Aneurysm of the abdominal aorta - what is it and how to treat it?

An aneurysm of the abdominal aorta is called partial local dilatation of the aortic lumen in the peritoneum, the cause which can be a congenital anomaly of the structure of the walls of the blood vessel, or their pathological changes.

This pathology is leading among all cases of aneurysmal diseases of blood vessels. Its frequency is almost 95%. In this case, the disease affects, mainly, men over 60 years of age. Female representatives are exposed to this disease much less often.

The danger of the disease is that often it is completely asymptomatic. But gradually the sizes of an aneurysm increase (annually - approximately on 10-12%). As a result, the walls of the aorta are so stretched that they can just burst at any moment. The consequence of rupturing an aneurysm is intense internal bleeding, and then - a lethal outcome of the patient.

Causes of aneurysm and damage

It is extremely important to determine the causes of the development of an aneurysmal sac, since 50-60% of all patients die from the disease. At the same time between the detection of pathology and the onset of a lethal outcome is quite a short time - only 1-2 years. The causes of deformation of the vascular wall can be inflammatory and non-inflammatory.

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With non-inflammatory origin of pathology, the cause of its development in a large number of cases is atherosclerotic disease. It is characterized by the formation of cholesterol plaques on the walls of the vessels, under the influence of which the structure of the layer lining them changes. Gradually, the tissues of the vascular wall are replaced by connective tissue structures, which makes it less elastic and more susceptible to deformation under the influence of blood pressure. The aorta can be expanded by hypertension, which has a close relationship with atherosclerotic processes.
Rarely, but, nevertheless, there is a traumatic form of an aneurysm. It arises due to closed injuries of the chest, abdomen or spine. It can be the consequence of an accident, when the victim strikes violently or rests against the belly or chest in the steering wheel. Increases the risk of developing the disease and falling from height, as well as fragmentation, knife or other injuries in the abdomen. In such circumstances, all layers of aortic tissues are damaged, resulting in the formation of a hematoma. Then there is a process of scarring the wall, and only then at the place of scar formation there may be a rupture of the aneurysmal formation.
Inflammatory. First of all, this group includes aneurysms of syphilitic etiology. Under such conditions, the inflammatory process in the vessels feeding the aorta first develops. After this, the wall of the aorta is affected, as a result of which its normal structure is disturbed. It is in the place of defeat and an aneurysmal sac is formed.
A specific inflammatory aneurysm can develop due to tuberculosis or rheumatism. In this case, the pathological process from the spine or other foci of inflammation passes to the aorta, which leads to protrusion of the arterial wall.
Nonspecific inflammatory aneurysms develop against the background of various infectious processes that have affected the human body. The pathogen penetrates the aorta along with the bloodstream, and can cause inflammation not only in it, but also in neighboring blood vessels. Such an aneurysm is called infectious-embolic. Disease-causing microorganisms can enter the abdominal aorta from the lungs, intestines, pancreas (with pancreatitis) and other organs.

Classification

Of particular importance is the anatomical gradation of aneurysms of the abdominal aorta. According to this criterion, the disease can be infrarenal (when the aneurysm is located below the branch of the renal branch arteries) and suprarenal (when the focus of the pathological process is above the renal arteries).

According to the classification of aneurysms in the form of protrusion of the aortic wall, they are:

saccular;
diffuse spindle-shaped;
exfoliating.

According to the structure of the aneurysmal wall, such formations are divided into true and false.

There is a classification of aneurysms and etiology (origin). This graduation divides the pathological process into an innate and acquired one. The second group can have non-inflammatory origin, and become a consequence of injuries, atherosclerosis, syphilis, infectious diseases, etc.

According to the clinical course, the aneurysm of the abdominal aorta is divided into uncomplicated and complicated aorta. In size, aneurysmal bags are:

small (from 3 to 5 cm);
average (from 5 to 7 cm);
large (more than 7 cm);
giant, whose diameter is 8-10 times the diameter of the infrarenal aortic region.

There is a classification of aneurysms and the prevalence, according to which there are 4 types of pathological process:

The first type is called an infrarenal aneurysm with a distal and proximal isthmus sufficient in extent.
In the second type of infrarenal aneurysm, the proximal isthmus is of sufficient length, with the pathological process spreading to the aortic bifurcation.
In the third type of infrarenal aneurysm, aortic bifurcation and iliac arteries are involved in the pathological process.
In the latter, the fourth type, we are talking about infra- and suprarenal aneurysm of the abdominal aorta.

