Right aortic arch: what is it, causes, development options, diagnosis, treatment, when is it dangerous? Development of the aorta and pulmonary trunk. What is the difference between thoracic and abdominal aortic aneurysms

What is a vascular aneurysm?

Aneurysm - local ( saccular) protrusion of the wall or diffuse ( circular, fusiform) an increase in the lumen of the vessel several times as a result of a violation of the structure during inflammatory processes, mechanical damage to the vessel, congenital and acquired pathologies ( Marfan syndrome, atherosclerosis, syphilis).

Aneurysms thoracic aorta classified depending on its localization, form, etiology ( causes), clinical course and other factors. When formulating a diagnosis, a classification is used for a more detailed description of the pathology.

Due to the disease of the aortic aneurysm are:

inflammatory etiology ( causes) - with syphilis, nonspecific aortoarteritis ( Takayasu's disease is an autoimmune inflammatory disease of the aorta and its branches.), fungal infection and others;
non-inflammatory etiology- with atherosclerosis, trauma, arterial hypertension;
congenital- with Marfan's syndrome ( hereditary connective tissue disease), coarctations ( congenital local narrowing of the lumen) aorta, hypoplasia ( underdevelopment of a tissue or organ) and others.

An aortic aneurysm can be localized in any area - from the exit of the aorta from the left ventricle of the heart to its transition to the abdominal part of the aorta.

Depending on the localization, there are:

aneurysm of the sinuses of the aorta sinuses of Valsalva);
aneurysm of the sinuses of the aorta sinuses of Valsalva) and the ascending aorta ( cardio aorta);
aneurysm of the ascending aorta cardio aorta);
aneurysm of the ascending aorta and its arch;
aneurysm of the aortic arch;
aneurysm of the ascending aorta, arch and descending aorta;
aneurysm of the arch and descending thoracic aorta;
aneurysm of the descending aorta thoracoabdominal aneurysm).

The type of aneurysm is:

True aneurysms ( aneurysma verum). With a true aneurysm, the expansion of the aortic lumen occurs due to the thinning and protrusion of all three layers of the wall with pathological changes in the structure. The aneurysm has a smooth expansion and is 50% or more larger than the aortic diameter.
Pseudoaneurysms or false aneurysms ( aneurysma spurium). False aneurysms are not an expansion of the lumen of the vessel, but only create its "appearance". Occur when the inner layer of the aortic wall is damaged. As a result, blood flows out of the lumen of the vessel through the defect and accumulates in a capsule of connective tissue called a pulsating hematoma. It looks like a unilateral protrusion of the aortic wall.

The size of an aneurysm is:

small- 4 - 5 centimeters in diameter;
medium- 5 - 7 centimeters in diameter;
large- more than 7 centimeters.

The form is divided into:

fusiform ( fusiform) aneurysms- the aortic area is evenly expanded along its entire circumference;
saccular ( saccular) aneurysms- protrusion of the aortic wall in the form of a sac, not exceeding half of its diameter in size;
dissecting aneurysms ( aneurysma dissecans) - characterized by blood flow between the internal ( tunica intima) and average ( tunica media) layers of the wall through the damaged inner shell, followed by delamination of the vessel.

Dissecting aneurysm is a very dangerous pathology. It can be an independent pathology or a complication of a true aneurysm. This process propagates along the length of the vessel and can lead to rupture of the outer layer of the wall ( tunica externa) within hours of aortic dissection. Rupture of an aortic aneurysm almost always leads to the death of the patient, regardless of timely surgical intervention. There are separate classifications for dissecting aneurysms of the thoracic aorta.

According to DeBakey's classification, aortic dissection is distinguished:

I type– damage to the inner layer ( tunica intima) at the level of the ascending aorta ( cardio aorta) with stratification of the wall to the level of the chest and abdominal aorta descending department;
II type- damage to the intima and stratification of the vessel wall in the ascending section ( cardio aorta) or in the aortic arch, without involvement of the descending aorta in the process;
III type- intimal tear and wall dissection affect the descending thoracic aorta, sometimes with the spread of the process in the abdominal aorta or retrograde in the arch and ascending aorta.

According to the Stanford classification, dissecting aortic aneurysms are:

type A - proximal ( near) - dissection of the ascending aorta cardio aorta);
type B - distal ( remote) - dissection of the aortic arch and descending aorta.

Downstream, dissecting aneurysms are:

sharp- from several hours to several days ( 12 o'Clock in the noon) from the onset of the disease;
subacute- several days to several weeks 3 – 4 weeks) from the onset of the disease;
chronic- a few months from the onset of the disease.

Causes of an aortic aneurysm

Many diseases, injuries and age-related changes can lead to a change in the structure of the aortic wall and its aneurysm. Etiological ( causal) factors and diseases are divided into two groups - congenital and acquired. Acquired diseases, in turn, are divided into diseases of an inflammatory and non-inflammatory nature.

TO congenital diseases relate:

Marfan syndrome. A genetic hereditary disease of the connective tissue, in which anomalies of the eyes, bones, cardiovascular and skeletal systems occur. Manifested by deformity of the chest "chicken breast", sunken breast), abnormally long fingers ( arachnodactyly, "spider fingers"), hypermobility ( pathological increased mobility and flexibility) joints, long limbs, farsightedness or myopia, and many others. Damage to the cardiovascular system is manifested by an aortic aneurysm ( more ascendant), rupture of the aorta, insufficiency of the heart valves, which in 90% of cases leads to death.
Ehlers-Danlos syndrome type IV ( vascular type). rare genetic systemic disease connective tissue caused by impaired collagen synthesis ( protein - the basis of connective tissue). There are several types of the disease that differ in symptoms and prevalence - vascular type, classical type, hypermobility type and others. Vascular type occurs in 1 person per 100,000 population. The disease manifests itself with bruising, hypermobility of the fingers and toes, pallor and thinning of the skin. As well as the fragility of the walls of blood vessels, which leads to aortic aneurysm and subsequently its rupture.
Lois-Dietz syndrome. An inherited genetic disease that most often affects the cardiovascular and skeletal system. Pathology is manifested by a triad - splitting of the sky ( cleft palate) or palatine uvula, widely spaced eyes ( hypertelorism), aortic aneurysms. Other symptoms include scoliosis ( spinal curvature), clubfoot ( deformity of the feet, in which they are turned inward), abnormal connection of the brain and spinal cord and others. Symptoms of damage to the cardiovascular system are similar to those of Marfan's disease. But they are characterized by the development of aneurysms not only of the aorta, but also of small arteries, as well as earlier dissection and rupture of the aorta.
Shereshevsky-Turner syndrome. Refers to chromosomal pathologies. With this syndrome, one X chromosome of a pair of XX or XY chromosomes is missing. More often, the pathology occurs in the female. It is characterized by short stature, malformation, barrel chest deformity, amenorrhea ( lack of a menstrual cycle), underdevelopment of internal and external genital organs, infertility. About 75% of patients with Turner syndrome have pathologies of the cardiovascular system. Aortic aneurysm and aortic dissection are often diagnosed. Aortic dissection is 100 times more common in women with Turner syndrome than in other women. These are usually people in their 30s and 40s.
Syndrome of arterial tortuosity. A rare genetic disease that is transmitted in an autosomal recessive manner, that is, when both parents are carriers of the defective gene. Vessels are affected - tortuosity, lengthening, narrowing appears ( stenosis), aneurysm of the arteries, in particular the aorta. The connective tissue of the skin is affected ( excessive stretching of the skin), skeleton ( chest deformity, pathological excessive joint mobility), facial features change ( face lengthening, underdevelopment upper jaw, narrowing of the palpebral fissure). About 40% of patients die before the age of 5 years.
Syndrome combining aneurysm and osteoarthritis. An inherited disorder that causes joint abnormalities, aneurysms, and aortic dissection. It accounts for 2% of all hereditary diseases of the aorta. The patient has osteoarthritis - damage to the cartilage tissue of the surface of the joints. As well as dissecting osteochondritis or Koenig's disease - separation of part of the cartilage from the bone and displacement into the joint cavity. There is excessive tortuosity of the vessel, aneurysms and dissection of the aorta in all its departments.
Coarctation of the aorta. It is a congenital defect of the aorta, which is manifested by partial or complete narrowing of its lumen. The main symptoms are shortness of breath, weakness, pain in the region of the heart, a more developed upper half of the body, cold lower extremities, and others. A complication of coarctation is an aneurysm ( protrusion of the walls) and bundle ( exfoliation of the inner shell - intima) aorta.

