An aortic aneurysm is usually called a lumen formed in it that is twice (or more) the normal diameter of the vessels. The defect appears as a result of the destruction of the elastic fibers (filaments) of the central shell, as a result of which the remaining fibrous tissue elongates, thereby expanding the diameter of the vessels and leading to tension in their walls. As the disease progresses and the size of the lumen subsequently increases, there is a possibility of rupture of the aortic aneurysm.
Classification of aortic aneurysm
In surgery, several classifications of aortic aneurysm are considered: depending on the origin, localization of segments, the nature of the clinical course, the structure of the aneurysmal sac and shape.
Based on location, the following types of thoracic aortic aneurysm are distinguished:
- aneurysm of the ascending aorta;
- sinus of Valsalva;
- arc areas;
- descending part;
- abdominal and thoracic regions.
It should be noted that the diameter of the ascending aorta should normally be about 3 cm, and the descending aorta should be 2.5 cm. The abdominal aorta, in turn, should be no more than 2 cm. The dimensions of the aortic aneurysm are considered critical if they exceed normal values by almost 2 times.
Based on the location of the abdominal aortic aneurysm, there are:
- suprarental aneurysms (belong to the upper part of the abdominal aorta with outgoing branches);
- infrarenal aortic aneurysm (without dividing the aorta into common iliac arteries);
- total.
Depending on the origin, the following are considered:
- acquired aneurysms (non-inflammatory, inflammatory, idiopathic);
- congenital.
Classification of aneurysm by shape:
- saccular – presented in the form of a limited bulging of the wall (does not occupy even half of the aortic diameter);
- are divided into iliac, lateral, spreading and descending arteries into the pelvic region;
- fusiform aortic aneurysm - occurs as a result of stretching of the aortic wall along the entire circumference or part of its segment;
The structure of the aneurysm sac differs:
- false aortic aneurysm, or pseudoaneurysm (the wall consists of scar tissue).
- true (the structure of such an aneurysm resembles the structure of the wall itself).
Depending on the clinical course, the following are considered:
- dissecting aortic aneurysm;
- aneurysm is asymptomatic;
- complicated;
- typical.
The term “complicated aneurysm” means rupture of the sac, which, as a rule, is accompanied by heavy internal bleeding and subsequent formation of hematomas. In this situation, thrombosis of the aneurysm, which is characterized by a slowdown or complete cessation of blood flow, cannot be excluded.
One of the most dangerous phenomena is a dissecting arterial aneurysm. In this case, blood passes through the lumen in the inner membrane, which penetrates between the layers of the aortic walls and spreads through the vessels under the influence of pressure. As a result of this process, dissection of the aortic aneurysm occurs.
What you need to know about aortic aneurysms?
As mentioned earlier, all aneurysms are divided into congenital and acquired. The development of the former is characterized by diseases of the aortic walls of a hereditary nature (fibrous dysplasia, Marfan syndrome, Ehlers-Danlos syndrome, congenital elastin deficiencies and Erdheim syndrome).
Acquired aneurysms arise as a result of ongoing inflammatory processes associated with specific (syphilis, tuberculosis) and nonspecific aortitis (streptococcal infection and rheumatic fever), as well as as a result of fungal infections and infections that arise after surgery.
As for non-inflammatory aneurysm, the main reasons for its occurrence are the presence of atherosclerosis, previous prosthetics and defects formed after suturing.
There is also a possibility of mechanical damage to the aorta. In this case, aneurysms of a traumatic nature occur.
You should not ignore the person’s age, the presence of arterial hypertension, alcohol abuse, and smoking. In this case, the likelihood of developing a vascular aneurysm is also high.
Description of abdominal aortic aneurysm
Abdominal aortic aneurysm is most often observed in men over 60 years of age. In particular, the risk of developing the disease increases with regular increases in blood pressure and smoking.
An abdominal aortic aneurysm manifests itself in the form of dull, aching and gradually increasing pain in the abdomen. Unpleasant sensations, as a rule, occur to the left of the navel and radiate to the back, sacrum and lower back. If such symptoms are detected, you should consult a doctor, otherwise the abdominal aortic aneurysm may rupture.
Indirect symptoms include:
- sudden weight loss;
- belching;
- constipation lasting up to 3 days;
- urinary disturbance;
- attacks of renal colic;
- motor disorders in the limbs.
Also, with an abdominal aneurysm, problems with gait may occur due to poor circulation.
Aneurysm of the thoracic aorta. Description of the disease
With an aneurysm of the ascending aorta, patients complain of severe pain in the chest and in the heart. If the lumen has increased significantly, then there is a possibility of compression of the superior vena cava, which may result in swelling in the face, arms, neck, as well as migraine.
An aortic arch aneurysm has slightly different symptoms. The pain is localized in the area of the shoulder blades and behind the sternum. Aneurysm of the thoracic aorta is directly related to compression of nearby organs.
Wherein:
- there is strong pressure on the esophagus, which disrupts the swallowing process and causes bleeding;
- the patient feels shortness of breath;
- there is profuse salivation and bradycardia;
- compression of the recurrent nerve is characterized by a dry cough and the appearance of hoarseness in the voice.
When the cardiac part of the stomach is compressed, pain appears in the duodenum, nausea, profuse vomiting, discomfort in the stomach, and belching.
Aneurysm of the descending aorta is accompanied by severe pain in the chest, shortness of breath, anemia and cough.
Where to go and how to identify the disease?
Aortic aneurysm is diagnosed using several methods. One of the most used is radiography. The procedure is carried out in 3 stages. The main thing when performing radiography is a complete display of the lumen of the esophagus. In the image, the aneurysm of the descending artery protrudes into the left lung.
It should be noted that in most patients a slight displacement of the esophagus is detected. In the rest, calcification is observed - a local accumulation of calcium in the form of salts in the aneurysmal sac.
As for the abdominal aneurysm, in this case, radiography shows the presence of calcification and Schmorl's hernia.
Ultrasound of the aorta of the heart is also important when diagnosing an aneurysm. The study allows us to identify the size of the ascending lumen, descending lumen, as well as the aortic arch and abdominal capillaries. An ultrasound can show the condition of the blood vessels leaving the aorta, as well as changes in the wall area.
A CT scan can also determine the size of the aneurysm that has formed and identify the causes of an abdominal artery aneurysm.
The likelihood of rupture of an aortic aneurysm with a size of less than 5 cm is minimal. Typically, in this case, the disease is treated with medications that are used to treat high blood pressure. These include beta blockers. Such drugs reduce the force of heart contractions, reduce pain and normalize blood pressure.
Your doctor may also prescribe medications to treat high cholesterol. They have been proven to reduce the risk of death and stroke.
If the aneurysm has reached a size exceeding 5 cm, the doctor will most likely prescribe surgery, since there is a possibility of its rupture and the formation of thrombosis. Surgical intervention consists of removing the aneurysm and further prosthetics of the area where it is located.
If a doctor discovers an aortic aneurysm, then most likely he will recommend radically changing your usual lifestyle. First, you should give up bad habits, in particular: smoking and drinking alcohol.
Prevention of aortic aneurysm involves eating heart-healthy foods (kiwi, sauerkraut, citrus fruits) and doing physical exercises that will increase your heart rate.
Symptoms
Symptoms of an abdominal aortic aneurysm
Most often, this pathology occurs in the abdominal cavity. And the disease is mainly affected by smoking men over the age of 60 years. In complex cases, multiple aneurysms of the abdominal aorta are formed. Symptoms in this case are more pronounced.
What can a patient feel when the walls of a vessel protrude? Bloating, constipation and digestive disorders, weight loss. If the aneurysm is large, you can feel a pulsating formation in the epigastric region.
When the expansion puts pressure on surrounding nerves and tissue, swelling, urinary tract dysfunction, and even leg paresis can occur. But most often, with an abdominal aortic aneurysm, the first signal is attacks of pain. They occur unexpectedly, often radiating to the lower back, groin area or legs. The pain lasts for several hours and is difficult to respond to medications. When the aneurysm becomes inflamed, the temperature may rise. Sometimes blueness and coldness of the fingers are observed.
Symptoms of a thoracic aortic aneurysm
It is easiest to diagnose the disease if the dilation of the vessel is localized in the area of the aortic arch. In this case, the symptoms are more pronounced.
Most often, patients complain of aching, throbbing pain in the chest and back. Depending on where the aorta enlarges, the pain may radiate to the neck, shoulders, or upper abdomen. Moreover, conventional painkillers do not help relieve it.
Shortness of breath and a dry cough are also observed if the aneurysm puts pressure on the bronchi. Sometimes the expansion of the vessel puts pressure on the nerve roots. Then you feel pain when swallowing, snoring and hoarseness appear.
Due to the dilatation of the aorta and slowing of blood flow, a protodiastolic murmur is often observed with an aneurysm of the ascending aorta.
With a large aneurysm, expansion can be noticed even during visual inspection. There is a small pulsating tumor in the sternum area. Veins in the neck may also swell.
Symptoms of aortic aneurysm
Pathology of the artery in this place may not manifest itself for a long time. The patient feels infrequent pain in the heart, which is relieved with pills. Other symptoms: shortness of breath, cough and difficulty breathing can also be taken as signs of heart failure. Often the disease is diagnosed only after a severe attack of angina during an ECG.
Symptoms of cerebral aortic aneurysm
Small extensions do not manifest themselves in any way. Headaches may occur, but patients rarely see a doctor with such symptoms. The disease can be detected with a large aneurysm, when it puts pressure on surrounding nerves and tissues. In this case, the patient experiences the following sensations:
pain is localized not only in the head, but also in the eyeballs;
blurred vision may occur;
sometimes loss of facial skin sensitivity develops.
Signs of dissection or rupture of an aneurysm
In many cases, the disease is diagnosed only when complications occur. In the case of large fusiform dilatations, aneurysm dissection occurs. This often happens in the abdominal aorta. Small saccular aneurysms can rupture when blood pressure increases. What symptoms are observed with such complications?
The first sign is sharp pain. It spreads gradually from one place throughout the head or abdominal cavity. With a thoracic aneurysm, pain is often mistaken for a heart attack.
The patient's blood pressure drops sharply. Signs of a state of shock are observed: the person turns pale, loses orientation, does not respond to questions, and begins to choke.
An aneurysm can rupture in a patient at any time. And in the absence of timely medical care, this condition often ends in the death of the patient. Therefore, any deterioration in well-being and disturbing symptoms should not be ignored.
