Aortic Aneurysm - Causes, Symptoms and Treatment .MF .
Aortic aneurysm - an extension portion of the aorta caused by pathological changes in connective tissue structures of its walls as a result of atherosclerosis, inflammatory lesions, congenital inferiority or mechanical damage.
Figure 1. Schematic representation of the normal thoracic aortic aneurysm and her.
Depending on the location of the aneurysm is isolated aneurysm of the thoracic aorta, thoracoabdominal (thoraco-abdominal) aorta and abdominal aorta.In turn, the thoracic aorta aneurysms may be subdivided into the aortic sinus aneurysm, the aneurysm of the ascending aorta, aortic arch aneurysms and descending aortic aneurysm.
addition, especially allocate dissecting aortic aneurysm - abnormal cavity or channel is formed in the thickness of the aortic wall due to delamination her blood pumped from the lumen of the aorta through a defect of the intima (inner lining of the vessel), which arose due to the disease process or injury.aortic wall Delamination occurs in the middle of her shell.
causes of aortic aneurysm
most often develops due to aortic aneurysm or atherosclerotic process has a syphilitic origin.Recently, on the first place among the causes of aortic aneurysm atherosclerosis leaves it, due to advances in the treatment of syphilis and increase life expectancy.Moreover, syphilis is often cause of aneurysms of the thoracic aorta, while atherosclerosis frequently results in the formation of abdominal aneurysm card.
Other causes of aortic aneurysms are medionekroz and nonspecific aortoarteriit.There are also traumatic aneurysm (eg, after closed abdominal injury) and false aneurysm of anastomoses after aortic surgery.In the scientific medical literature describes as mycotic aneurysms (fungal) origin.
The most common cause of aortic dissecting aneurysm is a long-existing hypertension on the background of atherosclerosis.In this case, the inner shell (intima) of the wall of the aorta, usually already available preexisting various small defects.Rarely as reasons for dissecting aortic aneurysm can act against the background of hypertension, coarctation of the aorta (congenital defect manifested by segmental narrowing of the lumen of the aorta);hypertension caused by other factors;Marfan syndrome (a genetic abnormality of the connective tissue), which is accompanied by severe weakness of the aortic wall.Perhaps the formation of acute dissecting aneurysm of the ascending aorta due to its rupture due to closed trauma (eg, automotive).Sometimes, dissecting aortic aneurysm may result from iatrogenic: a complication of aortic cannulation of arteries and for the purpose of perfusion during extracorporeal circulation.
Symptoms of aortic aneurysm
Clinical manifestations of aneurysms of the aorta determined compression (compression) of surrounding organs, respectively, depending on their location and the rate of increase in their size.In the final stage of aortic aneurysm disease often erupt in the nearby hollow organ, pleural, peritoneal cavity or the heart bag.Sometimes there is a breakthrough in pulmonary trunk with the formation of aorto-pulmonary shunt.
aneurysm aortic sinus may be accompanied by aortic valve insufficiency, or narrowing of the lumen of the coronary arteries of the heart.Reaching large, such an aneurysm can compress the pulmonary trunk, right ventricle and the right atrium, which leads to the formation of sub-acute right heart failure is characterized by enlargement of the liver, swelling of the neck veins, and the appearance of edema.The rapid compression of the pulmonary trunk aneurysm can lead to sudden death of the patient.
aneurysm of the ascending aorta appears, as a rule, dull retrosternal pain that some patients accompanied by reflex bouts of breathlessness.If the aneurysm reaches a large size, it can cause atrophy of the surrounding areas of the sternum and the ribs, thus abnormal vascular pulsation appears in the second and third intercostal space to the right of the sternum.Compression of the superior vena cava aneurysm or a breakthrough in her aneurysm leads to the development of superior vena cava syndrome, which in turn causes the connection swelling of the neck, face, hands, swollen neck veins.
aneurysm of the aortic arch often manifested by shortness of breath (this is usually more difficult to breathe), caused by compression of the trachea and bronchi.Compression of the left main bronchus aneurysm can lead to atelectasis (wears off) of the left lung.Sometimes there is hemoptysis, which may precede the break of aneurysm.Compression of the nerve left nizhnegortannogo aneurysm appears dry cough, attacks of breathlessness, a change in voice (hoarseness of his).Perhaps the development of superior vena cava syndrome.When compression of the aneurysm brachiocephalic trunk, left subclavian and left common carotid arteries gradually worsening symptoms of circulatory disorders of the upper limbs and head.Possible breakthrough aortic aneurysm into the esophagus or trachea, which usually develops gradually, which is manifested initially advent scant hemoptysis or bloody vomit, but then developed massive bleeding.
aneurysm of the descending aorta leads to compression of the nerve roots, the vertebral bodies, the esophagus and the left lung.Compression of the nerve roots leads to intense pain, resistant to the introduction of the most powerful painkillers.The pressure on the vertebrae and rear edges of the body leads to their deformation, to the extent that the aneurysmal sac may protrude between the inner edge of the left scapula and spine.These patients may develop lower paraplegia (complete loss of the possibility of voluntary movements of both lower limbs).Compression of the aneurysm of the left lung atelectasis causes it, and creates favorable conditions for the occurrence of pneumonia.Compression of the esophagus, in some cases can lead to difficulty passing through it the food (dysphagia).With the destruction of the esophageal wall by prolonged pressure on it as small aneurysms bleeding from the esophagus, and then, as a rule, there is a breakthrough in the lumen of the aneurysm with the development of excessive bleeding.A break in the pleural cavity of the aneurysm of the descending aorta develops rapidly increasing anemia (anemia) and a large hemothorax (accumulation of blood in the pleural cavity).
thoracoabdominal aneurysm (phrenic aorta) aorta is rare, usually caused by syphilis.Aneurysm compresses the esophagus and upper stomach department, which leads to crushing pain in the epigastric region, which may be related to food intake, sometimes - belching, vomiting, a violation of the passage of food through the esophagus.Thoracoabdominal aortic aneurysm can cause narrowing or complete coverage of the lumen of the superior mesenteric artery and the celiac trunk, supplying the abdominal organs, which is manifested attacks of painful abdominal pain (so-called intestinal angina).Because of the above reasons aneurysm this location leads to patient weight loss.
