The stratifying aorta aneurism – the defect of an internal cover of an anevrizmaticheska of an expanded aorta which is followed by formation of a hematoma it is longitudinal stratifying a vascular wall with formation of the false channel. The stratifying aneurism of an aorta is shown by the sudden intensive pain migrating on the stratification course, rise in arterial pressure, symptoms of ischemia of heart, head and spinal cord, kidneys, internal bleeding. The diagnosis of stratification of a vascular wall is based on these EhoKG, KT and MPT of a chest/belly aorta, an aortografiya. Treatment of the complicated aneurism includes intensive medicamentous therapy, a resection of the damaged site of an aorta with the subsequent reconstructive plasticity.
The stratifying aorta aneurism
The stratifying aorta aneurism – the longitudinal stratification of a wall of an aorta in the disteel or proximal direction on various extent caused by a rupture of its internal cover and penetration of blood into thickness of the degenerate changed center. Expansion of an aorta when stratifying its wall can have moderate character or be absent therefore the stratifying aorta aneurism is often called stratification of an aorta.
The majority of aneurisms are localized in most gemodinamichesk vulnerable zones of an aorta: about 70% - in the ascending department in several centimeters from the aortal valve, 10% of cases – in an arch, 20% - in the descending department of an aorta distalny mouths of the left subclavial artery. The stratifying aneurism in cardiology belongs to life-endangering states with risk of massive bleeding at a rupture of an aorta or sharp ischemia of vitals (heart, a brain, kidneys, etc.) at occlusion of the main arteries. Usually stratification of aneurism of an aorta arises at the age of 60-70 years, at men by 2-3 times more often than at women.
The reasons of the stratifying aorta aneurism
The diseases and states leading to degenerate changes of muscular and elastic structures of an average cover of an aorta (media) are the reasons of pathology. The main risk of stratification of an aorta is connected with the long arterial hypertension (70-90% of cases) which is followed by haemo dynamic tension and a chronic travmatizatsiy aorta. The stratifying aneurism can develop as a complication of hereditary defects of connecting fabric (Marfan, Turner, Elersa-Danlos's syndromes), aortal defects, a koarktation of an aorta, the expressed atherosclerosis of an aorta, system vaskulit, a polikistoz of kidneys. Advanced age of patients (60-70 years are more senior), thorax injuries, the III trimester of pregnancy at women is more senior than 40 years are considered as risk factors of stratification of aneurism of an aorta.
During the early and late postoperative period after surgical interventions on heart and an aorta (prosthetics of the aortal valve, an aorta resection) there is an increased risk of stratifying of aneurisms. The Yatrogenny stratifying aneurisms are connected with technical errors when performing an aortografiya and balloon dilatation, aorta kanyulyation for ensuring artificial blood circulation.
Primary pathogenetic link in most cases is the anguish intims with the subsequent formation of a vnutristenochny hematoma. Approximately in 10% of cases hemorrhage in media at a spontaneous rupture of the capillaries branching in an aorta wall can initiate the stratifying aneurism of an aorta. Spread of an intramuralny hematoma within media usually is followed by the subsequent gap intims, but can happen without it (in 3-13% of cases). In rare instances stratification of an aorta can be observed at a penetration of an atherosclerotic ulcer.
According to Debeyki's classification, define 3 types of stratification:
- I – the anguish intims in the ascending aorta segment, stratification extends to chest and belly departments;
- II – the place of an anguish and stratification is limited to the ascending department of an aorta,
- III – an anguish intims in the descending aorta, stratification can extend to disteel departments of a belly aorta, sometimes retrogradno to an arch and the ascending part.
The Stanford classification allocates the stratifying aorta aneurisms like A - with the proximal stratification affecting its ascending department and type B - with disteel stratification of an arch and the descending part of an aorta. Type A is characterized by higher frequency of development of early complications and a high pre-hospital lethality. On a current the stratifying aneurisms of an aorta can be sharp (from several hours to 1-2 days), subsharp (from several days to 3-4 weeks) and chronic (several months).
Symptoms of the stratifying aorta aneurism
The clinical picture of a disease is caused by existence and extent of stratification of an aorta, a vnutristenochny hematoma, a sdavleniye and occlusion of branches of an aorta, ischemia of vitals. Distinguish several options of development of the stratifying aorta aneurism: formation of the extensive not broken hematoma; stratification of a wall and break of a hematoma in an aorta gleam; stratification of a wall and break of a hematoma in the fabrics surrounding an aorta; a rupture of an aorta without stratification of a wall.
The sudden beginning with imitation of symptoms of various cardiovascular, neurologic, urological diseases is characteristic of the stratifying aneurism of an aorta. Stratification of an aorta is shown by sharp increase of the tearing apart, intolerable pain with wide area of the irradiation (behind a breast, between shovels and on the backbone course, in epigastralny area, a waist) migrating on the stratification course. Increase in arterial pressure with the subsequent recession, asymmetry of pulse on the top and lower extremities, plentiful sweating, weakness, cyanosis, motive concern is noted. The most part of patients with the stratifying aneurism of an aorta dies of development of complications.
