What is polyarteritis major?
Polyarteritis is a relatively common autoimmune disease. The symptoms are caused by inflammation that causes narrowing or occlusion of the arteries, resulting in ischemia or necrosis of the distal organ tissue at the site of the lesion.
What are the causes of aortitis?
The cause of this disease is not well understood, but it may be due to infection, poisoning, drugs and other factors acting on the body, causing autoimmune dysfunction, making the aorta wall antigenic, and the body’s immunologically active cells come into contact with the autoantigen and produce anti-aortic antibodies, which react with the aorta wall to form immune complexes and deposit in the aorta wall, resulting in autoimmune inflammatory pathological changes.
What is the incidence of aortitis?
The incidence of aortitis is worldwide, rare in Europe and the United States, but common in Asians, especially in Japan, India and China, and occurs in young women, commonly known as Oriental beauty disease, the ratio of men to women is 1:8. Most after the age of 10, the peak age of onset in 20-30 years. The duration of the disease can be more than 20 years, with chronic progressive changes.
What are the clinical stages of aortitis?
The disease is divided into 3 stages according to the condition.
1. Acute phase (active phase)
It is seen in the early stage of the disease or in the recurrent active stage of chronic inflammation, mainly manifested by systemic symptoms: fever, tiredness and weakness, night sweats, loss of appetite, weight loss, muscle or (and) joint pain, lesion vascular pain, nodular erythema, etc. Laboratory tests include increased leukocytes, elevated anti-“O” and alpha1 or gamma globulin values, rapid sedimentation, positive CRP, and increased potency of anti-aortic antibodies. It may last for weeks to months. In the early stage, when arterial stenosis and ischemic symptoms have not yet developed, it is easy to misdiagnose the disease as other diseases, such as rheumatic fever and myocarditis, and sometimes misdiagnosed for more than 10 years, until the symptoms or signs of ischemia in tissues and organs caused by obvious arterial stenosis appear, which is often in the chronic inflammatory phase. It means that the disease is progressing.
2.Migration extension (remission period)
When the symptoms of the acute phase disappear, the antigenic antibody-reactive inflammation of the arterial wall is still slowly proceeding, showing a long-term chronic inflammatory response phase. The positive laboratory findings may also return to normal. The active phase of the disease alternates with the remission phase. The ischemic signs depend on the location of the involved vessels and the extent of the lesion and the compensation of the collateral circulation.
3. Stable phase (scar phase)
The symptoms of disease activity disappear, and the affected artery wall is scarred and fibrotic, resulting in irreversible narrowing or occlusion of the lumen. Clinical manifestations vary greatly depending on the location of the affected artery and the degree of stenosis, mainly manifesting as ischemic signs.
What are the clinical manifestations of aortitis?
The clinical manifestations are diverse, ranging from asymptomatic in mild cases to life-threatening in severe cases. The clinical manifestations are related to the location of the lesion and the different periods of the disease process.
1.Renal artery type
Renal artery stenosis leads to renal ischemia and produces a series of signs and symptoms of renal hypertension. The effect of general antihypertensive drugs is difficult to control, and in severe cases, hypertensive crisis may occur, manifested as headache, dizziness, sudden increase in blood pressure, blurred vision, fundus bleeding, nausea and vomiting, and murmurs can often be heard on auscultation of the abdomen or back.
2.Head and arm type
When the common carotid artery and unnamed artery produce stenosis or occlusion, it can lead to cerebral ischemic symptoms, which may include tinnitus, blurred vision, dizziness, headache, memory loss, drowsiness or insomnia, and excessive dreaming. There can also be transient cerebral ischemic attacks such as vertigo, black haze, and in severe cases, episodic syncope or even hemiplegic coma, and in a few patients, vision loss, hemianopia, diplopia, or even sudden blindness. When the innominate artery or subclavian artery is involved, symptoms of inadequate blood supply to the upper extremities appear, which may begin with a diminished pulse or simply manifest as pulselessness. Blood pressure is undetectable or significantly reduced. In severe cases, there are obvious symptoms of ischemia such as cold, sore and numb fingers, weakness, and muscle atrophy of the upper limbs.