Acquired diseases of inflammatory etiology include:

Takayasu syndrome ( nonspecific aortoarteritis). This chronic inflammation walls of the aorta and its branches, followed by their narrowing ( stenosis). This syndrome can occur under other names - Takayasu's disease, nonspecific aortoarteritis, Takayasu's arteritis, aortic arch syndrome. The nature of the disease is autoimmune ( immunity attacks the body's own cells), but in Lately more relevant is the hypothesis of a genetic predisposition to the disease. In Takayasu's syndrome, the aortic arch is more commonly affected. During inflammation, the inner surface of the vessel is damaged, and the inner and middle layers of the vessel thicken. There is a destruction of the middle membrane and its replacement with connective tissue with the appearance of granulomas ( connective tissue nodules). This leads to damage to the aortic wall in the form of stretching, protrusion and thinning.
Kawasaki syndrome. A rare inflammatory disease of the arteries of various calibers. The disease often manifests itself in children aged from several months to five years. The disease develops when exposed to bacteria and viruses against the background of a genetic predisposition. Kawasaki syndrome is manifested by fever, swollen lymph nodes, loose stools, vomiting, pain in the heart and joint pain, skin rashes, inflammation of the outer shell of the eyes ( conjunctivitis), reddening of the mouth and throat ( enanthem) and other symptoms. One of the complications of this disease is an aortic aneurysm against the background of damage to the vessel wall by the inflammatory process.
Adamantiadis-Behçet disease. The disease belongs to the group of systemic vasculitis ( inflammatory process in the walls of blood vessels). The cause of the disease is viral and bacterial infections, toxins and autoimmune reactions. An important role is played by heredity. Patients develop ulcers in the genital area, oral mucosa, inflammation of the joints ( arthritis), inflammation of the mucous membrane and vascular membrane of the eye, nausea, diarrhea and others. Vascular lesions present with stenosis narrowing of the lumen), thrombophlebitis ( thrombosis and vascular inflammation) and aortic aneurysm.
Specific and nonspecific aortitis. Aortitis is an inflammation of a separate layer or the entire thickness of the aortic wall, as a result of which the walls become thinner, stretched and perforated. This leads to a bulge in the aortic wall - an aneurysm. Specific aortitis develops with certain diseases. These include syphilis venereal disease), tuberculosis ( infectious disease of the lungs, bones), rheumatoid arthritis ( inflammation of the joints). Nonspecific aortitis appears after infectious ( osteomyelitis, sepsis, bacterial endocarditis), fungal and allergic diseases.
Gsell-Erdheim syndrome ( idiopathic cystic median necrosis of the aorta). Rare disease of unknown etiology reasons for the appearance), in which the elastic skeleton of the middle shell is affected ( tunica media) walls of the aorta. In the middle shell, pathological changes occur, leading to tissue death - necrosis. Such a wall defect leads to dissection of the aorta in a limited area or throughout its length. Often the disease is complicated by aortic rupture with localization above the aortic valves, in the aortic arch, in the area before the aortic bifurcation. The disease is more common in young and middle-aged males ( 40 - 60 years old).

Acquired diseases of non-inflammatory etiology include:

Atherosclerosis. Atherosclerosis is the main cause of aortic aneurysm. It is a chronic disease manifested by thickening of the walls of the vessel and narrowing of its lumen, which leads to disruption of the blood supply to the organs. On the inner wall of the aorta, calcium, cholesterol and other fats are deposited in the form of plaque and plaques. The walls lose their elasticity and become brittle and brittle. An aneurysm appears in the weakest and most stressed place in the aorta.
Arterial hypertension. Hypertension is a persistent increase in blood pressure ( above 140/90 millimeters of mercury). With an increase in blood pressure, the load on the walls of the vessel increases. A high risk of aortic aneurysm formation appears with prolonged arterial hypertension against the background of atherosclerosis, syphilis, Marfan's syndrome and other diseases in which there are already defects in the vessel wall.
Injuries. Chest injuries are dangerous because the consequences can appear much later. A thoracic aortic aneurysm can develop up to twenty years after injury. On impact to the chest area usually in a head-on collision in a car accident) various forces act on the relatively immobile parts of the aorta. This leads to displacement, compression of the vessel, an increase in blood pressure. As a result, the integrity of the aortic wall is damaged, which gradually progresses to an aneurysm.
iatrogeny. Iatrogenicity is the appearance of pathological processes in a patient, unintentionally caused by the manipulations of medical personnel. In the case of the aorta, these may be various diagnostic procedures or surgical interventions. Injury to the aortic wall from these procedures may slowly progress to aneurysm formation. The risk is especially high in people with arterial hypertension, atherosclerosis and other diseases that cause pathological changes in the aortic wall.

The following are at increased risk of developing an aortic aneurysm:

people with a hereditary predisposition;
men;
persons over 60;
hypertension ( patients with elevated blood pressure );
obese people;
patients with diabetes;
smokers;
patients with a history of chest trauma medical history).

Symptoms of an aortic aneurysm

Symptoms of an aortic aneurysm directly depend on its location, size and rate of progression. This is due to the fact that the aorta borders on various organs, which, when compressed, give a different clinical picture. The larger the aneurysm, the more severe the symptoms. With the rapid progression of the pathology anatomical position and organ function will be severely impaired. With the slow progression of the aneurysm, the body begins to adapt to the disease to some extent. Symptoms will appear gradually and do not disturb the patient much.
In this case, the aneurysm can be diagnosed at a late stage. Often, an aortic aneurysm in the final stage breaks into an adjacent hollow organ, chest or abdominal cavity.

Depending on the location of the pathology of the aorta, there are:

symptoms of an aneurysm of the sinuses of the aorta;
symptoms of an aneurysm of the ascending aorta;
symptoms of an aneurysm of the aortic arch;
symptoms of an aneurysm of the descending aorta;
symptoms of an aneurysm of the thoracoabdominal aorta.

Dissecting aortic aneurysm deserves special attention, as it can reach enormous sizes in a fairly short period of time.

Symptoms of an aortic sinus aneurysm

Damage to the sinuses of the aorta leads to insufficiency of the aortic valves or narrowing of the lumen of the coronary arteries that supply the heart. These changes lead to symptoms. Aortic valve insufficiency is manifested by its inability to prevent the backflow of blood from the aorta into the left ventricle of the heart during diastole ( relaxation of the muscles of the ventricles of the heart). This is expressed by an accelerated heartbeat, shortness of breath, pain in the heart, dizziness, short-term loss of consciousness. Stenosis ( constriction) coronary arteries can lead to heart failure, ischemic disease ( decrease in blood circulation in a certain part of the body) heart, myocardial infarction.

A small aneurysm usually does not show up. Symptoms appear only if it breaks into neighboring organs. Often an aneurysm ruptures into the pulmonary trunk, a large blood vessel that runs from the right ventricle of the heart to the lungs. This is manifested by retrosternal pain, rapidly increasing shortness of breath, cyanosis ( cyanosis of the skin), liver enlargement, edema, progressive left ventricular and right ventricular failure. Similar clinical picture occurs when an aortic aneurysm ruptures into the right side of the heart. Such complications lead to the rapid death of the patient.

