Thoracic Aortic Aneurysm: Diagnosis and Treatment
Author Ольга Кияница
Thoracic aortic aneurysm (AGOA) is a sacciform enlargement, which is defined at the level of the thoracic aorta. Pathological formation is often a “balloon” located above the diaphragm. Failure to diagnose or treat a disease can be fatal due to the dissection of the aneurysm, which leads to almost instant death.
Thoracic aneurysms are less common than abdominal aortic aneurysms.However, syphilitic aneurysm most often affects the thoracic aorta.
In the diagnosis of AGOA, various research methods are used, starting with electrocardiography and ending with magnetic resonance imaging. There are also screening methods for determining the pathology, which allow to establish the risk group of a person. If necessary, surgical treatment is carried out to help prevent aneurysm rupture.
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Description of aortic aneurysm
The main causes of death caused by thoracic aortic aneurysms are dissection and rupture of the vessel. After rupture, mortality is 50-80%. Most deaths in patients with Marfan syndrome are the result of aortic disease.
Causes of AGOA
There are several reasons that contribute to the development of the disease.
- Aneurysms in patients younger than 40 years usually affect the ascending aorta because of the weakening of the aortic wall against the background of the growth of connective tissue. Diseases often complicated by AGOA: Marfan and Ehler-Danlos syndromes and congenital bicuspid aortic valve disease.
- In younger patients, aortic aneurysms of the thoracoabdominal area (that is, the thoracic and abdominal parts at the same time) may develop after dissection of the vessel.
- In some cases, aneurysm causes blunt trauma.
The diagnosis of aneurysm of the thoracic aorta is usually made in patients aged 60 to 70 years.
Hypertension and smoking are the most important predisposing factors. Also recently, the importance of heredity is increasingly recognized.
Approximately 10% of patients suffer from this disease other family members, including aortic aneurysm. It is also important to note that in individuals with aneurysms in other parts of the body, the likelihood of developing aneurysm of the thoracic aorta increases.
Each year in the United States, about 45,000 people die from diseases of the aorta and its branches. Acute aortic dissection, a life-threatening condition due to aortic wall rupture, is determined annually from 5% to 10% per million population. Most often, the pathology develops in men aged 50 to 70 years. In women, the peak of occurrence occurs at an age younger than 40 years, with almost half of the aneurysm occur during pregnancy. Most of these deaths occur as a result of aneurysm complications.
Aneurysm of the thoracic aorta is determined by the diameter of the vessel, which exceeds the following indicators:
- 4.5 cm according to data in the United States. [1 - Bret P Nelson (2015-10-01). "Thoracic Aneurysm"]
- 4.0 cm according to data in South Korea [2 - Cho, In-Jeong; Jang, Sung-Yeol; Chang, Hyuk-Jae; Shin, Sanghoon;Shim, Chi Young; Hong, Geu-Ru; Chung, Namsik (2014). "Aortic Aneurysm Screening in a High-Risk Population: A Non-Contrast Companion Tutorial." Korean Circulation Journal. 44 (3): 162.]
The diameter of the aorta in the region of 3.5 cm is already considered extended. However, the average values vary depending on the age and size of the control population, as well as on the individual characteristics of the person.
The clinical picture is important in the diagnosis of aneurysm of the thoracic aorta. Moreover, in most cases, AGOA develops asymptomatically or with minimal manifestations.
In some cases, there is an erosive or compressive effect of the pathological mass on mediastinal structures. This can lead to clinical exacerbation of the disease with the appearance of a number of symptoms:
- shortness of breath;
- chest pains.
Compression of the superior vena cava leads to the development of manifestations similar to the syndrome of the superior vena cava: dilatation of the veins of the neck and chest, fullness and swelling of the face, cyanosis.
Aneurysm rupture is manifested by the sudden appearance of chest pain, a sharp drop in blood pressure and shock .
The guidelines were published in March 2010 for the early detection of thoracic aortic aneurysms. In particular, the following recommendations are indicated:
- Relatives of the first line in people with aneurysm of the thoracic aorta or vessel dissection should be screened for an image of the aorta to detect asymptomatic pathology.
- People with symptoms that indicate a separation of the thoracic aorta should be regularly examined by a doctor in order to establish an exacerbation of the disease.
- People diagnosed with Marfan syndrome should immediately undergo echocardiography to measure aortic diameter, and then after 6 months a second test is performed for aortic dilation.
Instrumental research methods
In the case of an unexpressed clinical picture or in order to clarify the diagnosis, instrumental diagnostics may be prescribed, as represented by the following types of studies:
- CT scan
- Magnetic resonance imaging.
