Description of the Disease
Aortic aneurysm is an enlargement of the diameter of the main artery of the body by more than 2 times. Depending on the location in the human body, aortic aneurysms are divided into aneurysm of the ascending aorta, aneurysm of the aortic arch and descending aorta, and abdominal aortic aneurysm.
Aortic dissection is a life-threatening condition that occurs after damage and rupture of the inner layer of the aorta and the entry of blood between the layers of its wall. It is also classified depending on the site of dissection initiation into ascending aortic dissection, descending thoracic aortic dissection. Often, dissection of the descending thoracic aorta extends to the abdominal segment.
Cause of the Disease
The causes of aneurysm formation may include such diseases as systemic atherosclerosis, genetically determined diseases manifested in the weakness of the aortic wall (Marfan syndrome, Ehlers-Danlos syndrome, etc.), arterial hypertension, infectious diseases.
Blood pressure is transmitted to the weakened wall, leading to the progression (growth) of the aneurysm and ending with rupture of the aortic wall. Rupture of an aortic aneurysm leads to severe arterial bleeding beyond the vessel, hemorrhagic shock, and patient death.
The cause of aortic dissection is more often genetically determined weakness of the vessel wall and trauma (road traffic accidents). After damage and rupture of the inner layer of the aortic wall, blood dissects the wall over a significant distance due to pressure, leading to its rupture, disruption of blood supply to organs in the dissection zone, and below the dissection along the blood flow.
Symptoms of the Disease
A patient with uncomplicated aortic aneurysm typically does not present with typical complaints. In the vast majority of cases, aortic aneurysms are detected either during dispensary examination or during examination for other diseases. Sometimes patients with abdominal aortic aneurysm feel increased pulsation in the abdomen. With the development of such a complication of aortic aneurysm as rupture, the patient experiences characteristic complaints - back pain, abdominal pain, lumbar pain, accompanied by extremely low blood pressure, pallor of the skin, sweating, and confusion, up to loss of consciousness.
In aortic dissection, pain in the patient occurs suddenly, after some provoking factor (sometimes - without it), the pain is located in the chest, in the back, between the shoulder blades, the pain is intense, sharp, accompanied by low blood pressure, fear of death, loss of consciousness.
Diagnostics of the Disease
Aortic aneurysms are most often detected during abdominal ultrasound, echocardiography (ultrasound of the heart), chest X-ray, or during multislice computed tomography for another disease.
The 'gold standard' examination for aortic dissection is considered to be multislice computed tomography with contrast.
Treatment of the Disease
Indications for surgical treatment of aortic aneurysm depend on its size. When the diameter of an abdominal or thoracic aortic aneurysm reaches 50 mm, the patient is advised to consult a specialist to clarify the indications for surgical treatment and choose the method of treatment; for an aneurysm of the ascending aorta, this indication is 55 mm (50 mm in the case of genetically determined weakness of the aortic wall), for aneurysm of the aortic arch and descending thoracic aorta - 55 mm.
Indications for surgical treatment of aortic dissection depend on many factors - on the timing of dissection, on the extent of dissection, on the presence of impaired blood supply to organs and tissues in the dissection zone and below along the bloodstream.
There are two methods of treating aortic pathology:
1. Endovascular Method
A minimally invasive approach to treating aneurysms of the aortic arch and descending thoracic aorta or abdominal aorta (this type of treatment is currently not possible for aneurysm and dissection of the ascending thoracic aorta). The aneurysm is not removed; a special structure called a stent-graft is placed into the aneurysm, expanding and securing it in place, reinforcing the walls of the aorta and diverting the aneurysm from the bloodstream.
In cases of dissection, the stent-graft is placed at the site of the tear, closing the 'entry gates' of the dissection. The procedures are performed through a 2 cm incision in the groin, avoiding major surgery (opening of the chest or abdominal cavity). The operations are performed without general anesthesia; the patient remains conscious and breathing independently. Not every patient with aortic pathology can be helped by this method; the aorta must have certain anatomy, which limits this method.
2. Open Surgery
Aortic prosthetics allow for assistance to patients with aneurysms or dissections of the aorta of any localization. It is performed under general anesthesia. During the operation, the affected segment of the aorta is excised and replaced with a special synthetic prosthesis. The limitation of this method is its traumatic nature; not every patient can tolerate this operation.
Learn More about Aortic ProstheticsTreatment Prognosis
In the natural course of the disease without surgery, the likelihood of aortic aneurysm rupture and patient life expectancy depends on the size of the aneurysm. After an aneurysm reaches a size of 5 cm, the risk of rupture within a year is 1%; with further growth, the risk increases to 10-30%.
In the case of aortic aneurysm rupture, mortality in the first day exceeds 50%. With planned surgical treatment, the prognosis for patients is relatively favorable; mortality with planned surgical treatment - abdominal aortic prosthetics - is about 5.5%, repeat open surgical treatment is rarely required. With planned endovascular prosthetics of the abdominal aorta, mortality is about 1.5%, repeat endovascular interventions are required more often than with open surgical treatment. Long-term follow-up by a cardiovascular surgeon is mandatory.
In aortic dissection, the patient's prognosis depends on the localization of the dissection. Thus, in case of dissection of the ascending aorta without surgery, the non-operative mortality in the first hours is 1-2% per hour (50% in the first two days), while with emergency surgery, the mortality within the first month decreases from 90% to 30%.
In the case of dissection in the descending thoracic aorta without impaired blood supply to the underlying organs and tissues, the prognosis is favorable; conservative therapy, stabilization of the patient, and preparation for planned surgical treatment are possible. The mortality rate with planned surgery for dissection of the descending aorta is 8% with endovascular treatment and ~37% with open prosthetics of the thoracic aorta. The prognosis in the postoperative period is relatively favorable. Long-term follow-up by a cardiovascular surgeon is mandatory.