Large aneurysms compress neighboring organs and vessels. With compression of the pulmonary trunk, right atrium and right ventricle, subacute right ventricular failure develops. It is manifested by swelling of the veins of the neck, enlargement of the liver and the development of edema of the lower extremities. The rapid progression of compression of the pulmonary trunk can lead to the sudden death of the patient. In some cases, the aneurysm compresses the superior vena cava with the appearance of the so-called Stokes' collar - swelling of the neck and head, swelling of the upper limbs and shoulder blades.

Symptoms of an aneurysm of the ascending aorta

An aneurysm of the ascending aorta differs in that it does not lead to compression of organs and vessels and reaches a fairly large size. With this type of aneurysm, the patient may complain of dull retrosternal pain, reflex dyspnea, and in some cases atrophy ( exhaustion, decrease) ribs and sternum with protrusion of the chest area. With compression of the superior vena cava - swelling of the head and neck, hands.

When an aneurysm ruptures into the superior vena cava, superior vena cava syndrome occurs. Syndrome of cyanosis ( cyanosis) skin, swelling of the face and neck, expansion of superficial veins on the face, neck, upper limbs. Some patients may experience cough, swallowing disorders, chest pain, esophageal and nosebleeds. Symptoms are aggravated in the supine position, so patients take forced sex sitting position.

Symptoms of an aneurysm of the aortic arch

An aneurysm of the aortic arch that grows in size compresses the trachea, bronchi and nerves, which is manifested by a variety of symptoms.

With compression of the bronchi, trachea, lungs, shortness of breath appears ( frequent, labored breathing), which is more pronounced during inspiration. Hemoptysis may also occur, which usually precedes an aneurysm rupture. In severe cases, stridor breathing, noisy wheezing, may occur. When the aneurysm is located in the terminal part of the aortic arch, compression of the left bronchus occurs. The left bronchus is narrower and longer, so when it is compressed, air will not enter the lung. This may lead to a decline atelectasis) lung and the absence of gas exchange in it. This condition is manifested by pain in the region of the collapsed lung, cyanosis of the skin, shortness of breath, increased heart rate and arterial hypotension ( low blood pressure).

With compression of the left lower laryngeal nerve ( most often affected by the right inferior laryngeal nerve) the timbre of the voice changes, coughing and suffocation appear ( more often on inspiration). When a venous aneurysm is compressed, swelling and cyanosis appear ( cyanosis) face, swelling of the veins of the neck.

An aneurysm of the aortic arch may be complicated by a breakthrough into the esophagus or trachea. First there is hemoptysis, scanty vomiting of blood, and then profuse bleeding.

Symptoms of an aneurysm of the descending aorta

The anatomical location of the descending aortic aneurysm leads to compression of the nerve roots, thoracic vertebral bodies, left lung, and esophagus.

With pressure from the aneurysm nerve roots the patient develops severe and excruciating pain in the relevant departments, which cannot be treated with painkillers. The bodies of the thoracic vertebrae can be deformed and destroyed when constant pressure protrusion of the aorta. In severe cases, this can lead to loss arbitrary movements lower limbs.

lung collapse, pulmonary hemorrhage, development of pneumonia ( pneumonia) - all this is the result of compression of the lung by an aortic aneurysm.

When an aneurysm ruptures in lung tissue, bronchus, pleural cavity ( the space between the lung and its shell) appear hemoptysis, shortness of breath, cyanosis of the skin, accumulation of blood in the pleural cavity.

Symptoms of an aneurysm of the thoracoabdominal aorta

Aneurysm of the thoracoabdominal region is rare. With this arrangement of the pathology, the esophagus, stomach, and large blood vessels are affected. The patient will complain of swallowing disorders, frequent belching, pain in the stomach, vomiting, and weight loss.

In case of compression of blood vessels ( celiac trunk, superior mesenteric artery ) collaterals are formed - lateral bypass vessels that provide normal blood supply to organs. Therefore, the internal organs will not suffer from a lack of oxygen and nutrients but the patient will experience excruciating pressing pains in the abdomen ( ventral toad). At big size aneurysms compress the renal arteries, which can lead to a persistent increase in blood pressure.

Symptoms of a dissecting aortic aneurysm

Symptoms of a dissecting aortic aneurysm depend on the location, extent, and size of the pathology. A dissecting aortic aneurysm may present with extensive hematoma ( accumulation of blood), a breakthrough of the aneurysm into the lumen of the vessel or into the surrounding space. There is a rupture of the aorta without dissection of the wall.

Dissecting aneurysm appears suddenly and mimics the symptoms of neurological, cardiovascular and urological diseases. There is a sharp, unbearable, growing pain along the course of aortic dissection, which spreads to various areas ( along the spine, behind the sternum, between the shoulder blades, in the lower back and others). The patient's blood pressure first rises, and then drops sharply. There is asymmetry of the pulse on the upper and lower extremities, severe weakness, cyanosis of the skin, excessive sweating. With a large size of a dissecting aneurysm, compression of the nerve roots, blood vessels, and neighboring organs occurs.

This appears:

ischemia ( decreased blood supply) myocardium- pain, burning sensation in the region of the heart;
ischemia of the brain or spinal cord- impaired consciousness in the form of fainting or coma, loss of sensation or movement in the lower extremities;
compression of the mediastinal organs ( with dissecting aneurysm of the ascending aorta) - hoarseness, shortness of breath, superior vena cava syndrome and others;
ischemia and compression of the abdominal organs ( dissecting aneurysm of the descending aorta) - acute renal failure, hypertension, ischemia of the digestive system and others.

When a dissecting aortic aneurysm ruptures, the patient's condition deteriorates sharply. There is marked weakness, loss of consciousness, pulse deficit ( difference between heart rate and peripheral pulse). As well as a significant decrease in blood pressure, severe pain in the area of rupture of the aortic aneurysm, impaired breathing and heartbeat.

Complications of an aortic aneurysm

The aorta is the largest vessel in the human body that carries blood away from the heart. Large arteries branch off from the aorta, supplying all organs. Therefore, the pathology of the aorta and its functional insufficiency leads to damage to other organs due to lack of oxygen and nutrients.

Complications of an aneurysm of the thoracic aorta are:

heart, lung, kidney failure;
aortic rupture;
dissection of the aortic wall;
thrombus formation.

According to statistics, up to 38% of patients die from complications of thoracic aortic aneurysm within 3 years after diagnosis, and up to 58% of patients die within 5 years.

The main complications leading to death are:

aneurysm rupture - 40% of deaths;
heart failure - 35% of deaths;
pulmonary insufficiency - 15 - 25% of deaths.

Diagnosis of an aortic aneurysm

Diagnosis of an aortic aneurysm begins with the collection of an anamnesis - the history of the disease. The patient is asked in detail about complaints, the period of manifestation of symptoms and the duration of their course. A family history is also taken. The doctor asks about the diseases of the next of kin. Much attention is paid to genetic diseases - Marfan's syndrome, Turner's syndrome, Lois-Dietz syndrome and others. In some cases, genetic testing of patients is carried out.

After the anamnesis, the doctor proceeds to examine the patient. Body type, appearance, presence of physical defects ( characteristic of genetic diseases), skin color, type of breathing ( the presence of shortness of breath). Measure blood pressure, conduct an electrocardiogram ( ECG) hearts. Most often there are no changes on the ECG. In some cases, there may be signs of myocardial infarction, angina pectoris. In the presence of an aortic aneurysm on palpation ( probing) a pulsating formation may be felt. On auscultation ( listening) vascular murmurs are heard.

The doctor may prescribe a number of laboratory tests - complete blood count and biochemical blood test. The main attention is paid to the lipid profile ( blood lipid analysis). The level of lipids allows you to assess the risk of developing atherosclerosis. Examine the level of cholesterol - a fat-like structural component of cells. Low density lipids ( LDL - "bad" cholesterol) contribute to the formation of atherosclerotic plaques. High density lipids ( HDL - "good" cholesterol) prevent plaque formation. The level of sugar in the blood indicates the presence of diabetes.