Diagnostics
How to identify an aortic aneurysm if in some cases it develops asymptomatically and is discovered by chance during some examination or autopsy, but is not the cause of death? Some cases have specific signs of aortic aneurysm and lead to all sorts of life-threatening complications. This disease is most often observed in older people. This is caused by age-related pathologies of the vascular walls, the presence of hypertension or metabolic disorders.
There are two types of aneurysm, differing in location in the human body:
- Thoracic aortic aneurysm – located in the thoracic region;
- Abdominal aortic aneurysm is located in the abdominal cavity.
These aneurysms are distinguished by shape, parameters and complications. Signs of an aortic aneurysm determine the course of the disease and the surgical procedure. A complication in the form of internal bleeding in 2 out of 5 cases leads to death.
Establishing diagnosis
Diagnosis of dissecting aortic aneurysm is quite difficult due to several reasons:
- Signs of an aortic aneurysm are not monitored;
- Symptoms correspond to other diseases (for example, cough and discomfort in the thoracic region are observed with pulmonary diseases); Pathology is rarely encountered in medical practice.
If there are signs of the disease, you should consult a therapist or cardiologist. They will conduct an initial examination, based on the results of which examinations are prescribed. After testing, the diagnosis of aortic aneurysm is often confirmed.
How to diagnose an aortic aneurysm?
Diagnosis of dissecting aortic aneurysm is performed using certain instrumental research methods:
- A physical examination serves to collect initial data (complaints) without the use of complex examination methods. Diagnosis of an aortic aneurysm consists of external examination, percussion (tapping), palpation (palpation), auscultation (listening with a stethoscope) and pressure measurement. After detecting characteristic signs, further diagnosis of dissecting aortic aneurysm is prescribed;
- X-ray shows the internal organs of the chest and abdomen. The image clearly shows the protrusion of the aortic arch or its enlargement. To identify the parameters of the aneurysm, a contrast agent is injected into the vessel. Due to the danger and traumatic nature, such diagnosis of dissecting aortic aneurysm is prescribed for special indications;
- Electrocardiography is used to determine the activity of the heart muscle. An ECG of an aortic aneurysm will help distinguish this disease from coronary heart disease. With atherosclerosis, which causes the formation of an aneurysm, the coronary vessels suffer, which can cause a heart attack. How to detect an aortic aneurysm? On the cardiogram, you can track specific signs of an aortic aneurysm corresponding to this pathology of the cardiovascular system;
- Magnetic resonance and computed tomography make it possible to determine all the required parameters of the aneurysm - its location, size, shape and thickness of the vessel walls. The pathognomonic CT sign of a dissecting aortic aneurysm shows wall thickening and a sharp dilation of the lumen of the vessel. Based on these data, possible treatment is determined;
- Ultrasound examination – ultrasound of an abdominal aortic aneurysm is one of the most common diagnostic methods. It helps to determine the speed of blood flow and the existing turbulence that separates the walls of the vessel;
- Laboratory tests include general and biochemical blood tests, as well as urine tests. How to diagnose an aortic aneurysm using tests? They reveal the following signs of an aortic aneurysm: A decrease or increase in the number of leukocytes, characteristic of acute or chronic forms of infectious diseases that precede the formation of an aortic aneurysm. An increase in the number of unsegmented neutrophils is also observed. Increased blood clotting manifests itself in the form of an increase in platelet levels, changes in coagulation factors and indicates the probable formation of blood clots in the aneurysm cavity. High cholesterol levels indicate the presence of atherosclerotic plaques in the vessel. A urine test may show a small amount of blood.
The listed signs of aortic aneurysm are not characteristic symptoms of this disease and are not found in all patients.
Treatment
If diagnostic measures are carefully carried out and a diagnosis of “aortic aneurysm” is made, there are several options for the development of events. One option may be dynamic observation by a vascular surgeon, another option may be direct treatment of the aortic aneurysm.
Dynamic observation and x-ray examination are indicated only when the disease is asymptomatic and non-progressive, the aneurysm is small in size (up to 1-2 cm). As a rule, such a diagnosis is made as a result of passing a medical commission or a medical examination at work. This approach is possible only with constant monitoring and prevention of possible complications (antihypertensive and anticoagulant therapy). Drug treatment of aortic aneurysm is not used due to the lack of effective specific drugs.
Although there are some statements about the effectiveness of Siberian herbs, various dill infusions and other things in the treatment of aneurysms, treatment with folk remedies still remains absolutely ineffective and unproven, and can be used either in the process of postoperative rehabilitation or as an unconventional method of nonspecific prevention. To such procedures
In other cases, only surgical intervention is indicated.
When is surgical treatment not performed?
Contraindications to surgery are:
- Acute coronary circulatory disorders - a history of heart attacks that are reflected on the ECG during the last three months;
- Acute cerebrovascular accidents with the appearance of neurological symptoms - stroke and post-stroke conditions;
- Presence of respiratory failure or active tuberculosis,
- The presence of renal failure, both latent and existing.
- A person’s conscious refusal to hope to be cured without surgery.
Surgical treatment is quite varied and directly depends on the type of aneurysm, its location, the capabilities of the cardiology hospital or center and the qualifications of the vascular surgeon. Despite the fact that there are quite a few techniques (they are described below), each patient with an aneurysm receives preoperative preparation before surgery. It is as follows: approximately 20-24 hours before surgery, specific antibiotic therapy is carried out, sensitive to staphylococci and E. coli. Also, before the operation, the patient should abstain from foods and try not to eat anything 10-12 hours before the operation.
Depending on the location, there are:
- aneurysm directly of the aortic arch (emerging from the heart cavity), thoracoabdominal aortic aneurysms,
- aneurysm of the ascending (from which the coronary arteries arise) part of the aorta,
- Abdominal aortic aneurysm. The operation of an aortic aneurysm, or rather the method of implementation, directly depends on the above classification.
Treatment of aneurysm of the thoracic and ascending aorta.
Surgical treatment of patients with aneurysm of the thoracic aorta and ascending aorta is divided into:
- Radical interventions - in the case of them, marginal resection and resection of the aneurysmal cavity are used with its replacement with a prosthesis made of synthetic materials.
- Palliative – wrapping the thoracic aorta with a prosthesis. This operation is performed only in cases where it is not possible to perform radical surgery and there is a risk of aneurysm rupture.
It should be noted that emergency operations are performed if treatment of dissecting aortic aneurysm is necessary, and urgent operations are performed when the aneurysm is complicated by melena, increased pain and the appearance of hemoptysis.
Radical marginal resection is performed for saccular (bag-like) aneurysms and provided that it occupies more than a third of the radius of the aorta. The essence of this operation is resection and removal of the aneurysm sac and suturing of the aortic wall with two-layer sutures after a temporary cessation of local blood flow.
Tangential resection does not involve stopping blood flow through the aorta - otherwise, the surgical technique is the same.
Radical resection with endoprosthetics is performed if the aneurysm is fusiform and occupies more than a third or half of the circumference of the aorta.
Its technique, in principle, does not differ from marginal resection, except for the moment that an endoprosthesis is installed in place of the resected aneurysm - after implantation of the prosthesis, the blood flow is turned on and if the patency is adequate, then the prosthesis is sutured to the wall of the aneurysm itself.
Surgery for an aneurysm of the ascending aorta is performed either simultaneously or separately in case of aortic valve insufficiency. In a one-stage operation, a biomechanical aortic valve is sutured to one end of the endoprosthesis. In cases where there is no aortic insufficiency and only the ascending aorta is affected, a specially designed prosthesis with rigid (static) frames, the so-called combined prosthesis, is used. The essence of this method is that after an incision in the aorta, such an explant is carried out to the unaffected edges of the aorta and fixed externally with specific bands. Then, over the implanted endoprosthesis, the aortic wall is tightly sutured. Its advantage is that this technique allows you to reduce the time of absence of blood flow through the main vessels by 25-30 minutes.
Treatment of abdominal aortic aneurysm.
Surgical treatment of an abdominal aortic aneurysm is used when the aneurysmal dilation of the aorta is more than doubled or with a diameter greater than 4 cm. Treatment is indicated for patients of all ages and for any location of aneurysms.
Preoperative preparation, in addition to the main stages, includes the mandatory correction of concomitant pathologies that can complicate surgical intervention (atherosclerosis, arterial hypertension, unstable angina, and others). Infrarenal aneurysms are operated on from a median laparotomy approach; for suprarenal and total aneurysms, a left-side thoracophrenolumbotomy laparotomy along the ninth intercostal space is used. The operation can be performed using several methods:
- The aneurysm is resected and the sac is removed, and then either aortic replacement or bypass surgery is performed.
- The aneurysm is resected, but the sac is not removed, and a prosthesis is installed in its place or a bypass is performed.
- Endoprosthesis replacement of an abdominal aortic aneurysm: an endoprosthesis is installed on a frame (can be combined with or without resection of the aneurysm).
- Stenting of an aortic aneurysm is used when there is an increased risk of surgery and the risk of postoperative complications. The essence of this operation is to install an open stand under local (more often) or general anesthesia, which opens when approaching the aneurysmal sac and thereby turns it off from the bloodstream.
After surgery for an abdominal aortic aneurysm, patients are advised to undergo rehabilitation depending on the “malignancy” of the process, complications that arose during diagnosis and treatment, the extent of surgery and the general condition of the patient. Basically, rehabilitation consists of proper nutrition, giving up bad habits, a healthy lifestyle and moderate physical activity.
In addition to the most common localizations of aneurysms, there is another form: cardiac aortic aneurysm. Treatment for such localization is usually indicated surgically in cases of aneurysmal dilatation over 6 cm, the impossibility of conservative therapy and active progression of the process.
In cases where there is mitral valve insufficiency along with an aortic aneurysm of any location, MV repair is performed. For aortic aneurysms with such an underlying disease, the mitral valve is replaced with an artificial implant under general anesthesia. Such operations are performed using a heart-lung machine with the heart muscle turned off.
Medicines
The disease is not treated with medication, but there is prevention and rehabilitation after surgery. Some vitamins and medications are taken. Write about it. Make references to treatment through surgery.
Folk remedies
Treatment of aortic aneurysm using folk remedies
Aortic dissection and aneurysm rupture require immediate surgical intervention. At an early stage of the disease, if it proceeds without dangerous complications, prevention and treatment of abdominal aortic aneurysm with folk remedies will be effective.
