Common symptoms and signs of aortic aneurysm.
Patients with aortic aneurysms mostly have no clinical manifestations in the early stage, and as the aneurysm increases, corresponding symptoms and signs caused by pain or aneurysm compression, pulling and erosion of surrounding tissues may gradually appear.
(A) Pain
Acute aortic aneurysms are often characterized by sudden knife-like pain, while chronic aortic aneurysms are characterized by persistent dull pain. Ascending aortic aneurysms and aortic arch aneurysms often present with pain in the anterior thoracic region, which may radiate to the neck and jaw, while descending aortic aneurysms often present with chest and back pain, which may radiate to the left shoulder.
(B) Pulsatile mass
Patients with high-grade aortic aneurysms may present with pulsation at the sternoclavicular joint or a palpable pulsating mass in the superior sternal fossa. As the aneurysm gradually enlarges into the anterior chest wall and erodes the sternum, it can cause severe pain, and in severe cases the aneurysm may penetrate the chest wall and present as a pulsatile mass. Descending aortic aneurysms may erode the transverse processes of the thoracic vertebrae or the ribs, or even project outward in the back over the body surface.
(C) Aneurysm compression symptoms
When the aneurysm compresses the innominate vein, the venous pressure of the left upper limb is increased. When the aneurysm compresses the superior vena cava, it can cause superior vena cava syndrome. When acute onset occurs, patients may suffer from severe headache, dizziness, head swelling, drowsiness and breath-holding, and even increased intracranial pressure, leading to intracranial vein rupture and death.
When the aneurysm compresses the right ventricular outflow tract or pulmonary artery, it can cause symptoms of right heart failure, and in severe cases, pericardial effusion, decreased pulse pressure or oddity. Aneurysms may also compress branch vessels such as cephalobrachial artery branches, upper limb vessels, coronary arteries, intercostal arteries, renal arteries and mesenteric arteries, and cause corresponding compression symptoms.
When the tumor compresses the trachea and bronchus, it may cause coughing, difficulty in breathing and lung infection. If the tumor penetrates into the lung or bronchus, the patient may experience hemoptysis. Compression of the esophagus by the aneurysm may cause dysphagia.
Arch and isthmus aneurysms may compress the recurrent laryngeal nerve, causing hoarseness or loss of voice. Compression of the cervical sympathetic stellate ganglion may cause cervical sympathetic nerve palsy syndrome (Horner syndrome), which is characterized by pupillary constriction, eye entropion, ptosis, and absence of sweating on the affected side.
(iv) Aneurysm invasion of the aortic annulus
When an aneurysm encroaches on the aortic annulus and enlarges it, it can lead to secondary aortic valve insufficiency. Patients have no obvious clinical manifestations at the initial stage, but when it progresses to moderate (or above) aortic valve closure insufficiency, it may manifest as palpitations, dyspnea, chest pain, syncope, etc. In severe cases, it may manifest as congestive heart failure. On physical examination, murmurs due to aortic valve insufficiency can be heard, and the patient may have increased pulse pressure or a hydropulse pulse. In acute aortic valve insufficiency, patients may develop acute left heart failure or pulmonary edema. Patients with Marfan syndrome have their specific physical symptoms.
(E) Aortic aneurysm rupture
The larger the internal diameter of the aortic aneurysm, the greater the likelihood of rupture. When an aortic aneurysm ruptures or is on the verge of rupture, the patient will have sudden onset of severe chest and back or abdominal pain and a pulsating abdominal mass. Sudden severe abdominal pain (which may spread to the low back, pelvis, perineum and lower extremities), decreased blood pressure and shock are the triad of ruptured abdominal aortic aneurysm.
Rupture of aortic aneurysm into the pericardium may cause pericardial tamponade, typically with elevated venous pressure, decreased arterial pressure, and distant heart sounds (Beck’s triad). When an aneurysm ruptures into the trachea or bronchus, it can cause hemoptysis, which can lead to asphyxia if the hemoptysis is large. When the aneurysm breaks into the esophagus, it may cause vomiting of blood; when it breaks into the chest, it may cause dyspnea and hemothorax; when it breaks into the abdomen, it may cause accumulation of blood in the abdominal cavity. When the bleeding volume exceeds 30% of the blood volume, the patient may go into shock.
(F) Detailed description of abdominal aortic aneurysm
Abdominal aortic aneurysms account for about 3/4 of aortic aneurysms in foreign countries and are more common in elderly (>60 years old) men, who often have combined hypertension or atherosclerotic disease. The common causes of morbidity in young people are congenital malformations, infection or cystic necrosis of the middle layer of the arterial wall.
Abdominal aortic aneurysms may be asymptomatic in the early stages and patients often present with a pulsatile abdominal mass on physical examination. Systolic vascular murmurs and occasional tremors can be heard on abdominal auscultation. As the aneurysm gradually enlarges and compresses surrounding tissues or organs, the patient may experience pain or discomfort around the umbilicus or in the upper middle abdomen, which may radiate to the lower back, and in severe cases, symptoms related to intestinal obstruction.
Compression of the iliac vein by abdominal aortic aneurysm may cause lower limb edema, compression of the spermatic vein may cause local varicose veins, compression of one ureter may cause hydronephrosis, pyelonephritis and renal insufficiency, and compression of branch vessels (lower limb vessels, renal artery and mesenteric artery) may cause corresponding compression symptoms.