All of the above methods of diagnosing a patient do not allow to accurately diagnose an aortic aneurysm. To confirm or refute the diagnosis, the doctor prescribes instrumental methods visualization of the aorta. This helps to study its structure in detail, detect defects, determine the exact location and size of the aneurysm.

Instrumental methods for examining the aorta

Method	How is it carried out?	What symptoms does it reveal?
*Radiography*	Pass through the human body in the area under study X-rays which are projected onto special paper or film. Harder structures absorb more X-rays and appear lighter on film. soft tissues- darker.	With the help of x-rays, the contours and dimensions of the ascending and descending aorta are examined. With the expansion of the aortic shadow, a change in the contours of the mediastinum, an aneurysm is diagnosed. It is also characterized by compression of surrounding organs. Therefore, an additional x-ray may be prescribed ( projection of x-rays on a screen) and radiography of the esophagus, stomach and duodenum.
*Intravascular ultrasound* *(IVUS)*	It's invasive with penetration into the human body) method of ultrasonic research. A special conductor is inserted into the lumen of the aorta, at the end of which there is an ultrasonic sensor. When ultrasonic waves pass through the walls of the aorta, they are reflected and captured by the transducer. The received data is converted into an image on the monitor screen. Image recording occurs during the entire study.	All three layers of the aortic wall reflect ultrasound waves differently due to different thickness and density. This allows you to study the aortic wall in layers and obtain information about its thickness, shape and structure. Intravascular ultrasound allows to determine atherosclerotic plaques, blood clots, damage to the aortic wall in the form of a rupture or dissection. Often this research method is used during surgery.
*echocardiography* *(transthoracic and transesophageal)*	It is an ultrasound method for examining the heart and thoracic aorta. In transthoracic echocardiography, the transducer is placed on the patient's chest. The sensor emits ultrasonic waves and captures reflected images on the screen. In transesophageal echocardiography, a transducer is inserted into the esophagus. The procedure is performed under general anesthesia.	This method allows you to study the structure of the walls of the aorta, identify their defect and determine the location and size of the aneurysm. It is safer and less invasive than intravascular ultrasound ( IVUS).
*Doppler ultrasound* *(UZDG)*	Combination of methods of ultrasonic examination of blood vessels with Dopplerography. This method is based on the reflection of sound waves from a moving object ( moving red blood cells). The data is then processed by a computer and converted into an image on a monitor.	Ultrasound examination allows to determine the degree of damage to the aortic wall by sclerotic formations, the degree of narrowing ( stenosis) lumen of the vessel, damage and thinning of the walls of the aorta. Unlike other methods, it allows assessing the nature of blood flow in the aorta.
*CT scan* (CT)	The research method is based on the passage of X-rays through the human body at different angles and from different points. The image is projected onto a computer monitor. The doctor can study the anatomical structures in layers and from any angle.	This method allows you to study in detail the structure of the aorta, detect defects in the wall, determine the longitudinal and transverse diameter of the expansion and its exact location, identify parietal thrombi, calcification ( process of calcium salt deposition).
*Aortography*	Aortography is a method of studying the aorta, based on the introduction of a contrast agent into the vessel and further visualization using an X-ray machine. contrast agent ( cardiotrast, diode) is injected through a catheter ( handset) directly into the aorta or through large arteries - radial, brachial, carotid or femoral.	Aortography reveals structural and functional changes aorta. When the aorta is filled with contrast, the lumen of the vessel will be clearly visible on the image. This will allow diagnosing protrusion of the wall, narrowing of the lumen, dissection of the aortic wall, since blood with contrast will flow between the layers of the vessel wall.
*Computed tomography angiography* *(KTA)*	It is a combination of computed tomography and angiography ( study of the vessel with the use of a contrast agent). through a special catheter handset) inject a contrast agent ( iodine preparations). Then X-rays are passed through. The contrast absorbs x-rays and allows you to more clearly highlight the contours of the vessel against the background of the surrounding soft tissues and bones.	The method allows to clearly visualize the aorta, to detect narrowing ( stenosis) of its lumen, protrusion of the wall into the lumen. It will also be possible to visualize a dissection of the aortic wall, pseudoaneurysm, since blood with a contrast agent flows between the layers of the aortic wall. The image will clearly show the boundaries of the bundle.
*Digital subtraction angiography* *(CSA)*	A method for examining a vessel with the use of contrast and further computer processing. This method allows you to significantly reduce the dose of the contrast agent. On the resulting image, the doctor can remove all structures that do not have diagnostic value leaving only the vasculature.	Allows you to identify structural defects of the aorta, protrusion of its wall, stenosis, developmental anomalies.
*Magnetic resonance imaging* *(MRI)*	The principle of operation is the effect of electromagnetic waves on the atoms of hydrogen nuclei. The computer registers the electromagnetic response of atomic nuclei with its transformation into an image of anatomical structures on the monitor.	It makes it possible to visualize the boundary between the blood flow and the vessel wall. This allows you to determine the diameter of the aortic expansion, its shape and degree. Often, MRI is performed with the use of a contrast agent, which allows you to more clearly visualize the pathology of the aorta.
*Assessment of pulse wave velocity and augmentation index*	The ejection of blood from the left ventricle during systole increases the pressure on the vascular wall, causing it to stretch. This pressure wave is called a pulse wave. The speed of propagation of pulse waves allows you to assess the stiffness of the vessels. The lower the speed, the higher the degree of rigidity of the vessel wall. The speed of the pulse wave is determined by sensors located in the region of the carotid and femoral arteries.	This method allows you to assess the degree of rigidity of the aortic wall. Structural changes in the aorta occur with age. As a result, its walls become fragile, which increases the risk of developing an aneurysm, rupture of the aortic wall, pseudoaneurysm.

There are quite a few methods of instrumental examination of the aorta. Each of them has its own advantages and disadvantages, as well as contraindications. The doctor will pick up necessary methods studies individually for each patient. If necessary, conduct several studies using contrast.

Treatment of an aortic aneurysm

An aortic aneurysm is treated by a cardiologist and a vascular surgeon. After the examinations, the doctor will determine the exact location, extent, size of the aneurysm. This will influence the choice of treatment tactics and future forecast life for the patient. In general, the treatment of an aortic aneurysm is surgical. But surgery is a complex treatment with many risks and complications. Therefore, it is carried out only in the case of direct evidence.

If there are no indications for surgical treatment, then the doctor chooses expectant management and supportive drug treatment. Expectant tactics are constant surveillance a patient with a small aortic aneurysm. Once every six months, the patient must undergo diagnostic examinations to monitor changes in the aorta over time.

Supportive drug treatment is aimed at eliminating the causes of the aneurysm and maintaining concomitant diseases in the compensation stage, that is, the minimum negative impact of the pathology on the body. Also, drug treatment is aimed at reducing the impact of the deforming force on the walls of the aorta by lowering blood pressure and contractile function hearts.

The goal of maintenance drug therapy is:

Blood pressure control. The optimal blood pressure values for patients with concomitant diabetes mellitus and chronic kidney disease are 130/80 millimeters of mercury. For the rest, 140/90 millimeters of mercury is allowed. α-receptor blockers are used - prazosin, urapidil, phentolamine, β-receptor blockers - bisoprolol, metoprolol, nebivolol, angiotensin-converting enzyme inhibitors ( ACE) - captopril, enalapril, lisinopril.
Decrease contractility hearts. Use drugs from the group of β-receptor blockers ( atenolol, propranolol), which reduce myocardial contractility, its oxygen demand and heart rate.
Normalization of lipid levels. Dyslipidemia ( lipid metabolism disorder) leads to atherosclerosis - the deposition of cholesterol and lipoproteins ( complexes of proteins and fats) on the vessel wall. To normalize lipid levels, drugs of the statin group are used ( simvastatin, rosuvastatin, atorvastatin).