Effective folk remedies
Alternative treatment for aortic aneurysm will help normalize a person’s well-being and strengthen blood vessels. Herbal infusions are very effective and tonic.
- Hawthorn is the most accessible and effective remedy. Since ancient times, mankind has known the amazing properties of this plant. The fruits and leaves of hawthorn contain many important vitamins and are also capable of removing bad substances from the body (salts, heavy metals, etc.). Hawthorn is most effective for cardiac disorders. Decoctions and infusions will help improve blood circulation and normalize blood pressure. To prepare a simple medicinal infusion, you need to pour crushed dry hawthorn berries (4 tbsp) with boiling water (3 cups) and let it brew thoroughly.
- Viburnum infusion has anti-inflammatory properties, fights shortness of breath, and is also useful for vascular spasms and hypertension. The fruits of this plant contain a huge amount of vitamin C, which is necessary for the body, especially during illness. Therefore, for such a disorder as abdominal aortic aneurysm, treatment with folk remedies must necessarily include this miraculous infusion. Of course, viburnum is not a panacea, but with complex treatment it will only bring benefits. To prepare the infusion, dry berries are poured with boiling water and infused for 3.5 hours.
- Celandine - helps well in the fight against the most common cause of aneurysm development - atherosclerosis. The leaves, stems and flowers of this plant are dried and then infused in boiling water. It is recommended to drink 50 grams of infusion daily.
- Dill infusion is no less useful. Dill helps lower blood pressure, eliminates headaches and has a beneficial effect on heart function. You can use both herbs and seeds for infusion. 1 tbsp. dill is poured with boiling water (about 200 ml) and left for an hour. Treatment of aortic aneurysm with folk remedies must be combined with a healthy lifestyle and a balanced diet. Physical as well as psychological stress should be avoided.
Before starting treatment with these methods, you should consult a doctor.
The information is for reference only and is not a guide to action. Do not self-medicate. At the first symptoms of the disease, consult a doctor.
PRAKZHIYUKPGSHMUEVYAIU
UDC 616.132-007.64-035.7-071
DIFFICULTIES AND ERRORS IN DIAGNOSTICS OF DISLASING AORTIC ANEURYSMS
IN AND. Grandfather, candidate of medical sciences, associate professor; I.A. Serafinovich, candidate of medical sciences, associate professor
EE "Grodno State Medical University"
An analysis of the causes of errors in the diagnosis of dissecting aortic aneurysm was carried out. A diagnostic search algorithm has been developed for suspected dissecting aortic aneurysm. Key words: aorta, aneurysm, dissection, search.
The reasons of diagnostic errors in patients with aorta dissecting aneurysm were analyzed. The algorithm of diagnostic search in the case of suspicion of aorta dissecting aneurysm was worked out. Key words: aorta, aneurysm, dissection, search.
In practice, doctors often encounter acute diseases that require immediate differential diagnosis. These primarily include dissecting aortic aneurysm (DAA).
Aortic dissection is divided into proximal (the ascending aorta is involved) and distal (the ascending aorta is not involved) - Fig. 1.
Lifetime diagnosis of this formidable disease presents significant difficulties. The clinical picture of dissecting aneurysms largely depends on the localization and extent of the process, the degree of involvement in the process of arterial vessels extending from the aorta, compression of neighboring organs, and blood breakthrough into surrounding tissues and cavities. This determines the significant variability of the disease and the formation of various clinical syndromes.
Rice. 1. Classification of aortic dissection.
The problem of early diagnosis of dissecting aortic aneurysms remains relevant not only because of the high mortality rate, but also because of the tendency to increase the prevalence of this pathology. And at the same time, practicing doctors are not sufficiently familiar with this disease, which explains the large percentage of discrepancies between clinical and pathological-anatomical diagnoses.
The purpose of the work is to improve the early recognition of dissecting aortic aneurysm.
Materials and research methods
Over the course of 11 years (1993-2003), 28 patients aged from 46 to 83 years with dissecting aortic aneurysm were observed in the therapeutic and surgical departments of TMO-2 in Grodno. Among them there were 20 men and 8 women. A thorough analysis of the clinical picture of the disease was carried out, data from generally accepted laboratory and instrumental research methods (electrocardiographic (ECG), ultrasound and x-ray) and autopsy reports of patients were studied.
Dissecting aneurysm of the ascending aorta was diagnosed in 12 patients, aortic arch
In 2, descending department - in 4, abdominal department
In 7. In 3 patients, a supravalvular rupture of the aorta without the development of an aneurysm was detected.
Death occurred in 25 patients. All of them were subjected to pathological and anatomical examination. In 3 patients, the dissecting aneurysm of the ascending aorta subsequently took a chronic course. The immediate cause of death in our observations was the breakthrough of a dissecting aneurysm into the cavity of the cardiac membrane (9 patients), the left pleural
GRANDFATHER Vaclav Ivanovich - candidate of medical sciences, associate professor, head. Department of Faculty Therapy SERAFINOVICH Ivan Antonovich - Candidate of Medical Sciences, Associate Professor of the Department of Faculty Therapy
SHUAKTNG KM1U1200M\1> VRA CHU
cavity (6 patients), posterior mediastinum (3 patients), retroperitoneal tissue (6 patients), peritoneal cavity (1 patient).
Intravital dissecting aneurysm was diagnosed in 16 patients. In the remaining patients, myocardial infarction (5 patients), thromboembolism of the branches of the pulmonary artery (3 patients), and acute cerebrovascular accident (1 patient) were mistakenly assumed.
Results and discussion
In the clinical picture of stage I dissecting aneurysms, pain was dominant in all cases. Pain occurred suddenly at rest and only in 4 patients after slight physical effort. There was no prodromal period. It should be noted that there is a very wide pain zone associated with dissection of the aortic wall. The pain often (in 78.6% of patients) affected not only the chest, but also the back, interscapular space, abdomen, and lumbar region. There was irradiation of pain in the neck, shoulders, jaws, upper and lower extremities, and groin area. In 3 patients, pain migrated along the spinal column up to the lumbar region, which was explained by the spread of the hematoma along the aorta. In the majority of people (85.7%), it was tearing, tearing, burning and reached extreme intensity. These pains are usually resistant to repeated drug injections and neuroleptanalgesia. It is also characteristic that the maximum activity of the pain syndrome was noted at the very beginning of the disease, i.e. at the moment of rupture of the inner lining of the aorta.
Here is our observation. Patient Sh., 53 years old, was admitted to the surgical department of the 2nd clinical hospital in Grodno on the referral of an emergency physician with complaints of intense, “dagger” pain in the epigastric region, radiating into the interscapular space, nausea, repeated vomiting, and severe general weakness. .
She suddenly fell ill around 2200 on December 13, 1993. The patient was in a half-bent state for about an hour (washing the dog in the bath). With a sharp straightening of the torso, an unbearable pain suddenly appeared in the xiphoid process, which soon acquired a girdling character, a feeling of fluid spreading throughout the chest and abdominal cavity. An ambulance doctor took her to the surgical department with a diagnosis of acute pancreatitis.
For 20 years he has been suffering from irregularly treated grade III arterial hypertension, type 2 diabetes mellitus, and cystic degenerative struma.
Upon admission, the general condition was serious. The skin of the face and visible mucous membranes are purplish-bluish in color. Breathing 20 per 1 min. There is vesicular breathing in the lungs on both sides. Pulse 90 beats per minute, tense, rhythmic. The boundaries of relative cardiac dullness are shifted in both directions. The width of the vascular bundle was not determined by the doctor on duty. Auscultation of the heart revealed a muted th tone, an accentuated th tone over the aorta, and a pronounced systolic murmur over the base of the heart, which was carried out on the right half of the neck. Blood pressure 220/100 mm Hg. Art., the stomach is not swollen, symmetrical, participates in the act of breathing. In the epigastrium, palpation revealed sharp pain and rigidity of the abdominal wall.
Laboratory data - no significant changes. An X-ray examination revealed signs of a hiatal hernia with its “strangulation.”
On December 14, 1993, an upper-median laparotomy, revision and drainage of the abdominal cavity was performed. The diagnosis of strangulated hiatal hernia was rejected. Subsequently, she was bothered by mild pain in the area of the postoperative wound and general weakness.
A sharp deterioration in the condition occurred in 1000 December 18, 1993, when sharp pain in the chest suddenly resumed, radiating to the left collarbone, left half of the neck, jaw, left half of the chest, difficulty breathing, hoarseness. There were signs of fluid in the left pleural cavity. A dissecting aneurysm of the thoracic aorta was diagnosed. The diagnosis was confirmed by echocardiography and repeated x-ray examination (expansion of the aortic shadow, its contour is clear and uneven).
The patient was transferred to the cardiology clinic of Vilnius University, where resection of the dissecting aneurysm of the thoracic aorta was performed with prosthetics. However, death occurred on the 3rd day after surgery.
Severe pain in the chest primarily requires differential diagnosis with acute myocardial infarction. Most patients with dissecting aneurysms of the thoracic aorta were admitted to the hospital with suspected acute coronary insufficiency. In these cases, it is necessary to take into account that although in some cases pain during myocardial infarction can also occur suddenly, in the initial period of the disease it is not so intense. More typical for this
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disease gradual increase in pain. In addition, unlike patients in an anginal state, patients during the period of aortic dissection are often in a state of motor restlessness. After the first painful attack, sometimes there was short-term relief, after which the pain resumed with the same intensity. The tightening and weakening of pain is due to the wave-like process of dissection of the aortic wall. It is characteristic that severe pain in the chest during dissecting aortic aneurysm was not accompanied by the development of acute left ventricular failure. Blood pressure at the first stage of development of dissecting aortic aneurysm was always high. Hypotension developed with external aortic rupture. No dangerous arrhythmias requiring drug correction were observed in these patients.
However, it must be remembered that in patients with a dissecting aortic aneurysm, a true violation of the coronary circulation is possible, which was noted in 3 of our patients. In these cases, the development of myocardial infarction could not be explained by compression of the aortic hematoma at the mouth of the coronary arteries of the heart, since it developed in 2 patients with a dissecting aneurysm of the abdominal aorta, and in 1 patient with a dissecting aneurysm of the descending aorta.
Here is our observation. Patient K., 72 years old, was taken to the intensive care unit of the 2nd clinical hospital in Grodno at 2225 February 1, 1996 with complaints of intense, burning pain in the precordial region, radiating to the left arm and interscapular region, severe general weakness, dizziness .
