Aorta arch aneurism – the diffusion or local expansion of a gleam of an aorta on a piece between its ascending and descending part exceeding the normal diameter of a vessel. Aneurism of an arch of an aorta can be shown by short wind, cough, a dysphagy, a voice osiplost, puffiness and cyanosis of the person, swelling of cervical veins that is connected with a compression of nearby bodies. Diagnostic tactics at suspicion of aneurism of an arch of an aorta includes carrying out a X-ray analysis of a thorax, EhoKG and UZDG of a chest aorta, an aortografiya, KT and MRT. Treatment consists in an aorta arch aneurism resection in the conditions of IK with installation of an allotransplant or endolyuminalny prosthetics of aneurism a special endoprosthesis.
Aorta arch aneurism
Depending on the level of localization distinguish aneurisms of a root of an aorta and sine of Valsalva, the ascending aorta, an arch of an aorta, the descending aorta, a belly aorta. Quite often in cardiology and a heart surgery the combined defeats of adjacent segments of an aorta meet. So, aorta arch aneurisms seldom meet separately; in most cases they are continuation of anevrizmatichesky expansion of a root or the ascending department of an aorta.
Arch of an aorta it is accepted to call the part of an aorta located between its ascending and descending departments. The arch of an aorta passes between pulmonary arteries and bends around the left main bronchial tube. Three large vascular branches - plechegolovny a trunk, left the general sleepy and left subclavial arteries depart from an arch of an aorta.
According to autopsies, aneurisms of a chest part of an aorta meet in 0,9-1,1% of cases, is 3-7 times more often at men. From them about 18,9% of cases fall to the share of aneurism of an arch of an aorta. The lethality within 3 years after detection of aneurism makes 35%, and in 5 years reaches 54-65%.
Aorta arch aneurism reasons
The reasons and mechanisms of development of aneurisms of an arch of an aorta do not differ from those at aneurisms of other localizations. The hereditary diseases of connecting fabric promoting weakness of a wall of an aorta - Marfan's disease, a fibrous dysplasia, Elers's syndrome — Danlosa, cystous , a congenital izvitost of an arch of an aorta, a koarktation, etc. belong to congenital risk factors. Among acquired diseases the leading role belongs to inflammatory damages of an aorta - to specific and nonspecific aortita at rheumatism, syphilis, tuberculosis, mycoses, a bacterial infection, Takayasu's disease; to not inflammatory degenerate processes (to atherosclerosis, etc.).
The aneurisms of an arch of an aorta caused by defects of transplants and sutural material including poststenotichesky aneurisms even more often meet development of vascular surgery. As a result of injuries of a thorax post-traumatic aneurisms of an arch of an aorta can be formed. From the trauma moment before development of aneurism of an arch of an aorta there can pass long term (from several months to 20 years).
Weakening of a tone of walls of an aorta and formation of an anevrizmatichesky bag are promoted by persistent arterial hypertension. As independent mechanisms of development of aneurism of an arch of an aorta are considered age 60 years, a male, presence of aneurism at family members are more senior. The phenomena of a periaortit, a thickening of an external cover and an intimalny layer of an aorta, a productive inflammation with destruction of an elastichesky and muscular framework of a wall of an aorta are characteristic of aneurisms of an inflammatory origin.
In pathogenesis of aneurism of an arch of an aorta, except inflammatory and degenerate processes, haemo dynamic and mechanical factors play a role. Features of haemo dynamics in chest department of an aorta consist in the high speed of a blood-groove, the steepness of a pulse wave and its form. Besides, in a chest aorta there are most functionally intense segments — a root, an isthmus and a diaphragm. Therefore increase in blood pressure or a mechanical trauma easily leads to an anguish of an internal cover of a wall of an aorta with formation of a subintimalny hematoma, and in the subsequent — aneurisms.
Aorta arch aneurism symptoms
Aneurism of an arch of an aorta of the average and big size leads to a sdavleniye of the next anatomical structures that causes features of a clinical course of pathology. Pressure of an anevrizmatichesky bag upon surrounding fabrics and stretching of nervous textures of an aorta is followed by a pulsation in a breast, pain behind a breast with irradiation in a neck, a shoulder, a back. As a rule, pains have persistent, burning character and are not stopped by reception of nitrates.