3.Thoracoabdominal aorta type
Most of the lesions in this type of patients lead to stenosis or occlusion of the thoracoabdominal aorta. Clinically, it mainly manifests as symptoms of hypertension of head and neck, upper limbs and insufficient blood supply to lower limbs, such as dizziness, headache, palpitation, coldness of lower limbs, soreness and weakness of both lower limbs after walking, intermittent claudication, etc. In severe cases, incontinence or temporary weakness of lower extremities may occur after lower extremity activities due to insufficient blood supply to the spinal cord, resulting in a fall. Renal ischemic hypertension may develop secondary to the disease. The usual antihypertensive drugs are not effective. In severe cases, aortic regurgitation may lead to aortic valve insufficiency and even heart failure.
4.Mixed type
Patients with mixed type have a wide range of vascular involvement, and the symptoms and signs of the above-mentioned head and arm type, thoracoabdominal aortic type or (and) renal artery type may appear at the same time in the clinical presentation. The renal artery is the most frequently involved. The symptoms and signs are often more severe.
5.Pulmonary artery type
The pulmonary artery type has a long duration of disease and develops slowly. The symptoms are milder and appear later. Pulmonary hypertension (mild to moderate) may be present, such as palpitations and shortness of breath. The patient’s symptoms are related to the establishment of collateral circulation at the lesion site, the degree of stenosis, the speed of progression, the stage of disease, and the presence of thrombosis.
6.Coronary artery type
The clinical manifestation of coronary artery type is myocardial ischemia or infarction, which needs to be distinguished from myocardial ischemia and infarction caused by atherosclerosis.
What are the test methods and positive indicators for aortitis?
There are no specific indicators to diagnose aortitis. Only some non-specific tests can be used to diagnose aortitis.
1.Blood test: There may be anemia, increased leukocytes, increased blood sedimentation, CRP, gamma globulin, anti-“O”, anti-aortic antibodies and other 5 test results, which can be used as indicators of activity. In a few cases, there are positive anti-nuclear antibodies, positive rheumatoid factor, increased IgA and IgM and decreased C3. Stable stage is negative for anti-aortic antibodies.
2, urine and renal function tests: a few patients have positive urine protein, and when the renal artery lesion is serious, there may be hyperalgesia, increased serum creatinine and urea nitrogen levels, and renal ultrasound may show renal atrophy. Renal ultrasound may show renal atrophy. Renogram may show ischemic changes in the kidney on the side of the lesion.
3.Electrocardiogram: There may be ventricular hypertrophy, ST-T changes, arrhythmias and other changes.
4.Echocardiography: discernible membrane damage, myocardial hypertrophy, and heart enlargement are seen.
5.Color ultrasound Doppler imaging: It can check the diameter of artery, flow rate, flow rate, and the thickening and stenosis of the wall, intra-luminal thrombus, and so on. It is the commonly used preferred non-invasive examination method.
6.Thoracic plain film: In mild cases, no abnormalities can be seen; in severe cases, protrusion of the aortic node, inversion of the descending aorta, irregularity of the arterial wall, arterial dilatation or aneurysm can be seen in the anterior part of the narrowed artery. Calcification of the aortic wall. The left ventricular enlargement is seen in about 50% of patients with heart enlargement.
7.Arteriogram: Arteriogram shows uneven or uniform centripetal stenosis or occlusion of the arterial lumen, the aortic branch lesions mostly invade the proximal opening, the descending aorta can be extensively or limitedly stenosed, the coronary artery is narrowed at the entrance, and the pulmonary artery is multiply stenosed. Therefore, the location, extent and degree of lesions can be determined, and the diagnosis is confirmed.
8.Enhanced CT is a non-invasive examination method with high sensitivity, which can show the morphology, pathological characteristics, blood flow of organs and perfusion of tissues in layers.
9, fundus examination: carotid artery involvement of the eye ischemia, the incidence of fundus changes is 8-12%.
What are the treatment methods and principles of aortitis?
Treatment methods include conservative medical treatment and surgical treatment. Surgical procedures include traditional open surgery and endovenous treatment.
The treatment principle is mainly symptomatic treatment according to the condition and clinical symptoms. By controlling the activity and progression of the disease, medication and surgery are used to improve tissue ischemia, prevent and treat complications, and strive for a good prognosis.
What is the timing and method of internal treatment of aortitis?