She became acutely ill in 2100 on February 1, 1996, when suddenly unbearable pain appeared in the upper part of the sternum and a feeling of lack of air.
For 20 years, the patient’s blood pressure has risen to high levels, she has periodically been bothered by compressive pain behind the sternum, and has not received regular treatment.
Upon admission, the general condition was severe, cyanosis of the lips. The patient is excited, tossing about in bed. The number of breaths is 20 per minute. There is vesicular breathing in the lungs, silent fine bubbling rales in the inferolateral regions. The heart has an aortic configuration. The width of the vascular bundle was not determined. Heart sounds are muffled, arrhythmic, normosystolic form of atrial fibrillation. Pulse 56 beats per minute, arrhythmic, uneven. Pulse deficit 16 in 1 min. Blood pressure 100/60 mm Hg. Art. The abdomen is soft, painless on palpation. Liver + 3 cm.
General blood test - no pathology. ECG - atrial fibrillation, pathological Q wave in III, a"UB, II, U1 - U4. In these leads, the ST segment is dome-shaped raised above the isoelectric line. Taking into account the anamnestic, clinical and ECG data, the resuscitator and therapist on duty diagnosed coronary artery disease: large-focal combined anterior-inferior myocardial infarction of the left ventricle, complicated by cardiogenic shock.
According to the working diagnosis, treatment was prescribed: analgesics, including narcotics, intravenous streptokinase, heparin, rheopolyglucin, dopamine, prednisolone, a “polarizing” mixture.
The pain in the left half of the chest was wave-like: it was relieved with narcotic analgesics for 2-3 hours, after which it resumed again. The patient's condition progressively worsened. General weakness and lethargy increased. Pay attention to the pallor of the skin, cyanosis of the lips, blood pressure was in the range of 90/55 - 70/40 mm Hg. Art., despite intravenous drip administration of dopamine solution.
The patient died at 1100 on February 3, 1996, on the 2nd day of her hospital stay.
Pathological and anatomical diagnosis: atherosclerosis - pronounced aorta with ulceration of atherosclerotic plaques, heart arteries with stenosis of their lumen. Thrombosis of the right coronary artery. Acute myocardial infarction of the anterolateral wall of the right ventricle of the heart. Thrombosis of the splenic artery. Splenic infarction. Dissection of the aortic wall with rupture of its outer wall at the level of the 10th thoracic vertebra. Internal bleeding. Bilateral hemothorax (1000 ml in the right pleural cavity, 1300 ml of liquid blood and its clots in the left). Hemoperitoneum (350 ml of liquid blood in the abdominal cavity).
In this case, dissecting aortic aneurysm was not recognized intravitally, since, in the opinion of the attending physicians, the clinical picture corresponded to the diagnosis of acute myocardial infarction.
Dissection of the aortic wall may be accompanied by blockage of the lumen of the arteries extending from the aorta. In these cases, the pain syndrome is accompanied by signs of impaired blood supply to the organs receiving blood through these vessels. Dissection of the aortic arch can lead to disruption of blood flow through the carotid arteries, which leads to the development of cerebral infarctions. This complication was mistakenly mistaken for the underlying disease in one of our patients, which stopped further diagnostic searches. In this case, no attention was paid to such
SHUA&TIEURING DOCTOR
moment, as the development of a neurological symptom complex against the background of severe pain in the chest in the absence of pathological changes on the ECG.
With the onset of the 2nd stage of dissecting aortic aneurysm, the patients’ condition sharply worsened: symptoms of compression of vital organs, cyanosis in the upper half of the body, and shortness of breath appeared, which is the cause of the appearance of various “masks” of this disease, including pulmonary ones. Thus, in 3 of our patients, the cause of death was mistakenly considered to be thromboembolism of the branches of the pulmonary artery.
Dissecting aneurysm of the abdominal aorta was observed in 7 patients. All of them were admitted to the hospital with an erroneous diagnosis. In the clinic, the correct lifetime diagnosis was established in 5 patients. In 1 patient, the correct diagnosis was not established due to a short stay in the clinic (less than 1 hour). And at the same time, in another patient the correct diagnosis was not established, although the patient was in the surgical department for 12 days and underwent surgical interventions in the abdominal cavity twice.
Here is our observation. Patient D., 66 years old, was admitted to the surgical department of the 2nd clinical hospital in Grodno on October 2, 1993, with complaints of constant, periodically increasing pain in the lower abdomen, dry mouth, and dizziness. Ill for 2 weeks, when similar pains appeared in the lower abdomen, clean, loose, green stools. He did not seek medical help, he took some pills and alcoholic drinks (the patient is a chronic alcoholic). 10/1/93 was taken to the Grodno Infectious Diseases Hospital with a diagnosis of acute intestinal infection. On the second day of his stay in the infectious diseases clinic, in the afternoon the patient suddenly experienced unbearable abdominal pain. The patient rushed around the ward and tried to jump out of the window. The surgeon suspected thrombosis of the mesenteric vessels, and therefore the patient was transferred to the surgical department. The surgeons and therapists on duty carried out a differential diagnosis between abdominal ischemia, Crohn's disease and acute appendicitis. Due to an unclear diagnosis, 10/3/93. in 705 a laparotomy was performed and the catarrhal appendix was removed. On the 7th day after surgery, a tumor-like formation of unknown origin was detected in the right half of the abdomen. 10/11/93 A relaparotomy and revision of the abdominal organs were performed. A retroperitoneal hematoma was diagnosed. Check
drainage of retroperitoneal tissue is performed. The patient was transferred to the intensive care unit. The patient's condition progressively worsened. Shortness of breath, general weakness, cough, and tachycardia increased. 10/13/93 thrombosis of the left popliteal artery occurred. An ECG revealed signs of recurrent myocardial infarction against the background of cicatricial changes in the lower wall of the left ventricle. In the blood, neutrophilic leukocytosis with a shift to the left, normochromic anemia, increased ESR. When sowing stool from 10/1/93. Salmonella enteritidis was isolated.
Antibacterial and detoxification therapy, transfusion of fresh frozen plasma, protease inhibitors were carried out, and anti-anginal drugs were prescribed. The patient died on October 14, 1993.
Clinical diagnosis - salmonella sepsis. Diagnostic laparotomy - appendectomy (October 3, 1993). Relaparotomy with revision of the abdominal organs, drainage of retroperitoneal tissue (October 14, 1993). Arterial hypertension stage III, risk 4. Atherosclerosis of the aorta. Complications: DIC syndrome. Thromboembolism of the branches of the pulmonary artery, infarction-pneumonia of the lower lobe of the right lung. Thrombosis of the left subclavian artery. Coronary artery thrombosis with the development of myocardial infarction of the inferolateral walls of the left ventricle. Acute liver failure.
Pathological and anatomical diagnosis: pronounced atherosclerosis with calcification, ulceration of the aorta, iliac arteries; stenosing - arteries of the heart and brain. Dissecting aneurysm of the abdominal aorta. Right-sided retroperitoneal hematoma (mass of blood clots 900 g). Large-focal myocardial infarction of the inferolateral and anterior walls of the left ventricle. Thrombosis of the left femoral vein.
Bacteriological examination of the contents of the small and large intestine did not reveal any pathogenic flora.
The main reasons for misdiagnosis in this case:
1. Background diseases are not taken into account - long-term increased blood pressure, aortic atherosclerosis, chronic alcoholism.
2. Incorrect interpretation of abdominal pain.
3. Lack of alertness among attending physicians regarding dissecting aneurysm of the abdominal aorta.
4. Re-evaluation of data from bacteriological examination of feces.
Correct diagnosis of dissecting aneurysms and aortic ruptures is facilitated by careful detailing of the pain syndrome and a clear presentation
PRACTICING MUVZ&CHU
discussion about its features in these patients, identification of background diseases (long-term increase in blood pressure, aortic atherosclerosis, chronic alcoholism), a full clinical examination (determining the width of the vascular bundle in dynamics, identifying and correct interpretation of noises above the aorta, searching for peripheral vascular “masks” of the disease ), correct interpretation of ECG changes, timely X-ray and ultrasound examination.
Based on a thorough analysis of the features of the clinical picture, studying the reasons for the discrepancy between clinical and pathological-anatomical diagnoses, we have developed a diagnostic search algorithm for suspected dissecting aortic aneurysm.
Undoubtedly, clinical manifestations and differential diagnosis of dissecting aneurysms require further study, development and improvement.
1. Dissecting aortic aneurysm is a prognostically unfavorable complication of a number of diseases (aortic atherosclerosis, arterial hypertension, chronic alcoholism, Marfan syndrome, etc.).
2. The most common reason for the discrepancy between clinical and pathological-anatomical diagnoses is the unclear understanding by practitioners of the features of the clinical picture of dissecting aortic aneurysm, and the untimely use of X-ray and ultrasound examination methods.
Literature
1. Burov Yu.A., Mikulskaya E.G. Possibilities of Doppler ultrasound in the diagnosis of atherosclerotic lesions of the aorta and iliac arteries // Thoracic and cardiovascular surgery. - 1998. - No. 6. - P. 40-43.
2. Vinogradov A.V. Differential diagnosis of internal diseases. 3rd ed. add. and processed - M.: Medical Information Agency LLC, 1999. - 590 p.
3. Gurvits T.V., Svet M.Ya. Clinical variants of dissecting aortic aneurysm // Clinical medicine. - 1976. - T. 54, No. 11. -WITH. 88-91.
4. Dmitriev V.I. Clinic and diagnosis of dissecting aneurysms
aorta in young and middle-aged people // Military Medical Journal. - 1980. - No. 4. - P. 48-52.
5. Movsesyan R.A. Surgery of aneurysms of the ascending aorta // Annals of Surgery. - 1998. - No. 3. - P. 7-13.
Diagnostic search algorithm for suspected dissecting aortic aneurysm
Maximum pain syndrome at the onset of the disease ^
Migration of pain along the spine;
Signs of acute left ventricular failure;
Dangerous arrhythmias requiring medical correction;
Arterial pressure;
ECG signs of ischemia, damage, necrosis
Yes Yes No No
Increased No
ACUTE MYOCARDIAL INFARCTION
RAA ASSUMPTION
Clarification of risk factors (aortic atherosclerosis, arterial hypertension, history of syphilis, chronic alcoholism, nonspecific aortoarteritis, Marfan syndrome.)
