients die within a few minutes. With an incomplete break, this period may increase.

Inspection

The results may be normal.
Most patients present with hypertension. Hypotension is more characteristic of ascending aortic dissection (20-25%) and develops due to blood loss (which is sometimes accompanied by heart failure) or tamponade.
Pseudohypotension is observed when blood flow is disturbed in one or both subclavian arteries. During the examination, unequal blood pressure on the right and left hand, the presence of a peripheral pulse are detected and documented. The absence or changing pulse indicates an increase in the dissecting aneurysm.
Auscultation may reveal aortic valve insufficiency and, at times, a pericardial friction rub. A dissecting aneurysm of the descending aorta sometimes ruptures and leaks into the left pleural cavity, resulting in an effusion and blunting at the base of the lung.
Neurological disorders result from dissection carotid artery or its compression (hemiplegia) or due to occlusion of the spinal artery.

Research methods

General Research Methods

Electrocardiographic signs are often normal or there are certain changes (left ventricular hypertrophy). Purposefully differentiate with specific changes characteristic of acute MI (lower MI is observed if the dissection affects the mouth of the right coronary artery).
Radiography.
Blood tests.

Diagnostic methods

Echocardiography: Transthoracic examination is helpful in identifying aortic bulb dilatation, aortic valve backflow, and pericardial effusion/tamponade. Transesophageal sonography is the method of choice because it allows better evaluation of the ascending and descending aorta, identification of the location of the intima rupture, the relationship between coronary artery origin and detached flap, and provides information about aortic valve insufficiency. The method is less suitable for visualization of the distal portion of the ascending aorta and the proximal arch.
MRI angiography is considered the "gold standard".
Helical contrast-enhanced CT provides a three-dimensional image of all segments of the aorta and adjacent structures. True and false lumen are recognized by different currents of the radiopaque substance, entry and exit points under the intimal flap are observed, as well as pleural and pericardial fluid. However, the method cannot demonstrate divergence of the aortic valve leaflets, which sometimes accompanies ascending aortic dissection.
Angiography using a femoral or axillary approach shows altered two-lumen flow, aortic valve failure, branch involvement, and intimal rupture. The study is invasive, associated with an increased risk in a patient with an initially high probability of complications. The method has largely been superseded by CT/MPT and transesophageal echography.

Choice of diagnostic method

The diagnosis must be confirmed or rejected.
Whether the dissection is limited to the descending aorta or involves the ascending aorta/arch is determined.
Establish the extent, entry and exit points and the presence or absence of a thrombus.
Whether there is aortic insufficiency, involvement of the coronary arteries, or pericardial effusion is determined.
If possible, transesophageal echography is used first. The study is safe and provides all the information needed to plan the operation.
If this ultrasound method is not available or its results are inadequate, a helical CT with contrast is performed.
MRI is usually used for subsequent scanning.
Angiography is rarely used, but its results are valuable if other methods do not allow the diagnosis and / or are required. Additional Information about branching vessels.

Conditions predisposing to the development of a dissecting aortic aneurysm

Hypertension.
Hereditary vascular diseases.
Inflammatory vascular diseases.
Injury due to abrupt cessation of movement.
Chest injury.
Pregnancy.
Iatrogenic causes: catheterization, cardiac surgery.

Treatment of a dissecting aortic aneurysm

When the ascending aorta is involved, emergency surgery and antihypertensive therapy are indicated. Patients with descending aortic dissection are initially treated conservatively with strict BP control. Encouraging results are shown by endovascular stenting.

Stabilization of the patient's condition

If the disease in question is suspected, the patient should be transferred to a unit where resuscitation facilities are fully available.
Establish venous access using wide-bore catheters (for example, a gray Venflon brand catheter).
Take blood for deployed general analysis blood, determination of urea and electrolytes and cross-compatibility testing.
After confirmation of the diagnosis or the appearance of cardiovascular complications, the patient is transferred to the department intensive care, install an intra-arterial catheter (into the radial artery, if the subclavian artery is not affected, in such cases preference is given to the femoral access), a central venous catheter and a urinary catheter.
Immediate action is taken to correct blood pressure.
Adequate analgesia (intravenous diamorphine 2.5-10 mg and metoclopramide 10 mg).