Dry, painful cough, short wind and stenotichesky breath develop at a compression of bronchial tubes and tracheas. At a sdavleniye throat paresis (a dysphonia and an osiplost of a voice) arises aneurism of an arch of an aorta of a returnable nerve; squeezing of a gullet is followed by the dysphagy phenomena. Development of a syndrome of the top hollow vein is characterized by headaches, a face edema and the top half of a trunk, suffocation, cyanosis, swelling of veins of a neck, hyperaemia a skler.
In certain cases aneurism of an arch of an aorta is distinguished only in connection with its gap. This complication can be followed by hemorrhage in a sredosteniye, gemotoraksy, bleeding in a gullet, a blood spitting and pulmonary bleeding. Massive bleeding is followed by sharp pain, pallor, consciousness loss, threadlike pulse and, as a rule, quickly leads to a lethal outcome. Except a gap, aneurism of an arch of an aorta can tromboemboliya of arteries of a big circle of blood circulation, including brain, leading to development of an inyosult.
Diagnosis of aneurism of an arch of an aorta
At external survey strengthening of a pulsation of an arch of an aorta in jugular cutting, and also the protrusion of an anevrizmatichesky bag seen approximately in a breast can pay attention. The fact of existence in the anamnesis of a disease of syphilis, injuries of a thorax, a nonspecific aortoarteriit, etc. is important. Appearance of patients with Marfan's syndrome allows to suspect aorta arch aneurism in some cases: high growth, leanness, long hands, an arakhnodaktiliya, a funneled thorax, , the increased weakness of the copular device of joints.
The polyposition X-ray analysis of a thorax reveals a shadow of an expanded arch of an aorta and expansion of a vascular bunch. Often is defined aneurism walls. The X-ray analysis of a gullet and stomach allows to find the shift of a gullet and a sebesten of a stomach. The invasive X-ray contrast aortografiya is applied, mainly, to blood-groove assessment in aorta branches.
The leading role in recognition of aneurisms of an arch of an aorta belongs to ultrasonography: echocardiography (transthoracic, chrespishchevodny EhoKG), to UZDG and duplex scanning of a chest aorta. This method is irreplaceable for determination of diameter of an aorta, existence of stratification, blood clots in an anevrizmatichesky bag.
KT (MCKT) of a chest aorta with contrasting allows to reveal visually meshotchaty or spindle-shaped expansion of a gleam of an aorta, presence of trombotichesky masses, stratifications, a paraaortal hematoma, the centers of a kaltsinoz. The differential diagnosis of aneurism of an arch of an aorta should be carried out with tumors of lungs and a sredosteniye.
Treatment of aneurism of an arch of an aorta
Conservative waiting tactics can be applied at the isolated aneurisms of the small sizes which are not causing clinical symptomatology. In this case to patients hypotensive means, adrenoblokator, statins are appointed. At the same time each half a year the dynamic observation including survey of the cardiologist, carrying out EhoKG, KT or MPT is shown to patients. Aorta arch aneurisms over 5 cm in the diameter proceeding with a pain or compression syndrome and also the aneurisms which were complicated by stratification, a gap and thrombosis are subject to surgical treatment.
Radical treatment consists in an aorta arch aneurism resection. The essence of operation consists in excision of aneurism with replacement of defect of an aorta allotransplantaty, imposing of anastomoz of a brakhitsefalny trunk, left the general sleepy and left subclavial arteries with a vascular artificial limb. Operation is performed in the conditions of artificial blood circulation with protection of a myocardium and brain against ischemia by means of a hypothermia. The surgical lethality at this type of operations makes about 5-15%. The remote results after an aorta arch aneurism resection good.
Except open surgical intervention at aneurisms of an arch of an aorta the closed endovascular stenting (prosthetics) of aneurism is applied. At the same time the special endoprosthesis by means of the conductor is entered into a gleam of aneurism and fixed above and below an anevrizmatichesky bag. In some cases, in the presence of absolute contraindications to performance of radical operation, the palliative intervention consisting in an aneurism enveloping synthetic fabric at the menacing gap is carried out.
The forecast at aorta arch aneurism
In case of refusal from treatment the forecast at aorta arch aneurism adverse: about 60% of patients perish within 3 — 5 years from a rupture of aneurism, IBS, a stroke. The forecast is burdened at the aneurism sizes more than 6 cm, the accompanying arterial hypertension, post-traumatic genesis of aneurism of an arch of an aorta.