When the thrombus attached to the wall of abdominal aortic aneurysm is dislodged, it can lead to acute lower limb arterial embolism and cause corresponding symptoms.
Common symptoms of aortic coarctation.
Chronic aortic coarctation often undergoes aneurysm, and patients present with symptoms of aortic aneurysm. The typical symptom of acute aortic coarctation is sudden onset of severe pain (knife-like or tearing pain in the chest) that may radiate to the chest or back.
Pain due to acute aortic coarctation may extend to the neck, back of the shoulder, abdomen and lower extremities with heavy sweating, pallor and palpitations as the coarctation becomes involved. Most patients have a significant increase in blood pressure due to pain, and a progressive decrease in blood pressure if the outer membrane of the entrapment ruptures and bleeds.
(I) Differentiation from acute myocardial infarction
Clinical distinction between acute aortic coarctation and acute myocardial infarction is required. The pain of acute aortic coarctation is generally more intense and longer lasting than that of acute myocardial infarction, and further differentiation requires serological and imaging examinations.
(B) Symptoms due to different ranges of entrapment involvement
When the intercalation involves the aortic valve annulus, it may lead to aortic valve insufficiency; when it involves the carotid artery or femoral artery, it may lead to the weakening or disappearance of the corresponding vascular pulsation and bilateral blood pressure asymmetry; when it involves the carotid artery or intercostal artery, it may lead to cerebral or spinal cord ischemia, causing neurological symptoms such as limb numbness, hemiparesis, coma or dysfunction, or even cerebral infarction; when it involves the abdominal aorta and its branches, it may lead to severe abdominal pain, nausea, vomiting and other acute abdominal symptoms. If the abdominal aorta and its branches are involved, it may lead to acute abdominal pain, nausea, vomiting and other acute abdominal symptoms; if the renal artery is involved, the patient may show symptoms of renal insufficiency such as hematuria and anuria; if the abdominal artery is compressed or the mesenteric artery is involved, it may cause vomiting, abdominal distension, diarrhea, black stool and other symptoms, and even intestinal ischemic necrosis.
Imaging examinations
Aortic aneurysm and aortic coarctation imaging features.
The symptoms of aortic aneurysm and aortic coarctation lack specificity, so once a patient is suspected of having these diseases, he or she must undergo imaging examinations. Common imaging tests include X-ray chest radiograph, echocardiography, carotid ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and aortography.
1.X-ray examination
X-ray examination is of great significance in the diagnosis of thoracic aortic aneurysm. Its specific symptoms are irregularity of aortic margins, enlargement of aortic shadow, widening of mediastinum or widening of esophageal aortic pressure traces. Based on the images, the physician can estimate the size, location and morphology of the lesion, and sometimes calcified spots or flaky calcified shadows are seen. Under fluoroscopy, distending pulsations of the aortic aneurysm are seen. Some patients may present with pulmonary atelectasis and pleural effusion.
2.Cardiac ultrasound and carotid ultrasound
For proximal aortic lesions, cardiac ultrasound can more accurately show the size of the aortic internal diameter, aortic coarctation lesions, the presence of attached plaque and thrombus, heart valve involvement and cardiac function. The results of cardiac ultrasound are an important reference for selecting the proximal aortic procedure.
In addition, carotid ultrasound can clarify the carotid artery involvement in patients with aortic aneurysm or aortic coarctation.
3.CT
The introduction of CT, especially multi-row spiral CT, has provided a quick and accurate means to diagnose aortic aneurysm and aortic coarctation. Generally, patients with aortic aneurysm or aortic coarctation have to undergo CT examination with enhanced scanning, which can clearly show the site, size and scope of aortic lesion, the location of aortic coarctation, aortic wall lesion and attached thrombus, as well as the relationship between aneurysm and adjacent structures (superior mesenteric artery, renal artery, retroperitoneal cavity and spine, etc.), and exclude lesions of other organs in the abdominal cavity. The diagnosis of aortic coarctation can be confirmed when CT shows “double lumen disease”.
Multi-row spiral CT can also perform three-dimensional reconstruction of the aortic lesion (Figure 2), showing its overall structure. At present, multi-row spiral CT has good image quality and three-dimensional reconstruction function, and the examination speed is fast and the patient is not restricted, so it can be used to save time for emergency patients. Therefore, the author recommends that enhanced multi-row spiral CT can be the first choice of imaging for the diagnosis of aortic aneurysm and aortic coarctation.
4.MRI
MRI examination has the same role as CT in diagnosis, and it facilitates the dynamic display of the aorta, especially the observation of the aortic endothelial tear and its false lumen. MRI is equivalent to CT and ultrasound in determining the size of the aneurysm and the involvement of the artery. However, the main drawbacks are the low image resolution, long examination time, high cost and certain restrictions on the subject (e.g., no metallic foreign bodies in the body or on the body surface), which limit its application.
5.Aortography
With the widespread use of non-invasive examinations such as multi-row spiral CT, aortography is no longer used as a common means for aortic aneurysm and aortic coarctation, but it is still often used in the interventional treatment of aortic aneurysm and aortic coarctation.
It is worth noting that coronary angiography is relatively contraindicated in patients with aortic coarctation and should be avoided to prevent life-threatening conditions.