Patients with an aortic aneurysm should also change their lifestyle. You need to stop smoking, as it provokes an acceleration of the expansion of an aortic aneurysm. Intense physical activity, stress and injury should be avoided.

When is surgery necessary for an aortic aneurysm?

Surgical treatment is divided into planned and emergency. Planned surgical intervention carried out with an increase in the size of the aortic aneurysm, with circulatory disorders, with severe symptoms. Preparation of the patient for surgery can take from several days to a month. Typically, elective surgery is performed on patients who for a long time were under the supervision of a doctor, periodically underwent examinations and took medication.

An emergency operation is performed according to vital indications, regardless of concomitant diseases and the patient's condition. Indications are the threat of rupture or dissection of the aorta, as well as an aneurysm that has ruptured. Preparation for the operation is carried out as quickly as possible. These may be the necessary instrumental examinations, blood tests, blood grouping, carried out directly in the operating room.

Before the operation, the patient will undergo the necessary instrumental examinations and laboratory tests. An anesthesiologist, cardiologist, cardiac surgeon, vascular surgeon, as well as other specialists in case of concomitant diseases will be consulted. The anesthesiologist will select the type of anesthesia depending on the type of operation. After surgery, the patient expects a long recovery period and lifestyle changes. He will be registered with a cardiologist and periodically undergo instrumental examinations.

Indications for surgical treatment of aortic aneurysm are:

expansion of the thoracic aorta more than 5 centimeters ( Normal diameter does not exceed 3 cm), since the risk of dissection or rupture of the aorta increases significantly with its diameter of more than 6 centimeters for the ascending aorta and more than 7 centimeters for the descending aorta;
expansion of the thoracic aorta up to 5 centimeters in patients with Marfan syndrome ( the risk of aortic rupture with a diameter of up to 6 centimeters in such patients is 4 times higher) and other genetic diseases that provoke the development of an aneurysm;
dissecting aortic aneurysm ( is the leading cause of death and disability in patients);
rapid growth rate of the aneurysm ( more than 3 millimeters per year);
patients with cases of aortic aneurysm rupture in relatives;
pronounced symptoms of aortic aneurysm;
high risk of aneurysm rupture.

Contraindications for surgical treatment of aortic aneurysm ( except for life-threatening conditions) are:

myocardial infarction ( less than 3 months);
severe pulmonary insufficiency;
renal, liver failure;
malignant neoplasms last stage;
acute disorder cerebral circulation (ischemic, hemorrhagic stroke);
acute infectious diseases;
chronic diseases in the acute stage;
inflammatory processes.

For surgical intervention, it is necessary to compensate for the patient's condition. Weakened immunity, organ failure, and serious comorbidities can lead to serious complications and death.

Surgical operations for aortic aneurysm are divided into:

open– prosthetic aorta;
endovascular ( intravascular) – installation of a stent graft ( cylindrical metal frame);
hybrid- combined operations.

Aortic prosthesis

Aortic prosthesis is a surgical intervention in which the damaged section of the aorta is excised and replaced with a synthetic prosthesis. Refers to open operations. To access the aorta, an opening of the chest is performed - a thoracotomy, an incision of the abdominal wall - a laparotomy or a combination of thoracotomy and laparotomy.

The advantage of this treatment method is:

good visualization and the ability to correct all disorders caused by the aneurysm;
treatment of aneurysms of any shape and size;
higher reliability and long-term effect.

But open method operations many disadvantages, such as:

complex surgical access - the need to open the chest or abdominal wall;
prolonged anesthesia - from 2 to 6 hours;
necessity cardiopulmonary bypass and cooling the patient;
high risk of complications during and after surgery;
Availability a large number contraindications;
long recovery period;
large postoperative scars.

The main techniques for aortic prosthetics include:

Operation Bentalla-De Bono– simultaneous replacement of the aortic valve, aortic root and ascending aorta, which is used in pathology aortic valve and ascending aorta with Marfan syndrome);
operation david- prosthesis of the ascending aorta with preservation of its own aortic valve;
Borst technique– simultaneous replacement of the ascending aorta, aortic arch and descending aorta ( "elephant's trunk").

After open surgical intervention on the aorta with a stable course, a dynamic study is performed every six months during the first year after the operation. Then the interval between examinations can be increased at the discretion of the doctor.

Endovascular ( intravascular) operations

Endovascular surgery consists in the introduction of a special frame - an endoprosthesis or a stent graft - into the lumen of the affected area of the aorta. It allows you to strengthen the aortic wall and make it more resistant to external factors ( high blood pressure). The sac of the aneurysm is left, but the operation prevents its further growth.

Endovascular surgery is minimally invasive ( minor damage skin). Under local anesthesia in a vessel ( usually in the femoral artery) introduce a special catheter ( handset). Under X-ray control, a stent is delivered through this catheter to the area of the aorta with an aneurysm. The stent is a cylindrical metal frame that is folded in and opened at the site of the aneurysm. The patient is discharged the next day after the operation. This method has more advantages over aortic replacement.

The advantages of this operation are:

the use of local anesthesia;
less traumatic operation;
no need for artificial circulation;
minimal blood loss during surgery;
the possibility of carrying out with severe concomitant diseases;
minimal risks and complications;
fast rehabilitation (up to two weeks);
slight pain after surgery.

The disadvantage is the need for repeated surgical interventions, less visualization, limited manipulation, treatment of small aneurysms.

Hybrid operation

Hybrid operation is modern method surgical treatment of aneurysms. It is used for the defeat of several vessels. Its essence lies in the simultaneous stenting of one vessel and shunting of another.

Shunting is the creation of a shunt ( artificial branch), providing blood flow around the affected area of the vessel. advantage this method is less traumatic, the ability to avoid large-scale surgical intervention and multiple stenting.

Surgical treatment of thoracic aortic aneurysm

Department of the aorta	Types of surgical interventions	Peculiarities	Complications
*Ascending aorta*	supracoronary prosthetics; reconstruction of the aorta with supracoronary prosthesis; aortic prosthetics according to the Bentall-De-Bono method; aortic prosthesis about David's technique; prosthetic aortic valve; aneurysmophia ( longitudinal or transverse excision of protruding sections of the aorta, followed by suturing of the wall); stenting; prosthetics according to the Borst technique.	Pathological processes can affect not only the ascending section, but also the aortic valve. This creates problems during the operation, as the surgeon must temporarily stop the heart and provide artificial circulation, without forgetting the blood supply to the heart.	The risk of complications depends on the duration of the operation and the duration of aortic clamping. For example, the risk of paraplegia, paralysis of both limbs, depends on these parameters. Mortality in the planned prosthetics of the ascending aorta - 1.6 - 4.8%. These indicators are influenced by age, gender, concomitant diseases.
*Aortic arch*	complete prosthetics of the aortic arch of the type "end to end", "elephant's trunk"; prosthetics of a part of the aortic arch; reconstructive surgery on the aortic arch; prosthesis or reconstruction of the aortic arch with prosthetics of the ascending aorta.	During the operation, it is necessary to provide nutrition to the brain, since it is from the aortic arch that the arteries that supply the brain with blood depart. More often, operations on the aortic arch are repeated after emergency interventions for dissecting aneurysms.	Mortality in operations on the ascending aorta and aortic arch is 2.4 - 3.0%. For patients under 55 years of age, it is 1.2%, and the risk of strokes ( acute cerebrovascular accident) – 0,6 – 1,2%.
*Descending aorta*	prosthetics of the descending aorta; stenting.	During the operation, various methods of bypass blood circulation, cardiopulmonary bypass are used.	Surgical interventions on the thoracic aorta have common complications due to traumatic access, the need for cardiopulmonary bypass, and large blood loss. This can lead to neurological failure, ischemia of the internal organs.
*Thoracoabdominal aorta*	stenting; prosthetic aorta.	The peculiarity of the operation on the thoracoabdominal aorta is access - opening the chest ( thoracotomy) and abdominal wall ( laparotomy).	Complications from the heart, lungs, kidneys, intestines. The risk of paraplegia after surgery on the thoracoabdominal aorta is 6-8%.