Targeted clinical examination (determining the width of the vascular bundle in the 2nd intercostal space, identifying pathological noises above the aorta, searching for peripheral vascular “masks” of RAA - pulse asymmetry, disappearance of pulsation of individual arteries, appearance of symptoms of compression of internal organs);
RAA IS PROBABLE
X-ray of the chest organs
Tomography of the mediastinum with targeted examination of the aorta
Ultrasound examination of the heart, aorta
Aortography (according to indications)
RAA PROVEN
Surgery
Conservative treatment
6. Petrovsky B.V. Dissecting aneurysm // BME. - 3rd ed. -
M., 1974. - T. 1. - P. 502-504.
7. Pokrovsky A.V. Diseases of the aorta and its branches. - M.: Medicine,
8. Senenko A.N., Dmitriev V.I. Dissecting aneurysms and ruptures
you aorta // Clinical medicine. - 1978 - T. 56, No. 4. - pp. 73-79.
9. Smolensky V.S. Aortic diseases. - M.: Medicine, 1964. - 420 p.
10. Sprigins D., Chambers D., Jeffrey E. Emergency therapy: A practical guide: Trans. from English - M.: Geotar Medicine, 2000. - 336 p.
DIFFICULTIES AND ERRORS IN DIAGNOSIS OF AORTA DISSECTING ANEURYSM W.I. Dedul, I.A. Serafinovich Grodno State Medical University The clinical, laboratory and instrumental examination methods were analyzed in 28 patients with aorta dissecting aneurysm. The most frequent reasons of diagnostic errors of this disease were revealed and optimal plan of diagnostic search in patients with acute unbearable chest pain was developed.
The disease is a surgical pathology that is 4 times more common in men than in women.
The average age of patients is 64 years, the prevalence is 2-4 cases per 100,000 population. In 50% of patients, the pathology leads to instant death, up to 20% die during transportation to the hospital.
Dissection (dissection) of the aorta is the separation of its wall, accompanied by detachment of the inner and middle layers. Detachment results in a two-channel blood flow path. Part of the blood moves along the remaining healthy wall (true path), part - in the pathological channel formed by the middle and outer walls of the aorta (false path).
ICD-10 code: I71.0.
What is the difference between aortic dissection and dissecting aortic aneurysm? These definitions are synonyms in common terminology. However, dissection can be a complication of an aneurysm, or it can develop on its own.
Causes and mechanism of development
Causes of the disease:
- Connective tissue dysplasia;
- Genetic syndromes (Ehlers, Marfan);
- Syphilis;
- Hypertonic disease;
- Smoking;
- Addiction.
Defiberation is a consequence of chronic structural changes caused by the action of a primary factor. Irreversible processes develop in the vascular wall, leading to its stretching - degeneration, calcification, destruction of collagen fibers.
The affected area is easily susceptible to microtrauma. Penetrating under the middle tunic of the aorta through the smallest defects, the blood gradually pushes apart the layers of the wall and forms a blind canal. Due to the high speed of blood flow, the channel progressively enlarges and ruptures.
Classification of dissecting aortic aneurysm
By duration:
- Acute aortic dissection – up to 2 weeks;
- Subacute – 2-12 weeks;
- Chronic dissecting aortic aneurysm – more than 3 months.
Stanford classification:
- Type A – damage to the ascending spine and arch;
- Type B – defeat of the descending department.
Classification of aneurysms with aortic dissection according to DeBakey:
- Type 1 – delamination throughout;
- Type 2 – distribution within the ascending region and arch;
- Type 3 – defeat of the descending department.
Types of aortic dissection according to DeBakey in comparison with the Stanford classification of dissecting aneurysms:
Symptoms and signs
Characteristic symptoms:
- Acute pain in the back or abdominal area;
- Increased pressure;
- Redness of the face and neck;
- Feeling of interruptions in heart function;
- Neurological symptoms (paralysis, sensory impairment);
- Loss of consciousness;
- Disappearance of urine;
- Hoarseness of voice.
Additional less common symptoms:
- Vomiting, nausea;
- Dizziness;
- Fainting;
- Disappearance of stool;
- Intestinal colic;
- Coldness and pale skin;
- Sudden death.
Nature of pain
The intensity of the pain is similar to that of an acute heart attack and often immobilizes the patient. Character – unbearable, tearing, cutting. With abdominal dissection, the pain is shooting.
Asymptomatic course
An asymptomatic course is typical for patients with chronic dissection (10-15% of cases). Instant loss of consciousness also leads to a painless course.
Clinic depending on location
Rising department
Pathology leads to acute ischemia of the coronary arteries. Symptoms:
- Headache radiating to the neck, jaw, teeth;
- Increased pressure;
- Chest pain that is not relieved by analgesics;
- Heart failure.
Causes compression of the mediastinum, resulting in... Coronary syndrome later develops into the present one. As a rule, the wall of the left ventricle is affected.
You can find all the important information about aneurysm of the ascending aorta.
Aortic arch
The lesion leads to acute ischemia of the common carotid and subclavian arteries. Symptoms:
- Increased pressure;
- Headache;
- Neurological manifestations;
- Visual, hearing, speech impairments;
- Lack of response to external stimuli (stupor, numbness);
- Descending paralysis.
A stroke develops quickly. In most patients, symptoms are limited to neurological manifestations, which leads to delayed diagnosis.
You will learn all the details about aortic arch aneurysm.
Descending department - chest and abdominal cavity
Symptoms are caused by ischemia of the arteries supplying blood to the chest cavity:
- Chest pain;
- Tachycardia;
- Increased pressure;
- Impaired consciousness;
- Cough;
- Hoarseness;
- Pain at the height of inspiration.
There is a descending nature of the pain. A parietal hematoma compresses the roots of the spinal cord, simulating an attack of osteochondrosis or pleurisy, and forces the patient not to move and avoid deep breathing.
Symptoms are caused by ischemia of the abdominal branches:
- Shooting pain in the back, stomach;
- Swelling of the lower back;
- Decreased urine;
- Stool disorders;
- Loss of sensitivity and pale skin of the legs.
The first symptom may be sudden paresis or paralysis of the legs, accompanied by loss of consciousness. With chronic dissection, gangrene may develop.
In separate articles you will find important information about the aneurysm - and the cavity.
Diagnostic algorithm
Diagnosis includes anamnesis, examination, objective and laboratory-instrumental examinations.
| Method | Efficiency | results |
| Questioning and inspection | 50% | History: atherosclerosis, hypertension. On examination - marble pallor of the skin, rapid breathing, sweating, swelling of the neck veins. |
| Objective examination | 45-50% | Pulse deficiency, tachycardia. Percussion - pleural effusion, increased relative dullness of the heart. On palpation there is a dense painful swelling. Auscultation – continuous vascular murmur. |
| Radiography | 80-82% | Changes in the contour of the aorta, an increase in the cardiac shadow, displacement and expansion of the mediastinum, separation of the inner lining of the aorta from the outer one. |
| ECG | 80-87% | ECG signs of dissecting aortic aneurysm are increased R wave amplitude, ST segment depression, negative T wave. |
| Laboratory data | 43-45% | Anemia, leukocytosis up to 12-13 thousand/ml, increased bilirubin and LDH, thrombocytopenia, decreased fibrinogen levels |
| 80% | False lumen of the aorta, parietal hematoma, blood regurgitation, hemopericardium, concomitant aortic insufficiency. | |
| Aortography | 78-88% | False deformed lumen, oscillating flap of the vascular wall, blood regurgitation, thrombus formation. |
| CT | 94% | Parietal hematoma, false blood flow channel, soft tissue edema, spasm of peripheral arteries, hemorrhage, thrombosis, calcifications. |
| NMR | 98% | Oval shape of the lumen, thrombosis, hematoma, hemorrhage, symptom of “two peaks” - a ring-shaped thrombus with two peaks. |
Differential diagnosis
Differential diagnosis is carried out with:
- Pleurisy;
- Pneumothorax;
- Pneumonia;
- Acute heart attack;
- Thromboembolism;
- Esophageal rupture;
- Renal colic;
- Intestinal obstruction;
- Perforated ulcer;
- Osteochondrosis;
The clinical picture of dissection resembles that of a large-focal infarction:
- Pain may occur behind the sternum;
- Not controlled by analgesics;
- Does not disappear when physical activity stops;
- Lasts more than 15 minutes.
If acute cardiac pain develops and there are no signs of infarction on the ECG, dissection is most likely.
Treatment of aortic dissection
Urgent Care
Indications for first aid:
- Sudden increase or decrease in blood pressure;
- Sharp severe pain (behind the sternum, in the back, in the abdomen);
- The appearance of visible pulsation on the abdomen;
- Loss of consciousness.
Algorithm of actions:
- Transfer and place the patient in a safe place, remove tight outer clothing;
- Call an ambulance;
- Provide a flow of fresh air;
- If the patient is conscious, offer an analgesic;
- Place heating pads on your feet.
Providing emergency medical care
The ambulance team carries out:
- Oxygen therapy;
- Pain relief (fentanyl, diazepam);
- Control of blood pressure and breathing (esmolol, nifedipine, nitrates);
- Infusion of solutions;
- According to indications - resuscitation.
Suspicion of dissection is a direct indication for transportation to the hospital. A preliminary diagnosis is made when:
- Ineffectiveness of drugs;
- Progressive course;
- Collapse;
- Clinical death.
All patients should be urgently examined by a vascular surgeon. Executed:
- Determination of blood group;
- Clinical and biochemical tests of blood and urine;
- Coagulogram;
- Radiography;
- Aortography;
What not to do:
- Transport the patient to a therapeutic hospital;
- Use weak analgesics;
- Use vasodilators;
- Prescribe anticoagulants if ECG results are normal;
- Uncontrolled administration of blood substitutes.
Subsequent treatment - surgery and prognosis
Indications for surgical intervention:
- Localization of the process in the ascending aorta;
- Violation of the integrity of the outer membrane of the aorta;
- Ischemia of internal organs;
- Ineffectiveness of conservative therapy.
Types of interventions:
- Ascending aorta replacement with aortic valve correction;
- Endovascular stenting;
- Transluminal stent placement.
Technique:
- General anesthesia.
- Connection of artificial blood circulation.
- Opening the abdominal (thoracic) cavity.
- Isolation and opening of the aneurysm.
- Removal of thrombotic masses.
- Resection of the dissected area.
- Installation and suturing of the prosthesis to the ends of the aorta.
- Layer-by-layer suturing of the cavity.
Operations are completed successfully in 60-70% of cases. The prognosis is relatively favorable. The duration and quality of life depend on the course of the postoperative period and rehabilitation. After discharge, patients are registered for lifelong dispensary registration.
