Aortic lesions are mainly abdominal aortic aneurysms, thoracic aortic aneurysms and aortic coarctation. These aortic lesions are often at risk of rupture and haemorrhage, or even death. Therefore, when you have severe chest pain or abdominal pain, or manifestations of myocardial infarction, please call 120 as soon as possible and go to the hospital emergency room for specialist examination and treatment. At the same time, it must also attract the high attention of the medical staff of our department.
I. Aortic aneurysm
Aneurysm is an abnormal dilatation or bulging of the aorta, which is medically known as an aneurysm (Aneurysm). Aneurysms can occur in any part of the aorta, the most common being abdominal aortic aneurysms, followed by thoracic aortic aneurysms, and thoracoabdominal aortic aneurysms and aortic aneurysms combined with arterial coarctation. Aneurysms are divided into true aneurysms, in which all three layers of the aortic wall (intima, media and adventitia) are dilated or bulging, and pseudoaneurysms, in which only the outer 2 layers are dilated or bulging with clot formation (often caused by infection), which are very fragile and can easily rupture and cause hemorrhage. Therefore, bulging arteries are classified as true aneurysms, pseudoaneurysms and arterial coarctation. Aortic coarctation is a separation of the vessel wall that causes blood to enter between the layers of the vessel wall, which makes the vessel wall even weaker and more prone to rupture.
1. Etiology of aortic aneurysm.
(1) Atherosclerosis.
(2) Hypertensive disease.
(3) diabetes mellitus.
(4) cystic mesothelial necrosis.
(5) Mycotic aneurysms.
(6) infected aneurysms.
(7) trauma.
2. Risk factors for aortic aneurysm.
(1) Age ≥ 55 years.
(2) Male.
(3) Hypertensive disease.
(4) Smoking.
(5) Genetic disorders: e.g. Marfan’s syndrome.
(6) Family history.
Signs and symptoms of aortic aneurysm: Most aortic aneurysms are often asymptomatic before significant enlargement or rupture, and most are detected occasionally during routine or other examinations. Common signs and symptoms are as follows.
(1) Chest pain.
(2) Back pain.
(3) Abdominal pain.
(4) A pulsating mass or a very strong pulsation may be palpable in the abdomen.
(5) nausea, vomiting.
(6) increased sweating, rapid heartbeat and breathing, dizziness.
(7) Shock.
4. Diagnosis of aortic aneurysm: ultrasound of chest or abdomen, chest X-ray, CT, aortogram, MRI, etc. The most frequent quick and accurate test is thoracic and abdominal CTA.
5.Treatment of aortic aneurysm: Once aortic aneurysm is suspected, come to the hospital as soon as possible.
(1) When the diameter of abdominal aortic aneurysm is ≤5.5cm, it is less likely to be found to rupture and most of them are asymptomatic. Blood pressure can be controlled and ultrasound or CTA can be reviewed every 6-12 months.
(2) When the aneurysm diameter is >5.5cm, then it needs to be treated with surgery or endoluminal repair (branch plus implant), also some criteria are 6cm. while in case of Marfan’s syndrome, surgery should be considered even for 5cm.
(3) When the diameter of the tumor is >7cm, the probability of rupture of the tumor is about 20%.
(4) Surgical treatment Surgical methods.
① Ascending aorta resection + artificial vessel replacement.
② Bentall’s operation.
(iii) Bentall’s procedure + aortic arch replacement + intraoperative stenting.
(iv) Abdominal aortic aneurysm resection + artificial vessel replacement.
(5) Endoluminal aortic repair: for thoracic descending aortic aneurysms and abdominal aortic aneurysms that do not involve important branch vessels such as the renal artery, superior mesenteric artery and abdominal trunk.
(6) Hybrid surgery such as surgical bypass + endoluminal repair: for aortic lesions involving the arterial arch.
II. Aortic coarctation
Aortic coarctation is a tear in the intima of the aortic wall that causes blood to enter the aortic wall causing separation of the layers within the arterial wall. Aortic coarctation is an acute disease, and if the coarctation tears the entire aortic wall, it causes massive and rapid bleeding, which can lead to rapid death even with the best treatment. Ruptured aortic coarctation reaches 80% mortality and 50% of patients die before they reach the hospital. If the diameter of the entrapment reaches 6 cm, it is an indication for emergency surgical intervention.