Postoperative period for aortic aneurysm

The postoperative period is a very important and responsible stage in the treatment of aortic aneurysm. And the further prognosis of the disease depends on how seriously the patient takes it.

The patient will stay in the hospital for several days. If the attending physician notes the satisfactory and stable functioning of the cardiovascular and other body systems, the patient is discharged home.

Moderate physical activity. It is necessary to observe physical activity as much as the patient's well-being after the operation allows. You need to start with a short walk, then move on to light ones. exercise without causing pain. Early physical activity prevents the formation of blood clots in the lower extremities, improves blood circulation of organs and tissues, improves function digestive system.
Diet. In the first days after the operation, the patient will be prescribed diet No. 0, which is used in the rehabilitation of the patient. It includes rice water, low-fat broths, compotes. Next, the patient must follow diet number 10, prescribed for diseases of the cardiovascular system. It consists in limiting the intake of liquid and salt, excluding alcohol, fatty, fried foods. More fruits, vegetables, light soups, lean fish are recommended in the diet.
Mode of work and rest. In the first few days after the operation, it is recommended to observe bed rest and rest. After discharge from the hospital for a month or more, do not drive vehicles, do not lift heavy objects ( over 10 kilograms), instead of a bath, take a shower, observe the daily routine.
Medical treatment. It is necessary to strictly comply with the medical prescription of a doctor, aimed at maintaining a normal level of blood pressure, preventing thrombosis, and improving blood circulation.
Healthy lifestyle. The patient should stop smoking excess weight, eliminate alcohol, avoid stress. Also adhere to all doctor's recommendations on physical activity, daily routine, diet.

The patient should carefully monitor their well-being after the operation. If the temperature rises to 38ºС, there will be pain in the legs, back, pain in the wound area with discharge ( after open operation), you need to seek immediate medical attention.

After the operation, the doctor will explain the need and frequency of consultations and diagnostic procedures. This is necessary for dynamic observation and exclusion of postoperative complications. The frequency will depend on the type of operation performed and individual characteristics patient.

The full recovery period lasts from several weeks to 2-3 months, depending on the type of aneurysm and the extent of the operation. A healthy lifestyle and regular exercise play an important role.

Prognosis for aortic aneurysm

The prognosis for an aneurysm of the thoracic aorta is determined by its size, the rate of its progression, and concomitant diseases of the cardiovascular and other body systems. In the absence of timely diagnosis and treatment, the prognosis of aortic aneurysm is unfavorable. But, thanks to modern surgical treatment, it is possible to save the life of most patients. With planned surgical treatment of aortic aneurysm, mortality is 0-5%, in case of aneurysm rupture - up to 80% ( regardless of the urgency of the intervention). Within 5 years, the survival rate of operated patients is 80%, and that of non-operated patients is 5–10%.

The main causes of death in aortic aneurysms are:

rupture of the aneurysm 35 - 50% of cases);
ischemic disease hearts ( 35-40% of cases);
strokes ( 20% of cases).

The threat of an aneurysm rupture depends on the size of the aneurysm - an expansion of the vessel of more than 5 centimeters is considered life-threatening for the patient. Mortality in this case is 50% of cases during the first year. Extremely unfavorable prognosis in the first days of aneurysm dissection without surgical treatment. By the end of the second day, about 50% of patients die, by the end of the first week - 30%, and by the end of the second week only 20% of patients survive.

What is the difference between thoracic and abdominal aortic aneurysms?

Thoracic and abdominal aortic aneurysms differ in symptoms, treatment, and complications. This is due to their anatomical location.

The main differences between abdominal and thoracic aortic aneurysms are:

The frequency of the disease. Thoracic aortic aneurysm occurs in 6-10 cases per 100,000 people per year, the ratio of men and women is 2/1, 4/1. At autopsy, it occurs in 0.7% of cases. Abdominal aortic aneurysms account for 80–95% of all diagnosed aneurysms. About 200,000 cases are registered annually in the world. The ratio of men and women is 5/1, 10/1. Abdominal aortic aneurysm at autopsy occurs in 0.6–1.6% of people ( 5 - 6% of cases in patients older than 65 years).
Anatomical structure and location. The thoracic aorta includes the ascending aorta, the aortic arch, and the descending aorta. Thoracic part The aorta closely borders on the organs - the heart, bronchi and lungs, the esophagus. This leads to the appearance of a diverse and rapidly manifesting symptomatology.
Symptoms. Thanks to their anatomical features, thoracic aortic aneurysm has a diverse and severe symptoms. There are shortness of breath, cyanosis of the skin, impaired swallowing, pain in the heart, palpitations, swelling of the head and neck, and others. Abdominal aortic aneurysm long time may be asymptomatic until it ruptures. The main symptoms are pain and a feeling of pulsation in the abdomen, heartburn, constipation, impaired urination, lower back pain, numbness of the legs, impaired movement and sensitivity in the lower extremities.
Complications. Due to its proximity to vital organs, thoracic aortic aneurysm can lead to serious organ complications with further death. With abdominal aortic aneurysm, the most formidable complication is aortic rupture.
Treatment. Aortic aneurysms of the thoracic and abdominal sections with small sizes are treated with medication. Surgical treatment has a number of features. Surgical treatment of thoracic aortic aneurysm is much more difficult. This is due to access to the aorta - thoracotomy, that is, opening the chest wall, accompanied by a violation of the integrity of the ribs. When operating on the thoracic aorta, the surgeon is significantly limited in time, as the blood supply to vital organs suffers. Access to the abdominal aorta is obtained by incision of the abdominal wall - laparotomy.

How common is thoracic aortic rupture?

On average, an aortic aneurysm expands up to 2.5 millimeters per year. Descending aortic aneurysms grow faster ( up to 3 millimeters per year) compared with aneurysms of the ascending aorta ( 1 millimeter per year). There is a pattern - the larger the aneurysm, the faster it grows. So with an aneurysm size of 4 centimeters - an increase of 1 - 4 millimeters per year, with a size of 4 - 6 centimeters - an increase of 4 - 5 millimeters per year, with large sizes - up to 8 millimeters per year. The faster the aneurysm grows, the higher the risk of dissection and fatal aortic rupture. In most cases, a ruptured fusiform aneurysm is more common than a saccular aneurysm. This is due to the accumulation of thrombotic formations in the saccular extension, which strengthen the wall of the aorta.

The probability of rupture of an aneurysm with its diameter:

less than 5 cm– risk less than 1%;
more than 5 cm– the risk is more than 10%;
more than 7 cm– the risk is more than 30%.

More often, an aortic aneurysm is asymptomatic and is incidentally detected during prophylactic diagnostics or about another disease. In this case, the patient will undergo a planned operation. But if the patient is unaware of his pathology, then the rupture of the aneurysm can become a life-threatening complication with a fatal outcome. This condition requires emergency surgery. Minutes count, as the aorta is the most large vessel in the human body and its rupture leads to rapid and voluminous blood loss.

The main signs of an aortic rupture are:

sudden intense pain in the chest or abdomen ( can spread to the area between the shoulder blades, jaw, neck, perineum, legs);
headache - sharp, throbbing in the back of the head;
severe weakness;
nausea and repeated vomiting;
impaired consciousness ( short-term or long-term, mild or comatose);
thready pulse;
low blood pressure;
rapidly growing hematoma collections of blood);
hyperthermia ( elevated body temperature).