Echocardiography (echoCG) - works on the basis of sound waves, which, reflected from various structures of the body, show an image in real time. This method is especially good for assessing the work of the heart and determining the pathology of the ascending part of the aorta. If there are suspicions of the development of AGOA in the patient's relatives, an echoCG is necessarily performed.
Transesophageal echocardiography can be used to diagnose aortic aneurysm. For its implementation, a special probe device is inserted into the esophagus, which is capable of generating sound waves and transmitting images to a monitor. This study is unpleasant, but extremely effective in terms of determining AGOA.
Radiography (RG) - often performed to diagnose other diseases, such as pathologies of the pulmonary system. In such cases, the first signs of thoracic aortic aneurysm can be detected.
Computed tomography (CT) is a very reliable method of research, which is carried out without any subjective discomfort in the patient. It provides for the evaluation of high quality images, which determine the shape and size of the aorta as accurately as possible.
Performing CT involves placing the patient on a special table, which is located inside the x-ray machine, called a CT scanner. It is important not to make any movements, then the doctor will be able to take the required number of transverse images. For greater efficiency, the patient is offered to introduce a contrast agent, which makes the vessels more distinct. This research method is called computer angiography.
During CT, the patient is exposed to radiation and this is the main disadvantage of this research method. If a patient often has to undergo a follow-up diagnosis (for example, with Marfan syndrome), then radiation can be harmful to health.Given this moment, the developers of new computer tomographs are trying to minimize the negative impact of a working device.
Magnetic resonance imaging (MRI) - in the course of this diagnosis, a magnetic field and radio waves are used, so the person also receives a dose of radiation, although somewhat less than with CT. MRI is a painless way to diagnose. To create a series of shots, the patient is placed on a table that slowly goes through a magnetic tunnel.
MRI is less dangerous in terms of human exposure to radiation, therefore it is suitable for frequent patient examinations.Also, as in the case of CT, a special substance may be injected to contrast the vessels. Such a study is called magnetic resonance angiography.
The size of the aortic aneurysm is crucial in determining treatment tactics. Aneurysm of the thoracic aorta more than 4.5 cm is usually defined as aneurysmal, while education with a size of more than 6 cm is an indication for treatment, which can be carried out either endovascular or surgical. The first method is more often used to treat pathology in the descending part of the aorta.
Indications for surgery mainly depend on the size of the aneurysm. As a rule, the greater the pathological formation, the more extensive the surgical intervention. For small aneurysms, endoscopic treatment is most often used.
At the stage of monitoring, the doctor may prescribe additional methods of research such as echocardiography, computed tomography and magnetic resonance imaging. Especially the observation process is relevant for small aneurysms. In such cases, the patient may be recommended treatment of diseases that may affect the progression of AGOA. Additionally prescribed medications that can support overall health:
- Antihypertensive drugs - are extremely necessary with frequent high blood pressure, as this directly leads to rupture of the aneurysm.
- Statins are necessary for the treatment of atherosclerosis, which is based on an excess of cholesterol in the blood. If the vascular condition is bad, the disease also increases the risk of dissection or rupture of the aneurysm.
- Antiarrhythmic drugs - necessary for irregular and abnormal heart function. Especially these drugs need to be taken by patients for atrial fibrillation or ventricular tachycardia. Most often, beta-blockers or calcium channel blockers are used for these purposes.
This method of exposure is recommended for large aneurysms, about 5-6 cm in diameter. If the pathological formation is small, the operation is performed in cases where the risk of aortic dissection is very high. This is observed in the presence of major diseases such as congenital bicuspid aortic valve, Marfan syndrome, familial predisposition.
In most cases, open-heart surgery is performed, as it is carried out with an extensive amount of work. With uncomplicated pathology, doctors may recommend endoscopic intervention using a catheter. After this type of operation, the patient is more likely to recover and return to a normal lifestyle more quickly.
- Open heart surgery
It is based on the removal of the affected area of the aorta and the establishment of a graft by the type of artificial tube.For access is done dissection of the chest or abdominal cavity. After the operation, the recovery process begins, which takes a month or more.
In various diseases of the connective tissue, including Marfan syndrome, not only is the removal of the affected area and the installation of a synthetic tube, but also the replacement of the aortic root. Additionally, the aortic valve can be removed, in place of which a mechanical or biological analogue is placed.
