The aorta, the crutch of life
The aorta emanates from the heart to both iliac arteries and is shaped like a “crutch”. The branches of the aorta supply blood to all organs of the body to ensure the normal functioning of human life, and any lesion in any part of this “crutch” will affect the blood supply to all organs and endanger life. Therefore, we regard it as a “golden crutch” that supports human life.
What is aortic coarctation?
Answer.
The aorta has three layers, called the intima, mesentery and epima. The so-called aortic coarctation is caused by a tear in the intima of the aorta for various reasons, and the arterial blood flow enters the middle of the aortic wall through this fissure, thus causing a separation of the aortic wall. The blood flow extends distally and proximally along the aortic wall and can involve the entire length of the thoracic aorta and even the abdominal aorta and its branches. Therefore, aortic coarctation is so devastating that it is called “catastrophic disease” of the aorta. If the original lumen of the artery is called the true lumen, the lumen formed by the separation of the middle membrane is the false lumen. The false lumen and the true lumen are like the layers of a “sandwich”, and a rupture can be life-threatening. Therefore, we often compare aortic coarctation to a life-threatening “sandwich”.
What is the cause of aortic coarctation?
Answer.
The causes of aortic coarctation are complex. The common ones are: hypertension, diabetes, atherosclerosis, trauma, medical injury, pregnancy, inflammation, genetic factors (Marfan’s syndrome), and cystic lesions in the middle layer of the artery. Of these, hypertension is the most important.
Patients with Marfan syndrome
What are the risks of aortic coarctation to the human body?
Answer.
Aortic coarctation has a rapid and widespread destructive onset. In the acute phase, it can cause aortic rupture and ischemia of organs and limbs thus leading to death, while in the chronic phase, aortic coarctation can gradually expand to form a coarctation aneurysm. As the diameter of the aneurysm increases, the patient’s entrapped aneurysm will eventually rupture leading to death.
What are the clinical manifestations of aortic coarctation?
Answer.
1. Chest pain: 90% of patients will experience sudden onset of severe pain in the chest, back or abdomen at the onset of aortic coarctation. The pain often appears when making some sudden movements, such as lifting heavy objects, playing basketball, or even yawning, coughing, or straining to defecate. The pain is cut or torn, intense, and radiates distally from behind the sternum or back of the chest. The site of pain onset often suggests the site of the entrapment rupture. Patients are often irritable, sweating profusely, have a sense of near death, and may faint from the pain. In patients who survive the acute phase, the chest pain gradually disappears or turns to vague pain.
2. Hypertension: It is the most common sign in patients with aortic coarctation. Firstly, most patients with this disease have the basis of hypertension, and secondly, the formation of the entrapment will in turn further increase the blood pressure.
3. Rupture: Hemorrhage caused by rupture is the main cause of death from entrapment. When rupture occurs, in addition to the above-mentioned severe chest pain, there are also manifestations of hemorrhagic shock such as blood pressure drop, pale face, cold sweat, cyanosis, and some other special manifestations: rupture into the esophagus as vomiting blood, rupture into the trachea as hemoptysis, rupture into the pericardium as pericardial tamponade, rupture into the chest as dyspnea, etc.
4.Organ and limb ischemic manifestations: In addition to rupture, another danger of entrapment is to affect the blood supply of aortic branch vessels, including brain, heart, intestine, kidney, lower limbs, etc., which can cause ischemia, dysfunction and even functional failure of these organs. The common ones are cerebral infarction, heart attack, abdominal pain, jaundice, blood in the stool, oliguria or anuria and severe ischemia of the lower extremities.
How to diagnose aortic coarctation?
Answer.
A variety of special tests can be used to diagnose aortic coarctation. For example, enlarged aortic bulb and widened mediastinum can be seen on chest radiographs, but chest radiographs cannot be used as a means of confirming the diagnosis of entrapment. Enhanced CT is a common means of diagnosing aortic coarctation. It has the characteristics of safety, simplicity, accuracy and economy. Therefore, enhanced CT is of great value in both the diagnosis and preoperative evaluation of aortic coarctation. Magnetic resonance angiography (MRA) is also a good method to diagnose aortic coarctation, but MRA images are slightly blurred, especially in measuring the internal diameter of blood vessels, which is not accurate enough. Transesophageal ultrasound (TEE) is a safe, noninvasive, sensitive and specific method for the diagnosis of aortic coarctation, and it can make a diagnosis of aortic coarctation very accurately and quickly, with the disadvantage that the operation cannot be successfully completed in patients with unstable conditions in the emergency department, and there are limitations in the observation of the arch and its branch vessels due to the interference of the trachea. Also TEE cannot observe abdominal aortic entrapment and fissures. Digital subtraction angiography (DSA) is an effective tool for diagnosing aortic coarctation, but because it is an invasive and expensive test, DSA technology is more often used in endoluminal treatment techniques for aortic coarctation.