1. Typing.
(1) DeBakey’s staging: Named after Michael E. DeBakey, a surgeon and also a patient with aortic coarctation, it is an anatomical description. It is named according to the location of the intimal rupture in the aorta and the extent of the entrapment (confined to the ascending aorta, or descending aorta, or both ascending and descending aorta included).
① Type I: The location of the intimal rupture is in the ascending aorta, and the entrapment extends to at least the aortic arch and often to the distal aortic arch.
② Type II: Both the endothelial rupture and the entrapment are confined to the ascending aorta.
③ Type III: The endothelial rupture is in the descending aorta, and the entrapment rarely extends proximally, but extends distally.
(2) Stanford staging
① Type A: Includes the ascending aorta and/or aortic arch and possibly the descending aorta. The endothelial rupture is in the ascending aorta and aortic arch, and very rarely in the descending aorta. It includes DeBakey’s type I, type II and type III of reverse tear).
② Type B: It includes the descending aorta (distal to the opening of the left subclavian artery) and excludes the ascending aorta and the aortic arch. It includes DeBakey type III without reverse tears.
(3)
2. Signs and symptoms.
(1) 96% of patients have acute severe chest pain, mostly tearing-like.
(2) Chest pain migrates with the extension of the entrapment in 17% of patients.
(3) Anterior chest pain suggests ascending aortic entrapment, while posterior back pain suggests descending aortic entrapment.
(4) If the pain is pleuritic like, there may be pericardial hemorrhage.
(5) Chronic aortic coarctation may be asymptomatic.
3. Blood pressure.
(1) Many patients often have a history of hypertension. However, during the attack, blood pressure is variable.
(2) In patients with ascending aortic coarctation, 36% exhibit hypertension while 25% exhibit hypotension, while in patients with descending aortic coarctation, 70% are hypertensive and only 4% are hypotensive.
(3) Severe hypotension is often a sign of pericardial tamponade, severe aortic regurgitation, and coarctation rupture.
(4) Aortic regurgitation: 1/2 to 2/3 of ascending aortic coarctations have aortic regurgitation, and murmurs of aortic regurgitation can be heard in 32% of patients.
5. Myocardial infarction: 1-2% of patients develop myocardial infarction due to clamping involving the coronary artery opening, at which time the mortality rate increases to 70% if thrombolytic therapy is used, mainly due to bleeding leading to cardiac compression.
6.Pleural effusion: mostly left pleural effusion.
7.Etiology of aortic coarctation
(1) Hypertensive disease: 72%-80% of patients have a history of hypertension.
(2) Age and gender: mostly occurring between 50-70 years old, male: female 2:1.
(3) Aortic valvular diastasis: in 7-14% of patients with aortic coarctation, there is aortic valvular diastasis.
(4) Marfan’s syndrome: 5-9% of patients have Marfan syndrome.
(5) Chest trauma: mainly blunt chest injuries.
(6) History of cardiac surgery: 18% of patients with aortic coarctation have a history of cardiac surgery (e.g., aortic valve replacement)
8. Diagnosis.
(1) CTA of large blood vessels in the chest and abdomen: the fastest and accurate.
(2) Thoracoabdominal large vessel MRA: accurate but slower.
(3) Chest X-ray (CXR).
(4) Color ultrasound.
(5) Aortography.
9. Treatment: Similar to aortic aneurysm, but most of them need emergency treatment.
(1) Stanford type A: Surgical treatment only, no interventional treatment.
(2) Stanford type B: Aortic endoluminal repair treatment (large vessel stent implantation) is less invasive, basically non-bleeding, less risky and quicker recovery, but relatively more expensive. It can also be treated by external hand surgery, but the surgery is more traumatic, bleeding, risky and slow recovery.
(3) Conservative treatment: The main treatment is to control blood pressure, with the mean arterial pressure controlled at 60-75 mmHg, or blood pressure as low as the patient can tolerate. The most commonly used antihypertensive drugs are beta-blockers and calcium channel blockers. However, there is a risk of death due to rupture and hemorrhage at any time.
Combination of surgical and interventional treatment: i.e. hybrid surgery, mainly treating lesions involving important vessels such as the aortic arch and renal arteries.