Symptoms of an abdominal aorta aneurysm

Often, the pathology does not manifest itself, and is detected only when carrying out an x-ray, ultrasound, palpation, or laparoscopic examination of the abdominal cavity.

But sometimes the disease, nevertheless, can manifest itself by the following symptoms:

pain in the abdomen;
feeling of bursting and heaviness in the abdomen;
sensation of pulsation in the place of localization of the focus of the pathological process.

Often the source of pain is located on the left side of the abdomen. It can be mild, but sometimes it can become simply unbearable, because of which the patient has to put anesthetic injections.

Pain can be irradiated to various parts of the abdomen, in the lower back, and also into the groin area. In this regard, patients are often put false diagnoses - radiculitis, pancreatitis, renal colic, etc.

As the aneurysm grows, it begins to press on the walls of the stomach and PDC. This leads to the appearance of unpleasant symptoms, manifested:

nausea;
vomiting;
belching;
bloating and flatulence;
frequent constipation.

In some cases an aneurysm leads to a displacement of the kidney and compression of the ureter. This causes the appearance of dysuretic symptoms and the development of hematuria. When squeezing an aneurysm of veins and arteries, men experience pain in the testicles, in parallel with which the varicocele develops.

When squeezing the spinal roots increases in size aneurysm develops ishioradikulyarny symptom complex, accompanied by persistent pain in the spine, motor and sensitive disorders in the legs.

With this disease, there may be a development of chronic circulatory disorders in the vessels of the legs, which in turn causes trophic disorders and intermittent claudication.

If the aneurysm ruptures into the aortic region, the patient is exposed to intense bleeding, capable of leading to death in a matter of seconds. This pathological condition is accompanied by:

sudden attack of acute, burning pain in the abdominal region and / or lower segment of the spine;
a sharp attack of hypotension, leading to the development of collapse;
pulsating sensations in the peritoneum.

Clinical manifestations of aortic rupture of the aorta of the abdominal cavity depend on the direction of bleeding. Thus, with retroperitoneal bleeding there is a strong pain syndrome, characterized by a significant duration. If the hematoma begins to spread to the pelvic organs, the patient complains of pain in the groin, perineum, genitals, hips. Extensive hematoma damage to the internal organs is often masked by the clinical manifestations of a heart attack.

With intraperitoneal rupture of the aneurysm, a massive homeoperitoneum develops, for which the occurrence of intense pain and bloating is characteristic. In all its segments, the appearance of the Shchetkin-Blumberg symptom is noted. The method of percussion in the abdominal cavity reveals the presence of free fluid.

Along with the signs of an acute abdomen, the rupture of an aneurysmal sac is characterized by symptoms in the form of:

sudden blanching of the epidermis and mucous membranes;
a strong decline in strength;
the appearance of cold sweat;
physical and mental retardation;
frequent threadlike pulse;
severe hypotension;
decrease in the amount of daily urine released.

When the aneurysm ruptures, an arterio-venous fistula is formed in the region of the inferior vena cava. This process is accompanied by:

pain in the abdomen and lower back;
the formation of a tumor in the peritoneal cavity, over which systolo diastolic murmurs are clearly heard;
swelling of the legs;
increased heart rate and pulse;
exacerbated by attacks of dyspnea;
a pronounced decline in strength.

Gradually, heart failure develops. With the growth of her symptoms, a fatal outcome may occur.

The rupture of an aneurysmal sac into the cavity of the PDC leads to the discovery of intense gastrointestinal bleeding. In this case, the patient can have such clinical manifestations:

a sharp drop in blood pressure;
the discovery of bloody vomiting;
a strong decline in strength;
apathy.

To distinguish bleeding at rupture of an aneurysm from that at various diseases of GASTROINTESTINAL TRACT (for example, JAJ and DPC) is very difficult.

Diagnostics

If a pronounced clinical picture does not manifest, then the disease can be detected by accident, for example, with ultrasound of the abdominal cavity, conducted on a different occasion.

If there is a symptomatology characteristic of the aortic aneurysm of the abdominal cavity, a thorough examination and questioning of the patient, after which the doctor directs him to laboratory and instrumental studies. During the examination, pulsation of the wall of the abdominal cavity is determined. The patient is in a lying position.