As neurologic displays of pathology ischemic damage of a head or spinal cord (a hemiparesis, a paraplegia), peripheral neuropathy, consciousness violations (a faint, a coma) can serve. The stratifying aneurism of the ascending aorta can be followed by myocardium ischemia, a sdavleniye of bodies of a sredosteniye (emergence of hoarseness, a dysphagy, short wind, Horner's syndrome, syndrome of the top hollow vein), development of a sharp aortal regurgitation, haemo pericardium, heart tamponada. Stratification of walls of the descending chest and belly part of an aorta is expressed by development of heavy vazorenalny hypertensia and sharp renal failure, sharp ischemia of digestive organs, mezenterialny ischemia, sharp ischemia of the lower extremities.
At suspicion of the stratifying aneurism of an aorta urgent and exact assessment of a condition of the patient is necessary. The main methods of diagnostics allowing to visualize damage of an aorta are the X-ray analysis of a thorax, EhoKG (transthoracic and chrespishchevodny), UZDG, MRT and KT of a chest/belly aorta, an aortografiya. The X-ray analysis of a thorax reveals signs of spontaneous stratification of an aorta: expansion of an aorta and the top sredosteniye (in 90% of cases), deformation of a shadow of contours of an aorta or a sredosteniye, existence of a pleural exudate (is more often at the left), decrease or lack of a pulsation of an expanded aorta.
More informative research of the stratifying aorta aneurism available in any conditions, the transthoracic or chrespishchevodny EhoKG helping to define a condition of a chest aorta, to reveal the exfoliated rag intims, true and false channels, to estimate a solvency of the aortal valve, prevalence of atherosclerotic damage of an aorta is considered.
Performance of KT and MPT at the stratifying aneurism of an aorta demands a stable condition of the patient for transportation and holding a procedure. KT apply to detection of an intramuralny hematoma, a penetration of atherosclerotic ulcers of chest department of an aorta. MRT allows to determine precisely without use of intravenous administration of contrast substance localization of a gap intims, the direction of stratification by the direction of a blood-groove in the false channel, to estimate an involvement of the main branches of an aorta, a condition of the aortal valve.
Aortografiya is an invasive, but highly sensitive method of a research of the stratifying aorta aneurism; allows to see the place of an initial anguish, localization and extent of stratification, true and false gleams, existence of a proximal and disteel fenestration, degree of a solvency of the aortal valve and coronary arteries, integrity of branches of an aorta.
It is necessary to carry out differential diagnosis of the stratifying aorta aneurism with a sharp myocardial infarction, occlusion of mezenteralny vessels, renal colic, a kidney heart attack, a thrombembolia of bifurcation of an aorta, sharp aortal insufficiency without stratification of an aorta, not stratifying aneurism of a chest or belly aorta, a stroke, a sredosteniye tumor.
Treatment of the stratifying aorta aneurism
Patients with the complicated aorta aneurism are urgently hospitalized in office of a heart surgery. Conservative therapy is shown at any forms of a disease at the initial stage of treatment for the purpose of a stop of progressing of stratification of a vascular wall, stabilization of a condition of the patient. Intensive therapy of the stratifying aneurism of an aorta is directed to knocking over of a pain syndrome (by introduction of not narcotic and narcotic analgetics), removal from a state of shock, a lowering of arterial pressure. Monitoring of haemo dynamics, a warm rhythm, a diuresis, TsVD, pressure in a pulmonary artery is carried out. At clinically significant hypotonia bystry restoration of OTsK due to intravenous infusion of solutions is important.
Drug treatment is the basic at most of patients with the uncomplicated stratifying aneurisms like B (with disteel stratification), at the stable isolated stratification of an arch of an aorta and stable uncomplicated chronic stratification. At inefficiency of the carried-out therapy, progressing of stratification and development of complications, and also at once after stabilization of a state the emergency surgery is shown to patients with sharp proximal stratification of a wall of an aorta (type A).
At the stratifying aneurism of an aorta carry out a resection of the damaged site of an aorta with an anguish, removal of an intimalny rag, elimination of a false gleam and restoration of the excised aorta fragment (sometimes one-stage reconstruction of several branches of an aorta) method of prosthetics or rapprochement of the ends. In most cases operation is carried out in the conditions of artificial blood circulation. According to indications carry out a valvuloplastika or prosthetics of the aortal valve, a reimplantation of coronary arteries.
Forecast and prevention
In the absence of treatment of the stratifying aorta aneurism the lethality high, within the first 3 months can reach 90%. Postoperative survival at stratification like A makes 80%, type B – 90%. Long-term forecast in general favorable: ten-year survival makes 60%. Prevention of formation of the stratifying aneurism of an aorta consists in control of the course of cardiovascular diseases. The prevention of stratification of an aorta includes observation of the cardiologist, monitoring of arterial pressure and level of cholesterol of blood, periodic UZDG or UZDS of an aorta.