- Endovascular effects
It is considered a minimally invasive surgical procedure that is performed through a small incision in the femoral artery. A catheter is inserted into the vessel, at the end of which a graft is attached, after which the whole structure is delivered to the site of aortic damage.
The graft is a tube of woven material and coated with a metal mesh. After removal of the aneurysm and installation of the replacement is carried out its fastening with pins or small hooks .
This method of treatment may not be involved in all cases. If there are prerequisites for the formation of AGOA, you can ask your doctor about the indications for endoscopic treatment.
- Other operations
In some patients, in addition to the aortic aneurysm, valvular defects or other heart diseases are observed. In such cases, their surgical treatment can also be carried out in order to prevent the progression of AGOA based on them.Depending on the type of disease of the valves, they can be reconstructed or replaced. In the future, after surgery may require periodic monitoring of health.
- Emergency operation
Needed in cases where there was a rupture of the aneurysm. The restoration of the vessel in such cases is possible, but it takes more time, and the risk of complications, including death, is higher. Therefore, doctors often do not want to deal with a ruptured aneurysm, preferring to carry out timely diagnosis before a critical condition occurs. If the operation was nevertheless carried out, the patient should undergo lifelong monitoring, which, if necessary, can be supplemented with preventive surgery.
Lifestyle correction and home remedies
It is necessary to adhere to a certain lifestyle both after surgery and during the observation of the state of health. In particular, you should try to follow the following recommendations:
- Adhere to moderate exercise and physical activity. During hard work, blood pressure can rise, which in turn increases the risk of aneurysm rupture. In addition, a moderate load can be useful for a person even with AGOA, so you should ask your doctor about acceptable exercises or possible work that will not harm your health.
- Emotional stress should be avoided . If there is even a small aneurysm, any kind of stress should be avoided. With this disease, even a slight stressful situation can cause a serious complication. Also, the practice of physical activity should be promptly reported to the attending doctor, who, if necessary, will adjust the dose of the antihypertensive drug.
It is important to understand that there are no aortic aneurysm pills. This is an exclusively surgical pathology, but to maintain the general condition and reduce the risks of exposure to AGOA, antihypertensive drugs, statins, etc. can be prescribed.
Keeping the vessels healthy helps to prevent not only the appearance of AGOA and aneurysm rupture, but also strengthen the state of the cardiovascular system. In particular, the following recommendations should be followed:
- It is necessary to give up smoking, both passive and active.
- It is important to regularly check the level of blood pressure in order to take timely therapeutic measures.
- It is useful to conduct physical training, the intensity of which corresponds to the medical recommendations.
- It is necessary to eat right, for which they reduce the level of consumed fat and cholesterol.
The presence of risk factors involves the use of drugs that are prescribed by the attending physician. Screening tests in the form of echocardiography, etc. may also be involved.
Patients on an aortic aneurysm may experience constant stress due to their condition. But with various emotional outbursts, blood pressure can increase, which is very dangerous with AGOA. Therefore, it is better to prudently avoid the expressed experiences. In some cases, appropriate anti-depressant medications prescribed by a doctor may be used.
Hereditary diseases such as Marfan syndrome, causing aortic aneurysm, can cause such emotions as fear, anger, depression, and even despair. Then it is important not to be alone with yourself, but to immediately seek help from a specialist. As a rule, psychologists help to cope with emotional discomfort.
If there are support groups in the city or area where you have to live, then communication with other people facing an aortic aneurysm can significantly improve your psychological state.
Preparing to see a doctor
Consultation with a family doctor may be necessary for those people who are worried about the presence of aneurysm or have a burdened family history. In such cases, early detection of an aneurysm may allow for a more effective, less complex treatment.
A visit to a doctor often passes very quickly, so many do not manage to fully know everything about their condition. To help cope with this problem can be a simple list with pre-composed questions. In particular, you can pay attention to the doctor at the following points:
- Is there a significant cause of symptoms?
- What research will need to be done to clarify the presence or absence of aneurysm?
- Do I need to undergo any procedures that will strengthen the state of the cardiovascular system?
- What physical activity corresponds to the current state?
- Is it necessary to change the diet?
- How often do screening tests have to be done?
- In the presence of comorbidities can treatment be carried out so as to affect all the existing pathologies?
- Is there an alternative medicine from the popular methods of treatment that could replace the pharmacological drug?
- Should I notify my family and friends about the disease?
- What websites and literature can be used to get familiar with the disease and get more information?
This is just a sample list of questions that you can ask the doctor at the reception. If necessary, you should not hesitate to ask your exciting questions, because it will make you feel more confident, which is important for psychological comfort.
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