Obligatory action - listening of an abdominal cavity by a stethoscope for revealing systolic noise in a projection of an aneurysm. During palpation, a tumor-like formation can be detected. In the area of its localization, pulsation is often determined.

From hardware diagnostic methods, patients are often assigned to:

Radiography of the abdominal cavity, which is informative when calcified calcium salts form on the aneurysmal walls. In this case, the image shows a bulging of the aortic contours, which is not normally monitored.
Angiography - a variety of X-ray studies based on the use of a special contrast agent, which is administered intravenously.
MRI and CT scan, necessary to confirm or refute the preliminary diagnosis and determine the degree of aortic lesion.
Ultrasound and DS of the aorta. This is the most common diagnostic method, which makes it possible to detect thrombi and atherosclerotic foci in the aortic region. With the help of these procedures, the blood flow in the affected area of the vessel is assessed, and the degree of its damage by the pathological process is determined.

Great importance is attached to clinical analysis: rheumatic tests, blood analysis for sugar and cholesterol, general and biochemical blood tests.

Treatment

If the diagnosis has been confirmed, the patient must be accounted for life by a phlebologist or cardiac surgeon. The only radical treatment for the disease is surgical intervention. But it can not always be carried out, because:

the procedure is very complicated, and is highly traumatic;
there are big risks of development of postoperative complications, and even death;
the operation is difficult to tolerate by elderly patients and persons who have concomitant diseases of the heart, brain or vessels that take place in severe form;
in almost 95-99% of cases with aneurysm rupture, a lethal outcome occurs;
the operation is costly.

The main task of doctors in the treatment of such a serious disease is to find the right tactics of therapy that will not harm the patient. The advice in this regard is as follows:

Aneurysms of small size (up to 5 cm), not having a tendency to increase, or increasing in size by 0.3 cm in six months, are not operated. In this case, the dynamics of progression of the pathology is observed.
Large aneurysm formations (from 6 to 10 cm and more), which are rapidly increasing within 6 months, should be immediately removed. Such formations threaten to rupture with all the ensuing consequences.
Aneurysmal expansions localizing above the renal arteries should be operated without the presence of strict indications (that is, regardless of the propensity to increase, or without the presence of such).
Elderly patients older than 70 years of operation are dangerous for any location and size of an aneurysm. Especially it concerns patients who have coexisting diseases characterized by a heavy course. In this case, preference is given to conservative-observant therapeutic tactics.

Radical operative method of treatment of an aneurysm is its removal with the subsequent replacement of the excised site with a special homotransplant. Intervention is performed through a laparotomy incision. If necessary, iliac arteries can also be affected. Under such conditions, bifurcation aorto-iliac prosthesis is performed. With open surgery, the mortality rate ranges from 3.8 to 8.2%.

Excision of an aneurysm is strictly contraindicated when:

recently suffered heart attack (less than 30 days);
recent stroke (less than 1.5 months);
severe cardiopulmonary insufficiency;
a vast occlusive lesion of the iliac and femoral arteries.

If there is an aneurysm rupture or rupture, the operation is carried out for vital indications.

To date, a low-traumatic method of radical treatment of the disease is endoprosthetics of the aorta using the stent-graft. The operation is performed in the X-ray operating room.

In the region of the femoral artery, a small incision is made through which the implant is inserted. Control over the course of the procedure is carried out using a special X-ray television. The installation of the stent-graft provides isolation of the aneurysm, which helps to significantly reduce the risk of its rupture. Parallel to this, a new channel for blood flow is created.

Despite all the advantages of such an operation, sometimes some complications are possible. In particular, this concerns the possibility of distal migration of endovascular stents.

Prognosis and prevention

In the absence of treatment of pathology, the predictions are very unfavorable. This is due to the high risk of developing complications that can lead to death.

With a small aneurysmal sac, the annual mortality is less than 5%. With a size of more than 9 cm - 75%.
Lethal outcome after the detection of pathology with medium and large aneurysm during the first 2 years is 50-60%.
If the aneurysmal sac is ruptured, the lethality is 100%. After providing medical care 2 months after the operation - 90%.
With a timely operation, the forecasts are favorable. Survival in the next 5 years after the intervention is almost 65-70%.

For the prevention of the disease or its timely detection of patients at risk, it is necessary to carry out ultrasound diagnostics every 6-12 months, and undergo examinations with doctors. Huge importance is played by the refusal of smoking and alcohol, maintaining a healthy life style and complete cure for systemic, inflammatory or infectious pathologies.