- Elimination of risk factors;
- Adequate drug therapy;
- Control of the coagulation system;
- Maintaining pressure at 120-130 per 80 mmHg;
- Clinical examination.
How to live with aortic dissection?
Patients are recommended to consult a vascular surgeon twice a year. The medical examination includes tests, x-rays, ECG and ultrasound. If indicated, surgical intervention should not be abandoned.
- Elimination of stress, injuries, professional sports;
- Diet low in salt, sugar, fat;
- Normalization of sleep;
- Elimination of bad habits;
- Treatment of concomitant diseases;
- Prevention of infection.
Pathology leads to serious consequences that threaten life. For this reason, patients may be referred for disability determination. One group or another is determined according to the degree of impairment of life skills. Most planned patients remain able to work after treatment and are assigned to group 3.
Aortic dissection is a life-threatening complication of the natural history of an aneurysm. When the first signs of pathology appear, you should immediately consult a doctor. Timely diagnosis and surgical correction of the disease are the basis for saving the lives of patients, preserving their ability to work and health.
Useful video
Vascular surgery. Aortic dissection:
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The site provides reference information for informational purposes only. Diagnosis and treatment of diseases must be carried out under the supervision of a specialist. All drugs have contraindications. Consultation with a specialist is required!
Complications of aortic aneurysm
Aortic aneurysms can be asymptomatic for a long time, without leading to any symptoms or disorders. However, you always have to take into account the complications that an aneurysm can cause. The most dangerous is, of course, a rupture of an aneurysm, which should be discussed separately. However, besides the gap, there are quite a lot of different violations. Like the symptoms, they are caused by two main reasons - impaired blood flow and compression of adjacent anatomical structures. In the absence of timely treatment, patients with an aortic aneurysm may experience the following complications:
- Blood clot formation. In the cavity of the aneurysm, whether it is spindle-shaped or sac-shaped, the normal flow of blood is disrupted. It creates turbulence, which can lead to 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 blood flow. However, after leaving the aneurysm, the clot can become stuck in vessels of smaller diameter. It is almost impossible to predict where exactly thrombosis will occur. A cerebral artery (with a picture of an ischemic stroke), an artery of the kidney, liver, or extremities may be blocked. Thrombosis stops the flow of arterial blood to the corresponding organ, which leads to rapid tissue death. Thrombosis often ends in the death of the patient. The problem is that the aneurysm may not manifest itself in any way, and the patient is not aware of the presence of the disease. At the same time, blood flow disturbances already exist, and a stroke, for example, will be the first (and often the last) manifestation of the disease.
- Pneumonia. Pneumonia can be a consequence of a thoracic aortic aneurysm if the latter compresses the bronchi or puts pressure on the trachea. Normally, the epithelium of the airways secretes a certain amount of mucus, which cleanses the bronchi and humidifies the air. Compression leads to mucus accumulating in a certain part of the lung. Here favorable conditions are created for the development of infection. If it gets in, pneumonia develops.
- Compression of the bile ducts. Aneurysms in the upper abdominal aorta are adjacent to many different organs. A large aneurysm can, for example, compress the bile ducts that run from the gallbladder to the duodenum. In this case, firstly, the outflow of bile from the gallbladder is disrupted, and, secondly, the digestion process worsens. The risk of cholecystitis and pancreatitis increases, and the patient may suffer from diarrhea, constipation, and flatulence.
- Risk of heart disease. A thoracic aortic aneurysm of significant size can compress the nerve plexuses that regulate the functioning of the heart. Because of this, patients sometimes experience persistent bradycardia or tachycardia. In addition, the pressure in the thoracic aorta itself often increases, which creates additional stress on the left ventricle. As a result, irreversible changes may 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 functioning of the heart may remain.
- Ischemia of the lower extremities. Ischemia is called oxygen starvation of tissues. Arterial blood may reach the lower extremities in smaller quantities due to an infrarenal aortic aneurysm (located below the origin of the renal arteries). Lack of oxygen leads to deterioration of cell recovery. The risk of frostbite, trophic ulcers (due to lack of nutrition) and other soft tissue damage increases. In this case, the aneurysm will play the role of a provoking factor.
Ruptured aortic aneurysm
Aneurysm rupture is by far the most dangerous of the complications. It is the risk of rupture that explains the need to surgically solve the problem at the first opportunity. Because the walls of an aneurysm are thinner and less elastic than other parts of the vessel, even minor increases in blood pressure or trauma can cause a rupture. The consequences of a rupture almost always lead to death. The aorta has a large diameter, and a significant amount of blood passes through it in a short period of time. Through the defect formed when the aneurysm ruptures, blood begins to enter the free chest or abdominal cavity (depending on the location of the aneurysm). Massive internal bleeding often does not give doctors time to even take the patient to the operating room.Rupture of an existing aortic aneurysm can be caused by the following factors:
When an aortic aneurysm ruptures, the patient may experience the following symptoms:
- sudden weakness;
- sudden pain;
- rapid paleness 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).
Diagnosis of aortic aneurysm
Diagnosing a thoracic or abdominal aortic aneurysm can be very difficult for several reasons. Firstly, the disease often does not manifest itself with any symptoms, and even a preventative visit to the doctor does not always reveal any abnormalities. Secondly, the symptoms of an aortic aneurysm are very similar to a number of other diseases. The appearance of such general complaints as a dry cough or chest discomfort makes you think, first of all, about other pathologies. Thirdly, aortic aneurysm itself does not occur very often in medical practice, so many doctors simply do not think about it when analyzing the patient’s first complaints. If you suspect an aortic aneurysm, you should contact your family physician or cardiologist. They are the ones who can competently conduct an initial examination and prescribe further tests and examinations. A targeted search for a thoracic or abdominal aortic aneurysm is successful in most cases. Doctors manage to detect the formation itself, as well as collect all the necessary data (shape, type, size, etc.).
When diagnosing an aortic aneurysm, the following research methods may be prescribed:
- physical examination;
- X-ray examination;
- magnetic resonance imaging (MRI) and computed tomography (CT);
- lab tests.
Physical examination for aortic aneurysm
The purpose of examining a patient is to collect information without using additional examination methods. The doctor tries to identify visible abnormalities and deviations from the norm. This examination sometimes makes it possible to make a correct diagnosis with a high degree of probability, even without the involvement of additional funds.During a physical examination, the following research methods are used:
- Visual inspection. Visually, very little information can be obtained for aortic aneurysms. Any changes in the shape of the chest are observed extremely rarely and only in cases where the patient has lived with a large aneurysm of the thoracic aorta for at least several years. With a large abdominal aortic aneurysm, pulsation can sometimes be observed, which 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 layer of the peritoneum), and hemorrhage occurs primarily in the retroperitoneal space.
- Percussion. Percussion involves tapping body cavities to determine the boundaries of different organs by ear. With an abdominal aortic aneurysm, the approximate size and location of the formation can be determined in this way. Often the area of dullness of percussion sound coincides with the area of the “vascular bundle”. Then, according to percussion data, 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 abdominal aortic aneurysm, 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 thoracic cavity is almost impossible due to the rib frame, therefore palpation is almost never used in the diagnosis of thoracic aortic aneurysm. With an abdominal aneurysm, you can often find a formation pulsating in time with the heart. This speaks volumes about the presence of an aneurysm, since such formations do not occur in other diseases. In addition, palpation can include detection of the pulse. If the frequency or filling of the pulse is different in different arms or in the carotid arteries, this may indicate the presence of an aortic arch aneurysm. Weak or absent pulsations in the femoral arteries (or different rates in different legs) may indicate an infrarenal aneurysm.
- Auscultation. Listening with a stethoscope (listener) is a very common and valuable diagnostic method. With an abdominal aortic aneurysm, by applying a stethoscope to the site of the aneurysm projection, you can hear an increased noise of blood flow. With an aneurysm of the thoracic aorta, pathological changes can be different - a metallic accent of the second tone above the aorta, systolic murmur at the Botkin point, etc.
- Pressure measurement. The most common finding in patients with an aneurysm is hypertension (high blood pressure). With large aortic arch aneurysms, the pressure on different arms may be different (the difference is more than 10 mm Hg).
X-ray for aortic aneurysm
X-ray is the most common method of imaging the abdominal or thoracic organs. X-rays passing through tissue are blocked by them in different ways. This is how borders appear in the photo. They talk about areas (organs, tissues, formations) with different densities. With a thoracic aortic aneurysm, it is often possible to see either one of the edges of the aneurysm cavity (for example, a bulging of the aortic arch) or the entire dilatation of the vessel. This depends on the quality of the image and the location of the aneurysm.X-rays can also be used to study with contrast (aortography). In this case, a special substance is injected into the aorta, which intensely stains the vessel in the image. Thus, the doctor receives clear boundaries of the vessel and its main branches. The shape and size of the aneurysm and its location are well determined. In practice, however, contrast studies are rarely used. Firstly, this is an invasive (traumatic) procedure, since it is necessary to insert a special catheter into the aorta through the femoral artery. Because of this, there is a risk of bleeding, infection, etc. Secondly, if there is an aneurysm (especially a dissecting one), there is a high risk of causing a rupture during the study. Therefore, this procedure is performed only for special indications.
Ultrasound for aortic aneurysm
Ultrasound examination is based on the passage of sound waves through tissue. When reflected, these waves are captured by a special sensor, and a computer, based on the information received, constructs an image that is understandable to the doctor. In medical practice for aortic aneurysms, ultrasound is one of the most common diagnostic procedures. This is because in Doppler mode the ultrasound machine can also measure the speed of blood flow. This information is very important in the case of aneurysms, since they cause turbulence in the flow, and some vessels do not receive enough blood.Ultrasound for patients with aortic aneurysm has the following advantages:
- 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 ability to detect some complications of an aneurysm;
- the ability to assess blood flow in the aorta and its branches;
- the ability to detect forming blood clots.
MRI and CT for aortic aneurysm
Magnetic resonance imaging and computed tomography are different diagnostic methods in their operating principles, but in general they have much in common. Both procedures are very informative, but also expensive, so they are not prescribed to all patients. Often these research methods are used before a planned operation to remove an aortic aneurysm. In this case, it is necessary to collect as much information about education as possible.MRI uses a special property of nuclear magnetic resonance. The image is obtained by placing the patient in a powerful electromagnetic field, in which a computer detects the movements of hydrogen nuclei. A high-precision image is formed, which shows not only the volumetric shape of the aneurysm, but even the thickness of its walls. All this is very important when making a prognosis for the patient and for deciding on surgical treatment. The examination lasts approximately 15–20 minutes, during which the patient cannot move.