Aortic replacement is the main treatment for a rupture. During the operation, the integrity of the vessel and blood flow are restored, as well as the volume of blood loss by blood transfusion ( human blood transfusion). After such an operation, there is a high risk of developing serious complications, as the internal organs and tissues suffer from a lack of blood circulation. This can lead to renal, cardiac, lung failure, neurological complications, tissue death. Despite a successful operation, complications can lead to the death of the patient some time after the intervention. Therefore, the lethal outcome after aortic rupture is quite high - only 10% of operated patients survive.

What can be done to prevent aortic rupture?

The disease is easier to prevent than to cure. An aortic aneurysm is often asymptomatic and discovered incidentally during physical examinations or when complications develop. The risk of aortic rupture is individual in each case.

Causes of aortic rupture include:

a significant increase in blood pressure;
pregnancy and childbirth;
psycho-emotional overexcitation;
heavy physical activity.

Every year you should undergo medical preventive examinations, regardless of the state of health. Consultation with a cardiologist and instrumental examinations are especially important for patients at risk ( with arterial hypertension, atherosclerosis, aggravated heredity).

Patients diagnosed with an aortic aneurysm should undergo a thorough evaluation. The doctor must accurately determine the type of aneurysm, its location and size, and then select the treatment. The risk of aortic rupture depends not only on the size of the aneurysm, but also on comorbidities and lifestyle of the patient. In the presence of an aneurysm, the best prevention of aortic rupture is surgical treatment. Your doctor may suggest more gentle surgeries such as aortic stenting and hybrid surgeries.

To prevent aortic rupture, you should:

see a cardiologist
periodically undergo instrumental examinations ( echocardiography, MRI, ultrasound);
maintain a normal weight;
maintain blood pressure within normal limits;
eliminate the factors of atherosclerosis ( high cholesterol, smoking, sedentary lifestyle);
surgery ( especially patients with genetic diseases of the aorta);
avoid strenuous exercise weight lifting, air travel, sauna visits, sports).

How to issue a disability group for aortic aneurysm?

Disability is determined by a medical commission for labor examination, consisting of doctors of various specialties, including a cardiologist. The family doctor is in charge of paperwork and referral to the commission. During the examination, the patient's ability to self-service and perform physical activity without harm to health is assessed.

During the examination, medical and even surgical treatment, there is no question of determining the disability group. After the diagnosis of an aneurysm for several months, the patient undergoes a full course of drug therapy, if necessary, surgical removal of the aneurysm is performed with a long course rehabilitation measures. And only after that, if the patient has persistent impairment of the functioning of the body, it makes sense to send the patient to medical and social expertise to determine the disability group.

When determining disability, the following are taken into account:

the patient has heart failure due to impaired blood flow, with aneurysm;
the presence of concomitant diseases that prevent surgical treatment and aggravate the patient's condition ( diabetes, renal and hepatic pathology);
the age of the patient, his profession and working conditions.

Heart failure is manifested by peripheral edema, shortness of breath on exertion, a feeling of increased heart rate and interruptions in the work of the heart. The degree of heart failure is determined on the basis of complaints of patients, as well as with the help of additional instrumental examinations - electrocardiography, echocardiography and others.

What are the features of thoracic aortic aneurysm during pregnancy?

Pregnancy is a serious test for a woman's body. At this time, chronic diseases may manifest or worsen, as well as new pathological conditions, in particular, aortic aneurysm. It's connected with hormonal changes of the whole organism - an increased level of estrogen and progesterone plays an important pathological role in the violation of the structure and loss of elasticity of the aorta.

During pregnancy, the load on the initial sections of the aorta also increases, cardiac output increases, followed by an increase in heart rate and circulating blood volume, especially in the last trimester of pregnancy.
All this, ultimately, can lead to the formation of an aortic aneurysm or expansion with dissection of an existing aneurysm.

The causes of an aortic aneurysm during pregnancy do not differ from the main causes. It can also be congenital and acquired diseases. Of the congenital pathologies accompanied by the formation and dissection of the aorta, the most studied is Marfan's syndrome ( congenital pathology of the connective tissue), occurring with a frequency of 1/3000 - 1/5000.

The causes of acquired aortic aneurysm are:

hereditary predisposition;
injuries, accidents;
arterial hypertension;
vascular atherosclerosis;
syphilis in the advanced stage with a violation of the architectonics of the vascular wall;
wrong image woman's life, obesity, smoking.

Symptoms of an aneurysm in pregnant women often appear fairly quickly and depend on the location and size of the aneurysm.

With an aneurysm of the thoracic aorta, a pregnant woman may complain of:

back pain, aggravated by inhalation;
labored breathing;
feeling of a coma in the throat with difficulty swallowing;
snoring in sleep.

Abdominal aortic aneurysm is characterized by:

feeling of numbness of the fingers and toes with chilliness due to circulatory disorders;
pain in the abdomen and lower back;
sensation of pulsation in the abdomen;
fainting;
jumps in blood pressure.

For a pregnant woman with an aortic aneurysm, dangerous complications are:

Ruptured aortic aneurysm. This is extremely dangerous state for a woman's life. If the aneurysm is small, then the pregnant woman must observe certain mode work and rest, diet.
High risk of thrombosis. This is due to a violation of the normal blood circulation in the cavity of the aneurysm. Blood clots can clog arteries and veins, and in some cases wander through the circulatory system and get into the heart valves with its subsequent stop.
Spontaneous abortion. Termination of pregnancy can be caused by insufficient blood circulation of the fetus due to compression of the vascular aneurysm.
Detachment of the placenta, followed by severe uterine bleeding. This complication often leads to the death of the fetus and mother.

specific methods there is no study of aortic aneurysm during pregnancy.

According to vital indications, they carry out:

chest x-ray;
computed tomography with contrast injection of a contrast agent intravenously), which allows to trace the accumulation of contrast in the aneurysm;
aortography with contrast;
Ultrasound of the abdominal and thoracic cavity.

Depending on the size and location of the aneurysm, different methods of treatment are used. If a large aneurysm is found with a risk of rupture, then doctors resort to urgent surgical intervention. A woman is given a premature birth or a caesarean section, so it is very dangerous to remove an aneurysm while the fetus is in the womb. If the aneurysm is small and there is no threat of its rupture, then its removal is delayed until the moment of delivery. After the birth of a child, a woman must be operated on to prevent the growth and rupture of the aneurysm.

The basis for the prevention of aneurysm formation is timely medical control of blood pressure, coagulation and anticoagulation systems of the body, as well as maintaining a healthy lifestyle with proper nutrition and moderate physical activity.

In medical practice, there are rare cases of aortic aneurysm during pregnancy with consequent severe complications.

Do aortic aneurysms occur in children?

Aortic aneurysm is extremely rare in children. It can develop in the womb or appear after birth. For children, the location of the aneurysm on the bend of the aorta is typical. The main cause of protrusion of the aortic wall is genetic diseases and congenital malformations of the aorta.

Aortic aneurysm in children is caused by:

Marfan syndrome;
Ehlers-Danlos syndrome;
Turner syndrome;
Lois-Dietz syndrome;
congenital disorder of connective tissue formation ( gene defect, magnesium deficiency, collagen deficiency);
coarctation of the aorta;
arterial tortuosity syndrome;
Kawasaki syndrome.

Diseases such as syphilis, arterial hypertension, atherosclerosis are very rare in children. Therefore, these pathologies are rarely the cause of aortic aneurysm. Also, sports injuries, injuries after an accident can lead to damage to the aortic wall and its aneurysm.

The symptoms of an aortic aneurysm in children do not differ from those in adults. This is a cough, hoarseness, difficulty breathing, chest pain with irradiation ( bestowal) in the back. The difficulty in diagnosing an aneurysm in children is that the child cannot always explain what is bothering him. This is especially true for newborns.
Diagnosis of aortic aneurysm in children consists of genetic and instrumental examination ( x-ray, MRI, CT, ultrasound, echocardiography).