Radical treatment plan

Depends on the type of dissection and its effect on the patient, but comes down to two main principles:

Patients in whom the ascending aorta is involved are subject to emergency surgery and antihypertensive therapy.
Patients with a dissection limited to the descending aorta are initially treated conservatively with strict BP control. However, these positions may change in the near future due to the encouraging results of endovascular stenting.

Indications and principles of operations

Ascending aortic dissection.
External rupture (hemopericardium, hemothorax, effusion).
Involvement of outgoing arteries (limb ischemia, renal failure, stroke).
Contraindications to conservative treatment (adverse reactions, left ventricular failure).
Progression (continued pain, increased hematoma on subsequent scans, loss of pulse, pericardial friction rub, or aortic regurgitation).

The goal of surgical treatment is to replace the ascending aorta, which prevents retrograde dissection and cardiac tamponade (the leading cause of death). Sometimes it is required to perform a reconstructive intervention on the aortic valve, in the presence of structural anomalies (bicuspid valve, Marfan's syndrome), prosthetics are performed.

Indications and principles of conservative tactics

Conservative treatment is the most preferred method of treatment in case of:

uncomplicated dissecting aneurysm type B;
stable isolated dissection of the aortic arch;
chronic (>2 weeks) stable type B dissection.

Treatment of all patients, with the exception of those with hypotension, is primarily aimed at reducing systemic blood pressure and myocardial contractility. The main goal is to stop the spread of intramural hematoma and prevent rupture. The best criterion is adequate pain relief. Strict bed rest in a quiet room is a prerequisite.

Decreased blood pressure:

They start with the use of β-blockers (in the absence of contraindications) in order to reduce the heart rate to 60-70 per minute.
Once the pulse has slowed down, if BP remains high, a vasodilator such as sodium nitroprusside is added. Vasodilators in the absence of β-blockers sometimes increase myocardial contractility and rate of increase (dP/dt). Theoretically, the named effect contributes to the spread of stratification.
For antihypertensive therapy, other traditional drugs related to slow calcium channel blockers, α-adrenergic blockers and ACE inhibitors are further used.
Patients with aortic valve insufficiency and congestive heart failure are not recommended to prescribe drugs that reduce myocardial contractility. Only vasodilators are used to control blood pressure in these patients. Hypotension occurs due to bleeding or cardiac tamponade.
BP is restored by rapid intravenous infusion (colloids or blood are ideal, but crystalloids can also be used). The Swan-Ganz pulmonary artery catheter is used to monitor wedge pressure and to control the volume of infusion therapy.
If there are signs of aortic insufficiency or tamponade, an urgent echocardiogram should be performed and surgeons should be consulted.

Emergency indications and principles of endovascular interventions

Recently, there have been a growing number of reports and small case series that indicate favorable outcomes (prognostic and symptomatic) of endovascular stenting in the treatment of mainly type B aortic dissections and, to a lesser extent, type A.

Based on current data, endovascular stents should be considered as a way to isolate the entrance to the false lumen and expand the compressed true lumen in the following situations:

Unstable dissecting aortic aneurysm type B.
Impaired perfusion syndrome (proximal aortic stent and/or distal fenestration/stenting of branch arteries).
Elective treatment of type B dissection (under study). Cardiac tamponade: If the patient is relatively stable, pericardial puncture may cause cardiovascular collapse and therefore the procedure is not recommended. The patient must be urgently taken to the operating room for immediate surgical recovery. Pericardiocentesis is warranted in cases of tamponade and electromechanical dissociation or severe hypotension.
Long-term treatment: should include strict BP control.