MRI has the following contraindications:
- ear implants and built-in hearing aids;
- the presence of metal pins or plates after operations;
- presence of a pacemaker;
- some types of prosthetic heart valves.
With computed tomography, the method of obtaining the image is slightly different. As with radiography, we are talking about differences in the absorption of x-rays in different tissues of the body. In modern tomographs, the radiation source rotates around the patient, taking a series of images. The computer then simulates the result. The result is a series of high-precision cross-sectional images. Based on the results of computed tomography, an experienced doctor can not only detect changes in the structure of the aorta, but also determine their size, position and other features. The possibility of using contrast makes CT even more informative. The introduction of a contrast agent into the vessel allows you to obtain a computer model of the patient’s vessels in 3D format. The intensity of X-ray radiation during the procedure remains low, despite the series of images taken. An absolute contraindication for this procedure is pregnancy (there is a risk to the fetus).
ECG for aortic aneurysm
Electrocardiography is an inexpensive and painless research method that is aimed at assessing the electrical activity of the heart. If a thoracic or abdominal aortic aneurysm is suspected, it is recommended to take an electrocardiogram for several reasons. First, in patients with chest pain, it will help differentiate aortalgia from anginal pain (coronary artery disease), which can be easily confused. Secondly, atherosclerosis, which is the most common cause of aortic aneurysm, often affects the coronary vessels, increasing the risk of heart attack. It is advisable to identify these disorders using an ECG before starting treatment. Thirdly, sometimes specific changes that are characteristic of an aortic aneurysm can be seen on the ECG. Also, with the help of this study, changes in the functioning of the heart are sometimes detected, which are complications of an aneurysm. Before and during surgery to remove an aneurysm, an ECG is taken continuously.The main advantages of ECG are the speed of the study (the standard procedure lasts about 10 minutes), safety for the patient (the procedure has no absolute contraindications) and immediate results. The resulting record should be carefully studied by a cardiologist, who can use it to obtain a variety of information about the functioning of the heart.
Lab tests
In most cases, a blood test or urine test in patients with an aortic aneurysm will not show any specific changes. A standard general and biochemical blood test is prescribed rather to identify the possible cause of the formation of an aneurysm after the aneurysm itself has been detected.In patients with an aortic aneurysm, the following changes in laboratory tests may be detected:
- Changes in leukocyte levels. It can be observed with certain infections, which, in turn, cause the development of an aneurysm. The level of leukocytes usually increases during acute infectious processes and decreases during chronic ones. In chronic cases, the proportion of non-segmented neutrophils in the leukocyte formula also increases.
- Changes in blood clotting. The study of platelet levels, clotting factors and a number of other indicators often changes if blood clots form in the aneurysm cavity.
- Increased cholesterol levels. Hypercholesterolemia is an increase in blood cholesterol levels to 5 mmol/l or more. Most often this indicates atherosclerotic damage to the aorta. This is also indirectly indicated by elevated levels of triglycerides or low-density lipoproteins (even if total cholesterol is normal).
- In rare cases, urinalysis may detect blood impurities (microhematuria), which are detected during a specific analysis.
Treatment of aortic aneurysm
Treatment for an aortic aneurysm almost always involves surgery. A deformed vessel wall cannot restore its shape with the help of medications. At the same time, there is always a risk of rupture with massive internal bleeding. Therefore, at first, the patient is carefully examined, the extent and possibility of surgical treatment is assessed, and preliminary medicinal (conservative) therapy is prescribed. An important part of treatment is preventing aneurysm rupture. It includes changes in lifestyle, nutrition, and some of the patient’s habits. Compliance with preventive measures will allow the patient to better prepare for surgical treatment (it will not be urgent due to dissection or rupture, but planned).
Prevention of aneurysm formation and rupture includes the following recommendations:
- stopping smoking is perhaps the most important measure both to prevent the development of an aneurysm and to delay the increase in the diameter of an 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 low-cholesterol diet to prevent atherosclerosis;
- refusal of serious physical activity;
- prevention of psycho-emotional stress (including taking sedatives).
Medicines for aortic aneurysm
The natural course of such a disease as aortic aneurysm is a steady and progressive increase in the diameter of the aneurysm, followed by its rupture. At the moment, there are no sufficiently reliable medications in medicine that could prevent the development of degenerative processes in the aortic wall and further growth of the aneurysm. Accordingly, adequate treatment can only be surgical intervention with resection (removal) of the affected area and its replacement.But in the following cases, it is necessary to resort to medications in order to delay the growth of the aneurysm for as long as possible and alleviate the symptoms of the disease:
- 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 case of severe concomitant diseases, when the risk from the operation exceeds the risk of rupture of the aneurysm itself. These conditions include acute coronary circulatory disorders, acute cerebral circulatory disorders, and heart failure of II – III degrees.
- During the period of preparation for surgery.
For aneurysms of the thoracic or abdominal aorta, medications with the following effect can be prescribed:
- drugs that reduce heart rate (heart rate);
- drugs to lower blood pressure;
- cholesterol-lowering drugs.
Drugs to lower heart rate in patients with aortic aneurysm
Drug name | Composition and release form | Dosage and regimen |
Propranolol (anaprilin, obzidan) | Tablets 10 mg, 40 mg | The initial dose is 20 mg, the average dose is 40 - 80 mg 2 - 3 times a day. |
Metoprolol (egilok, betalok, corvitol) | Tablets 25 mg, 50 mg, 100 mg | 50 or 100 mg 1 - 2 times a day. |
Bisoprolol (concor, coronal, cordinorm) | Tablets 2.5 mg, 5 mg, 10 mg | The daily dose is from 2.5 to 10 mg at a time. |
Nebivolol (nebilet, nevotenz) | Tablets 2.5 mg, 5 mg, 10 mg | 2.5 mg, 5 mg or 10 mg once a day. |
Verapamil (isoptin, finoptin) | Tablets 40 mg, 80 mg | 40 - 80 mg 3 times a day. |
Blood pressure also needs to be reduced to reduce tension in the aortic wall. For these purposes, calcium channel blockers and ACE inhibitors (angiotensin-converting enzyme inhibitors) are used. For each patient, the attending physician selects drugs from the group that best suits him. In some cases, a combination of drugs is possible. The purpose depends on the causes that cause hypertension.
Drugs to lower blood pressure in patients with aortic aneurysm
Drug name | Composition and release form | Dosage and regimen |
Amlodipine (Norvasc, Tenox) | Tablets 5 mg and 10 mg | Daily dose 5 mg or 10 mg once. |
Enalapril (Renitec, Berlipril) | Tablets 5 mg, 10 mg, 20 mg | 5 mg, 10 mg, 20 mg 2 times a day. |
Lisinopril (diroton, lysinoton) | Tablets 5 mg, 10 mg, 20 mg | 5 mg, 10 mg, 20 mg once. |
Ramipril (hartil, tritatse) | Tablets 2.5 mg, 5 mg, 10 mg | 2.5 mg, 5 mg, 10 mg 1 time per day. |
Perindopril (prestarium) | Tablets 2 mg, 4 mg, 8 mg, 10 mg | 2 - 10 mg 1 time per day. |
Atherosclerosis is a risk factor for rapid aneurysm growth, contributing to weakening of the vessel wall. Timely treatment can delay the progression of the process for a long time. Drugs from the group of statins, fibrates, and bile acid sequestrants are used. The doctor chooses the drug for the treatment of a particular patient, based on the test results.
Drugs to lower cholesterol in patients with aortic aneurysm
Drug name | Composition and release form | Dosage and regimen |
Simvastatin (vasilip, simgal) | Tablets 10 mg, 20 mg, 40 mg | 10 - 80 mg at a time, taken once in the evening. |
Atorvastatin (atorvox, atoris) | Tablets 10 mg, 20 mg, 40 mg | 10 - 80 mg at a time in the evening. |
Rosuvastatin (crestor, roseart) | Tablets 10 mg, 20 mg, 40 mg | 10 - 80 mg 1 time in the evening. |
Fenofibrate (traikor, lipantil) | Tablets 145 mg, 160 mg, 200 mg, 250 mg | 145 - 250 mg 1 time per day. |
Cholestyramine | 12 - 16 g per day in 3 - 4 doses. |
For various complications of an aortic aneurysm or concomitant disorders, the patient may require other medications. For example, if an aortic aneurysm appears against the background of a systemic infection, a course of treatment with antibiotics is necessary, which are effective against the causative microbe. Various vitamin complexes, drugs to strengthen the vascular wall, and drugs against the formation of blood clots may also be prescribed. However, there are no uniform standards of treatment. The specialist navigates the situation based on the disorders 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 put excessive strain on other internal organs.
Surgical treatment of aortic aneurysm
The very presence of an aortic aneurysm is already an indication for surgery to eliminate this problem. Surgery, as noted above, is the only effective treatment for such patients. Whether surgical treatment will be performed depends on what contraindications the patient has. The operation to remove an aneurysm of both the thoracic and abdominal aorta is very extensive and complex. In some patients with serious chronic diseases, the risks of the operation itself may outweigh the possible benefits. In such cases, surgery is not performed.Currently, the following contraindications to surgical treatment of aortic aneurysm are identified:
- 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 (if there are corresponding neurological problems);
- impossibility of adequate revascularization of at least the deep arteries of the femur (after the operation there will be insufficient blood circulation).
In general, in each individual case the possibility of surgical treatment and its plan are considered separately. The duration of the operation and its complexity are influenced by the type of aneurysm, its location, and the presence of complications.
To detect contraindications and complete preoperative examination of the patient, the following procedures are prescribed:
- detailed examination of the state of the respiratory system (spirography);
- assessment of the condition of the kidneys, in order to exclude hidden 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 Escherichia coli (these microorganisms most often cause postoperative complications).
Currently, there are several options for surgical treatment of aortic aneurysm:
- Classic surgery. Classic 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 the aneurysm and replace it (usually with a graft). As a result, blood flow through the aorta is completely restored. The big disadvantage of this operation is its traumatic nature. There is a high risk of complications during and after surgery. Even in the absence of complications, the patient usually takes a long time to recover and loses his ability to work for a long time.