In principle, patients with active or early-stage aortitis should not be treated surgically, and should be treated with hormones and other medications until the condition is stable. Drug treatment includes steroid hormones (steroid hormones), immunosuppressants, anticoagulation, vasodilators, and antihypertensive drugs. Anti-infective treatment is given in case of infectious diseases such as tuberculosis. So far, blood sedimentation is still the main laboratory index for observation of aortitis. If blood sedimentation is not yet normal, conservative treatment should be used first.
What are the timing and principles of surgical treatment for aortitis?
The timing of surgical treatment for aortitis should be chosen during the stabilization period, usually six months to one year after the lesion has stabilized, when the patient’s body temperature has returned to normal and laboratory tests including erythrocyte sedimentation rate, white blood cell count and IgG should be normal. However, if there is an impaired blood supply to the vital organs, and if the blood supply to the distal part of the lesion is not improved in time there will be irreversible ischemic necrosis of the vital organs or the patient’s life will be endangered, surgical operation will have to be performed, but the postoperative results are often unsatisfactory.
The principle of surgical treatment is to reconstruct the artery and improve the distal blood supply. Mostly, bypass diversion of normal arteries distal and proximal to the lesion is used, usually without freeing the lesion, and the anastomosis is in normal arterial tissue, with relatively good results.
What are the advantages of the endoluminal approach for the treatment of aortitis?
In recent years, interventional treatment has been widely used in multiple aortitis at home and abroad, including percutaneous endoluminal angioplasty and stent implantation. This method is minimally invasive, simple, easy to perform and can be repeatedly applied, especially for younger patients, and stent implantation is feasible for patients with recurrent stenosis after balloon dilation. The treatment effect is related to the length of the stenosis, with shorter stenoses having better results than longer ones. For patients who are not suitable for open surgery in the acute stage, repeated endoluminal treatment can be performed to improve the distal blood supply, and open surgery can be performed after the lesion is stabilized.
Do I need to continue to take medication after surgery for aortitis, and if so, how should I regulate the medication?
Surgery for aortitis does not remove the cause of the disease, but merely treats the blood supply obstruction caused by the inflammation. Since the condition of patients with aortitis often alternates between the active and stable phases, the active phase of arteritis can still occur after surgery, so postoperative medical medication is closely related to the long-term efficacy of surgery. The principle of medication is determined by the activity of the arteritis in the patient. For patients in the stable phase, oral medications are mainly antiplatelet, anticoagulant, vasodilator, and circulatory improvement. For patients with re-emerging active disease, oral medication is administered according to the principles of active treatment.
Do I need to go to the hospital for regular medical checkups after surgery for aortitis?
It is necessary for patients with aortitis to go to the hospital for regular review and physical examination after surgery, not only to understand the patency of the surgical bridge or stent placement on a regular basis so that problems can be dealt with in a timely manner, but also to monitor the progress of aortitis for the purpose of controlling the disease. Regular follow-up examinations should be performed at 3 months, 6 months, 1 year, 2 years and 5 years after surgery, including blood sedimentation, immunological indicators and patency of the treated arteries.
What do post-operative patients with aortitis need to pay attention to in their life?
Post-operative patients should have a regular life and adapt to the changes of the seasons. For example, in spring, summer and autumn when the weather is warm, it is advisable to get up early and go for a walk, do exercises, play tai chi and other relatively gentle exercises, while paying attention to the combination of work and rest. Cold weather in winter should pay attention to keep warm. Emotions such as anger, sadness, anxiety, goosebumps and fright can cause changes in the condition, so it is necessary to maintain a healthy mental state and optimistic and good stable emotions to improve the ability to resist disease. Treat family, life and work correctly, make self-psychological adjustment at the right time, establish confidence in overcoming the disease, and actively cooperate with the treatment so that the drug can play its maximum effectiveness in the long term. Regularly self-monitor pulse rate and blood pressure to observe the effect of treatment. If there is any abnormality, get in touch with the doctor in time, so as to diagnose and treat as soon as possible, recover early, and prevent the occurrence of cerebral infarction, cerebral hemorrhage and other comorbidities. Review regularly after discharge from the hospital. Use medication under the guidance of the doctor and adhere to reasonable treatment to prevent prolongation of the disease, which will have a very good prognosis if persisted.