Abdominal aortic aneurysm over time manifested by pain caused by pressure on the nerve plexus of the aneurysm and the nerve roots, which are located directly next to it.The pain may be epigastric or in the lumbar region.The large size of the aneurysm, located below the point of origin of the renal arteries may compress the ureters, causing the development of hydronephrosis and anuria.If there is a compression of the renal arteries, appears symptomatic hypertension.When compression of the duodenum aneurysm disrupted the passage of food masses on it, which is manifested by vomiting and weight loss.Most often, abdominal aortic aneurysm manifested by the presence of a pulsating tumor formation in the abdomen at the navel or just below and slightly to the left of it.Thrombosed aneurysm does not pulsate, and therefore can be mistaken for a tumor.Sometimes there is the rise in body temperature.Breakthrough aneurysm in the abdominal cavity takes place quickly, usually painless, and retroperitoneal fat - to severe pain in the abdomen and the back, with the development of shock phenomena.After some time, the patient may die because of increasing blood loss.
aortic aneurysm appears suddenly there is an acute pain in the chest, do not remove the pain relievers, and collapse.Sometimes it is developing a complete loss of the possibility of voluntary movements of both lower extremities, which may be temporary or permanent nature take.Because of the localization and nature of clinical manifestations of pain arising dissecting aortic aneurysm can be mistaken for acute myocardial infarction.
Complications of aortic aneurysm
1. Malformations of the aortic valve and cardiac failure .When an aneurysm of the ascending aorta syphilitic origin may develop cardiac decompensation due to the defect of the aortic valve overlap or the mouth of the coronary arteries.
2. aneurysm rupture with bleeding .Bleeding can occur in the respiratory tract (bronchi, trachea), pleural cavity, heart bag, esophagus, large blood vessels located in the thoracic cavity, and sometimes even out through the skin during the destruction of the sternum.In case of bleeding in the pericardial cavity of the heart tamponade occurs.Bleeding leading to rapidly increasing hemorrhage.
3. acute and subacute thrombosis of the aneurysm of the aorta. most often develops in the abdominal aorta and leads to the closure of its branches located here.
listed complications Veduga quickly to the patient's death, if appropriate measures are not taken in time.
X-ray examination.With aneurysms of the thoracic aorta radiography is performed in three projections with a sine-contrast esophageal lumen.Characteristically extension shadow of vascular bundle.Aneurysms of the descending aorta to the left pulmonary vybuhayut field.Most patients have to contrast the displacement of the esophagus.Sometimes determined calcification (calcification) aneurysmal sac.With aneurysms of the abdominal aorta abdominal plain radiography in two projections reveals calcification of the aortic wall and uzuratsiyu the lumbar vertebral bodies.
Figure 2. Panoramic radiography of the patient's chest and arch aneurysm of the descending thoracic aorta.
Ultrasonography (ultrasound) aorta and heart.Ultrasound reveals the presence and size in diameter and aneurysms dlinniku ascending, descending aorta, aortic arch, abdominal aorta, a condition extending from the aortic vessels, as well as the presence of defect of the aortic valve, the character changes in the aortic wall.
Computed tomography (CT) .When the value of the lumen of the aorta 4 cm it is considered as an extension of the aneurysmal.When performing computed tomography it is possible to determine the involvement in the process of large arteries and identify signs of the bundle (dissection) of the walls (with dissecting aortic aneurysm).
angiographic study (aortography).It is used, as a rule, before the surgery when planning its nature and scope.
Figure 3. angiograms aneurysm of the ascending and descending portions of the thoracic aorta and arch.
treatment of a patient with aortic aneurysm
aneurysm of the thoracic aorta having a diameter greater than 5 cm, subject to surgical treatment due to the high risk of its rupture and the development of thromboembolic complications.Surgery is performed under cardiopulmonary bypass and hypothermic (low temperature) and reduced to a resection (removal) of the aneurysm with simultaneous replacement of the prosthesis remote site.
In asymptomatic abdominal aortic aneurysm indication for planned surgery is its diameter greater than 4 cm. In case of increase of pain and the threat of rupture shown emergency surgery.The operation is reduced to aneurysm resection with direct prosthetic abdominal aortic bifurcation or execution aortofemoral prosthetics.
prognosis of aortic aneurysm
In the absence of timely treatment and the occurrence of severe complications of an aortic aneurysm poor prognosis.Lethal outcome may occur as a result of cardiac decompensation due to malformations of the aortic valve with ascending aortic aneurysm, cardiac tamponade due to the breakout of the aneurysm in the pericardial cavity, massive blood loss as a result of a breakthrough in the hollow organs of the aneurysm and the pleural or peritoneal cavity.
However, the progress made at the present time in the surgical treatment of aortic aneurysms, allow in the case of timely and adequate surgical intervention to save the life of most patients.In elective surgery mortality rate is 0-5%, and even at an emergency surgical intervention is 50-80% in the case of rupture of the aneurysm.The five-year survival rate among patients operated on was 80%, and among the non-operated - 5-10%.
Surgeon Kletkin ME