Forecast

Mortality in the absence of treatment is approximately 20-30% on the first day and 65-75% in 2 weeks.
If the dissection is limited to the descending aorta, short-term survival is better (up to 80%), but in approximately 30–50% of patients, the dissection progresses despite aggressive therapy and surgery is indicated.
Operational mortality is about 10-25% and depends on the initial state before the intervention. Postoperative 5-year predicted survival is up to 75%.

Dissecting aortic aneurysm often gives a clinical picture similar to that of myocardial infarction. Aortic dissection usually occurs with inflammatory process various etiologies (including syphilitic mesoaortitis), as well as severe atherosclerosis. Dissection of the aortic wall can often be facilitated by prolonged and severe hypertension, less often by chest trauma.

Clinical picture and diagnosis of dissecting aortic aneurysm

The most important sign of a dissecting aortic aneurysm is pronounced pain, which occurs in most cases acutely in the chest. The onset of pain does not always coincide with complete aortic dissection. Sometimes the appearance of pain indicates only the beginning of the process, tearing the aorta. At the time of complete dissection and aneurysm formation, a significant drop in blood pressure often occurs, accompanied by fainting and even collapse.

Especially severe pain occur when the aortic wall ruptures. Then they weaken, but then, when the aneurysm extends down the aorta, the pain may periodically intensify. With the progression of the aneurysm, the pain increases, radiating to the back, spine, lower back, sacrum, sometimes to the groin, both legs. Such localization and migratory nature of pain are not typical for myocardial infarction.

The activity of "cardiac enzymes" (CPK, LDH, ACT, ALT) with dissecting aneurysm may remain normal or slightly increase, the level of myoglobin does not change significantly. The ECG may show signs of subendocardial ischemia (decrease in the ST segment), as well as disturbances in the repolarization phase in the ventricular myocardium (change in the shape of the T wave).

Cases of compression of the mouth of the coronary artery by a dissecting aneurysm with the development of myocardial infarction are described. Almost always, coronary circulation suffers to some extent due to a drop in blood pressure in the aorta. Therefore, the above changes are more often recorded on the ECG.

A lethal outcome in a dissecting aortic aneurysm usually occurs suddenly, but sometimes, with a slowly progressive process and an increase in clinical symptoms, after 1 to 2 weeks or later. If death does not occur immediately, then moderate anemia appears on the 2-3rd day, which is not typical for myocardial infarction.

Occasionally, the condition of patients with a dissecting aneurysm gradually stabilizes, the dissection stops, and a chronic aortic aneurysm is formed. Of great importance in the diagnosis of dissecting aortic aneurysms, including chronic ones, are radiopaque and echocardiographic studies.

Treatment of a dissecting aortic aneurysm

Surgery is performed in specialized hospitals. Correction of blood pressure, treatment and prevention of atherosclerosis, as well as other diseases of the aorta, play an important role in the prevention of the disease.

B.V. Gorbachev

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MRI and CT for aortic aneurysm

ECG for aortic aneurysm

Laboratory tests

Treatment of an aortic aneurysm

Medications for aortic aneurysm

Surgical treatment of aortic aneurysm

Alternative treatment of aortic aneurysm

Prognosis for aortic aneurysm

Do aortic aneurysms give disability?

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Classification

Cause of dissecting aortic aneurysm

Symptoms and signs of a dissecting aortic aneurysm

Diagnosis of a dissecting aortic aneurysm

Inspection

Research methods

General Research Methods

Diagnostic methods

Choice of diagnostic method

Conditions predisposing to the development of a dissecting aortic aneurysm

Treatment of a dissecting aortic aneurysm

Stabilization of the patient's condition

Radical treatment plan

Indications and principles of operations

Indications and principles of conservative tactics

Emergency indications and principles of endovascular interventions

Forecast

Clinical picture and diagnosis of dissecting aortic aneurysm

Treatment of a dissecting aortic aneurysm