- Endovascular surgery. Endovascular surgery is understood as a set of methods in which large-scale tissue dissection does not occur. All necessary instruments are brought to the aneurysm through other vessels (often through the femoral artery). Depending on the type and size of the aneurysm, there are several intervention options. Sometimes a special reinforcing mesh is installed into the lumen of the vessel, which prevents the growth or separation of the formation. For small saccular aneurysms, sometimes they resort to “sealing” the mouth. Currently, there is a fairly wide range of manipulations through endovascular access. However, all of them are performed, as a rule, for small saccular aneurysms, when there is no serious threat of rupture.
Traditional treatment of aortic aneurysm
Since the main method of treating aneurysm is surgery, no folk remedy can completely cure this disease. Their use is possible only as a preventive symptomatic treatment. For example, some folk remedies have a good calming effect (important for preventing stress), others lower blood pressure. However, in most cases, there are more effective pharmaceutical analogues that have a more pronounced and faster effect. It is reasonable to turn to folk remedies if there are contraindications or if you are intolerant to drugs.As an alternative to drug treatment, the following folk remedies are sometimes used:
- Dill infusion. Infuse one tablespoon of finely chopped dill in 400 ml of boiling water. Divide this portion into 3 parts and drink throughout the day.
- Hawthorn infusion. Dry and chop the red hawthorn fruits well. To prepare the infusion, you need two spoons of the resulting powder. Pour the powder into 300 ml of boiling water and leave for half an hour. Divide into three parts and consume 30 minutes before meals.
- Infusion of gillyflower. This infusion is prepared from two tablespoons of jaundice. Pour in 150 ml of boiling water. 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 chopped elderberry root, let simmer over low heat for 15 minutes. Remove from heat and leave for another 30 minutes. Strain the resulting broth and pour into a glass container. Drink one tablespoon 3 times a day.
Prognosis for aortic aneurysm
The prognosis for patients with an aortic aneurysm depends on a number of different factors. They try to identify them upon patient admission in order to understand how urgently treatment is needed. Determine the type and size of the aneurysm as accurately as possible. After this, the attending physician (usually a surgeon) draws up a rough plan for further research and treatment.The prognosis for aortic aneurysm is influenced by the following factors and indicators:
- Aneurysm shape. As a rule, dissecting aneurysms are the most dangerous. The best prognosis is often for fusiform true aneurysms, the walls of which are stronger.
- Reason for formation. Aneurysms that appear against 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. Congenital connective tissue diseases generally have a poor prognosis because there is no effective treatment.
- Aneurysm size. Larger aneurysms often cause more symptoms and are more likely to rupture. The prognosis for them 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 - coronary heart disease, kidney or liver problems, etc. All this can become a relative or even absolute contraindication to surgical treatment. The prognosis, of course, is getting worse.
- Stage of the disease. Fresh aneurysms that form within the last few weeks have a worse prognosis because it is more difficult 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, 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 will be for multiple aortic aneurysms located in both the thoracic and abdominal cavities.
Is there any disability for an aortic aneurysm?
The disability group is assigned by a medical and social examination consisting of specialists in several fields. In principle, each case is considered individually. The main criterion for obtaining a group is ability to work - the ability to perform various workloads without serious harm to health and the ability to self-care in everyday life. If the patient is unable to work or care for himself, doctors assess the severity of the situation and determine the disability group.With an aneurysm of the thoracic or abdominal aorta, at first there is no talk of disability. First, you need to undergo a full course of treatment, which includes surgical correction of this pathology. In other words, while doctors have treatment options, the patient is not referred for a medical and social examination.
After surgical treatment, a certain time must pass - usually from six months to 1 - 2 years. During this period, the patient visits rehabilitation centers, which do everything possible to restore health. In the absence of complications or serious consequences of the disease (or surgery), the patient is considered healthy. Of course, the question of obtaining a disability group does not arise again.
If the patient, after a course of rehabilitation, does not get rid of the serious consequences of the operation or illness, he is referred for a medical and social examination. With an aneurysm of the abdominal or thoracic aorta, such consequences can be, for example, disruption of the heart, deterioration of the blood supply to individual organs. Sometimes the diseases that led to the formation of an aneurysm (Marfan syndrome and a number of other congenital diseases) progress, and the patient receives a group not so much because of the aneurysm, but because of the underlying pathology. With Marfan syndrome, for example, there is joint weakness, severe visual impairment, and heart defects. The medical and social examination will consider these manifestations together.
An unoperated aortic aneurysm can also become a reason for receiving a disability group. For example, if the patient has an aneurysm, but there are serious contraindications to surgery (disorders of the heart, lungs, kidneys, liver and other concomitant pathologies). All this confuses doctors, since it becomes impossible to solve the problem surgically. The risk of surgery becomes too high. Because the patient has to constantly reckon with the risk of aneurysm rupture and other complications, he is forced to frequently visit doctors and regularly take various medications. This may be a reason to refer him for a medical and social examination.
Before use, you should consult a specialist.8255 0
Diagnosis of dissecting aortic aneurysm begins with a preliminary diagnosis based on clinical data, which is considered an extremely important stage in recognizing this life-threatening condition. Currently available instrumental diagnostic methods include aortography, contrast CT, MRI, transthoracic or transesophageal echocardiography (Table 1).
Firstly, the most important feature of instrumental diagnosis is the need to confirm or exclude the diagnosis of dissecting aortic aneurysm using any of the listed studies. Second, the diagnostic study must clearly show whether the area of dissection involves the ascending aorta or whether the dissection is limited to the descending aorta and aortic arch. Thirdly, during the study it is necessary to establish the anatomical features of the dissecting aneurysm, namely: length, sites of entry and return entry, the presence of a thrombus in the false lumen, involvement of aortic branches in the area of dissection, the presence or absence of pericardial effusion and the degree of involvement of the coronary arteries. Unfortunately, performing only one research method does not provide all the necessary information. The diagnosis should be made quickly and reliably, preferably using readily available and non-invasive methods.
Based on the results of laboratory tests, it was found that two thirds of patients experience mild or moderate leukocytosis, and anemia may occur due to bleeding or accumulation of blood in the false lumen. A marked increase in blood D-dimer is possible, especially characteristic of an acute dissecting aneurysm, reaching a level typical of PE. Dissecting aortic aneurysm causes severe damage to medial smooth muscle cells, resulting in the release of smooth muscle cell structural proteins, including myosin heavy chains, into the circulation. The most common ECG sign is LV hypertrophy as a result of arterial hypertension. Acute ECG changes occur in 55% of patients and can manifest as ST segment depression, T wave changes, and in some cases ST segment elevation. MI occurs in 1-2% of patients due to obstruction of the ostia of the coronary arteries due to a hematoma or intimal flap.
Table 1
Comparative utility of radiological methods for diagnosing aortic dissection
| Signs |
Gastrodigestion water echocardiography | CT | MRI |
Aorto- graph and I |
|
Sensitivity | ||||
|
Specificity | ||||
|
Determining the type of delamination | ||||
|
Identification of the intimal flap | ||||
|
Aortic valve insufficiency | ||||
|
Pericardial effusion | ||||
|
Involvement of vascular branches | ||||
|
Coronary artery involvement |
Source: Erbel R., Alfonso F., Boileau C. et al. Task force on aortic dissection of the European society of cardiology. Diagnosis and management of aortic dissection // Eur. Heart J. - 2001. - Vol. 22. - P. 1642-1681.
Chest X-ray is one of the main methods of examining a patient with acute chest pain in the emergency department. Moreover, pathological changes of the aorta on a plain chest radiograph are found in 56% of patients with suspected dissecting aortic aneurysm.
The classic radiographic sign that makes it possible to suspect aortic dissection is a widening of the mediastinal shadow. Other signs that may also occur include changes in aortic configuration, a limited hump-shaped protrusion on the aortic arch, dilatation of the aortic bulb distal to the origin of the left subclavian artery, thickening of the aortic wall (assessed by the width of the aortic shadow) that does not correspond to the usual intimal calcification, and displacement of the area of calcification in aortic bulb.
For type A dissecting aneurysm, the sensitivity of transthoracic echocardiography is about 60%, the specificity is 83%; the method also makes it possible to detect AV insufficiency, the presence of pleural effusion and pericardial effusion, and cardiac tamponade. EchoCG with color Doppler mapping allows you to remove the limitations inherent in the conventional research technique (sensitivity when determining the intimal flap is 94-100%, when determining the entry site - 77-87%). In this case, the specificity is in the range of 77-97%. In addition to excellent imaging of the thoracic aorta, transesophageal echocardiography provides excellent images of the pericardium and assessment of aortic function.
A significant advantage of this research method is its accessibility, allowing for rapid diagnosis at the patient’s bedside. For this reason, transesophageal echocardiography is especially useful in the evaluation of patients with circulatory disorders and suspected dissecting aortic aneurysm.
MSCT is used in many hospitals and is usually used in emergency cases. This examination method provides complete information about the anatomical features of the aorta, including the involvement of the lateral branches in the area of dissection, and makes it possible to image the orifices and proximal parts of both coronary arteries. In the diagnosis of dissecting aneurysm, the sensitivity of this research method is 83-100%, specificity - 90-100%.
According to the results of randomized studies, cardiac MRI is a more accurate method compared to transesophageal echocardiography and CT (specificity for dissecting aortic aneurysm is 100%). For establishing the site of entry, the sensitivity of MRI is 85% and the specificity is 100%. Aortography is no longer used to diagnose dissecting aneurysms, since the sensitivity and specificity of this research method is lower than other, less invasive methods.
In the case of the same degree of contrast between the true and false lumens, as well as in the case of a significant degree of thrombosis of the latter, which prevents the flow of contrast, false negative results can be obtained. Aortography is an invasive procedure, the results of which depend on the experience of the surgeon. It does not allow the detection of intramural hematomas of the aorta and requires the use of a nephrotoxic contrast agent. Coronary angiography does not provide additional information for decision making and is generally not indicated for type A dissecting aneurysms.
In a large study of the International Aortic Dissection Registry, the first diagnostic test was transthoracic and transesophageal echocardiography in 33% of patients, CT in 61%, MRI in 2%, and angiography in 4%. The second diagnostic study in 56% of patients was transthoracic and transesophageal echocardiography, 18% CT, 9% MRI and 17% angiography. Thus, an average of 1.8 methods were used to diagnose dissecting aneurysm.
Christoph A. Nienaber, Ibrahim Akin, Raimund Erbel and Axel Haverich
Aortic diseases. Injuries of the heart and aorta
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