DSA angiography
How is the traditional surgical approach performed?
Answer.
The traditional treatment method is to perform artificial vessel replacement, specifically, the patient will be under general anesthesia, open the chest (some patients have to open the abdomen at the same time), establish extracorporeal circulation, dissect out the entrapped aneurysm, remove the diseased and broken aortic segment, and then use artificial vessels to anastomose with the relatively normal aorta at both ends of the aneurysm to restore the blood flow of the aorta, and sometimes it is necessary to reconstruct multiple branch vessels. Depending on the degree of difficulty, the operation can take anywhere from 4 hours to more than 10 hours, with significant bleeding and transfusion. Because of the complexity of the operation, the long duration of arterial blockade, and the huge trauma, it has a direct impact on the patient’s heart, lungs, brain, kidneys, and other important organs. The postoperative period is prone to a variety of complications such as heart attack, brain attack, respiratory failure, and kidney failure. More unfortunately, aortic coarctation aneurysms usually occur in the middle-aged and elderly population, and most of them coexist with different diseases such as hypertension, coronary artery disease, diabetes, and pulmonary and renal decompensation, making the surgery more dangerous and many patients lose the opportunity to be treated because they cannot tolerate the surgery.
How is endoluminal treatment performed?
Answer.
The purpose of endoluminal treatment of aortic coarctation is to prevent rupture of the aneurysm and to improve blood supply to the organs. Instead of opening the chest or abdomen, the procedure requires only a small incision 3-5 cm long at the root of the thigh. Under X-ray fluoroscopic surveillance, a delivery device containing a graft (stent-type vessel) is introduced through the femoral artery, and after reaching the diseased aorta, the graft is released and propped open and fixed in the aortic wall at both ends of the fissure, thus closing the fissure and avoiding the continuous impact of high-velocity blood flow into the false lumen.
What are the advantages of endoluminal repair?
Answer.
Compared with traditional open-heart and open-abdomen surgery, the most prominent feature of endoluminal repair is its simplicity, minimal invasiveness and proven efficacy. The patient recovers quickly after surgery because of the small trauma of treatment, short operation time and low blood transfusion. Patients can usually eat and drink normally and get out of bed 24 hours after surgery. These features provide treatment opportunities for many elderly and frail patients with multiple coexisting diseases that cannot tolerate traditional surgery. Therefore, endoluminal repair has been called a revolution in the history of aortic coarctation treatment.
Does the success of endoluminal treatment give the patient peace of mind?
Answer.
The rupture in aortic coarctation is often multiple, with the first rupture usually in the isthmus of the descending aorta, with multiple ruptures distal to it and often next to important visceral arteries. Endoluminal treatment is to cover the first rupture with a stent-type artificial vessel to prevent blood from continuing to enter the false lumen and to reduce the pressure inside the false lumen so that a thrombus can form in the false lumen with the aim of achieving healing of the false lumen, but sometimes blood still flows into the false lumen from the distal rupture, and although the pressure has been greatly reduced, there is still a risk that the distal false lumen will continue to grow and lead to rupture. This is why it is critical for patients to be reviewed regularly after successful endoluminal treatment of aortic coarctation. If the distal coarctation is still present and gradually increasing in size, surgery is still needed.
What do patients need to pay attention to after surgery?
Answer.
1. Control blood pressure and heart rate. Take oral antihypertensive drugs regularly as prescribed by the doctor to control blood pressure within the normal range (systolic blood pressure not higher than 140 mmHg and diastolic blood pressure not higher than 90 mmHg), especially to avoid blood pressure fluctuation. Heart rate should be controlled within 80 beats/min.
2, improve lifestyle, moderate exercise, avoid strenuous exercise, low salt and low fat light diet, avoid emotional excitement, and actively control blood lipids and blood sugar.
3.Take antiplatelet, statin and other drugs strictly according to the doctor’s instruction.
4, 3 months, 6 months and 1 year after surgery, you should regularly seek professional doctors to do aortic enhancement CTA.
DSA chart