Treatment of an aortic aneurysm in children is usually surgical. The enlarged section of the aorta is excised and replaced with a prosthesis. The operation is followed by a long rehabilitation period and regular preventive examination at the doctor's. Life prognosis for aortic aneurysm ( even after her surgical treatment) is often unfavorable. This is due to severe comorbidities ( valvular insufficiency, heart and aortic defects, collagen deficiency) and complications ( aortic rupture).

Can an aortic aneurysm be treated with traditional methods?

Aortic aneurysm is not treatable by folk methods. This is a very serious and dangerous disease. In advanced cases, the aneurysm ruptures with heavy bleeding, resulting in 90% to lethal outcome. The disease is asymptomatic for a long time and is often an incidental finding on ultrasound and MRI examination of the abdominal and thoracic cavities.

The tactics of treatment are selected by the doctor individually for each patient. Treatment may be surgical or medical alone, depending on the size and location of the aneurysm, as well as the risk of complications. In any case, supportive drug therapy is prescribed, which can be combined with traditional medicine. But do not self-medicate and before treatment folk remedies you should definitely consult with your doctor.

Medicinal herbs are used to strengthen the vascular wall, regulate blood pressure, lower cholesterol levels.

These include:

infusion of jaundice levokoy- Pour 2 tablespoons of dry grass with a glass of boiling water, leave for 30 minutes and strain, take 4-5 times a day, 1 tablespoon;
hawthorn infusion- 4 tablespoons of dried and chopped fruit pour 3 cups of boiling water, leave for 30 minutes, strain and drink 200 milliliters three times a day before meals;
dill infusion - Pour 1 tablespoon of dry grass with 1 cup of boiling water, leave for 15-20 minutes, strain and take 1/3 cup 3 times a day before meals;
Siberian elderberry infusion - Pour 1 tablespoon with 200 milliliters of boiling water, leave for 30 minutes, strain and take 1 tablespoon 1 time per day;
a decoction of yarrow, St. John's wort and mountain arnica- leaves of yarrow, St. John's wort and arnica in a ratio of 4/3/1 dry, grind and pour 200 milliliters cold water for 4 hours, then boil for 5 minutes, cool, strain and take 3 times a day in equal portions.

During treatment with folk remedies, it is important to monitor the general condition, monitor blood pressure and blood sugar levels. Don't be misled that medicinal herbs can replace tablets.

Can you fly with an aortic aneurysm?

In case of aneurysm of the thoracic aorta, air travel is contraindicated. During flights, the body experiences an increased load. So during takeoff and landing, significant pressure drops occur, which negatively affect the functioning of blood vessels and the heart. In addition to physiological blood pressure, other forces act on the vessels. healthy blood vessels able to withstand this pressure anatomical structure allows them to stretch under the action of external forces and then return to normal condition. In case of thinning of the vessel wall, atherosclerosis, loss of elasticity, existing aneurysm, arterial hypertension, a rupture may occur in this area. Therefore, it is extremely dangerous for patients with aortic aneurysm to fly on airplanes. This does not depend on the size and type of aneurysm, since aneurysm rupture can occur even with small aneurysms.

Blood clots can form in an aortic aneurysm. They can be attached to the vessel wall and not disturb the patient. But during a flight under pressure, a blood clot can break off and be carried with the blood stream through the human body. This is extremely dangerous as it can lead to pulmonary embolism ( occlusion of a blood vessel by a thrombus), ischemic stroke ( acute disorder blood circulation of the brain due to blockage of the vessel by a thrombus) and death. A long flight, immobility, sitting position, pressure drops lead to vasoconstriction in the lower extremities, slowing down blood flow and increasing blood viscosity. All this significantly increases the risk of thrombosis.

Also, when climbing to a height, it falls Atmosphere pressure, which leads to a decrease in the oxygen concentration in the aircraft. For people with a sick heart and blood vessels, this is extremely dangerous, as it can lead to a heart attack. These patients require an additional source of oxygen. But due to the explosive nature of oxygen, not all planes allow you to take oxygen on board.

During the flight, the patient cannot be provided with the necessary medical care. Especially in critical conditions requiring immediate surgical intervention ( ruptured aortic aneurysm). This can lead to the death of the patient.

Before flying, a patient with an aortic aneurysm or cardiovascular disease should:

get advice from a cardiologist;
undergo instrumental examinations;
carry out the necessary medical treatment;
read the rules of the airline ( clarify what medications you can take with you, is it allowed to take oxygen on board the aircraft).

Air travel can be dangerous for patients:

recent stroke or myocardial infarction less than six months);
with aortic aneurysm of medium and large sizes;
with dissecting aneurysm increased pressure contributes to even greater stratification of the vessel wall);
with an increased risk of aneurysm, blood clots;
with the risk of aneurysm rupture;
with arterial hypertension;
with heart disease;
after surgery on the aorta or heart ( the period after the operation is less than a month or six months, depending on the operation).

To minimize the negative impact of air travel, you should:

try to move more get up every 30 minutes, do leg exercises);
provide additional inhalations of oxygen;
take medications to reduce anxiety, blood pressure, to prevent blood clots, and others.

How long do people live with an aortic aneurysm?

It is impossible to unequivocally answer the question of life expectancy in aortic aneurysm. An aortic aneurysm is called a "time bomb". In any case, without appropriate monitoring and treatment, the prognosis is poor.

Not all patients are diagnosed with an aortic aneurysm on time. In this case, the aneurysm can develop asymptomatically for a long time. The patient, unaware of his disease, continues to smoke, work hard physically, do not monitor blood pressure. This leads to an increase in the protrusion of the aortic wall in size and an increased risk of its rupture and death of the patient. Also, not all patients can undergo surgical treatment.
This is due to the general condition and severe concomitant diseases, in which the patient may not survive anesthesia and surgery.

Aortic rupture and dissection can occur at any time, regardless of the size and location of the aneurysm. Survival in such cases is low - from 20% to 50% of patients.

Once an aortic aneurysm is diagnosed, life expectancy for patients depends on:

The patient's age. Patients under 50 years of age have fewer comorbidities, but at the same time, they are more susceptible to stress and heavy physical exertion.
Causes of aortic aneurysm. With genetic diseases of the aorta, life expectancy is short, since often genetic diseases are accompanied by life-incompatible complications and lack of treatment. After a chest injury, it is possible to develop a thoracic aortic aneurysm for decades. In hypertension, atherosclerosis, aneurysm progresses in proportion to the progression of these diseases. Life expectancy in these cases depends on the compensation of diseases.
The size of the aneurysm and its rate of enlargement. Larger aneurysms increase the risk of rupture. Also, the rapid progression of the aneurysm can lead to life-threatening complications.
Lifestyle and bad habits. Overweight, strenuous exercise some sports, weight lifting), smoking lead to accelerated development of aortic aneurysm. For example, smoking contributes to an increase in the growth rate of aortic aneurysms up to 35 millimeters per year.
Associated diseases. Diabetes mellitus, arterial hypertension, atherosclerosis and other diseases that cause pathological changes in the vessel wall significantly accelerate the development of an aortic aneurysm.
Supportive care and regular medical check-ups. The life expectancy of the patient significantly depends on treatment and monitoring. So the doctor can find an aortic aneurysm on the very early stage its development and delay the time of surgical treatment for many years thanks to the supportive drug treatment and modification of the patient's lifestyle. Also, regular medical check-ups will help prevent such dangerous complications like aortic rupture and aortic dissection.

Under certain conditions, you can live with an aortic aneurysm for years. But the percentage of such people is very small. In 7% of deceased patients, an aortic aneurysm is found, which is not the cause of death. Any time ( in case of impact, car accident, physical overexertion) aortic rupture can occur with subsequent death. To increase life expectancy, it is necessary to undergo regular examinations, observe the correct lifestyle and conduct surgical treatment on time ( also for preventive purposes.).

- congenital segmental stenosis (or complete atresia) of the aorta in the isthmus - the transition of the arc to the descending part; less often - in the descending, ascending or abdominal sections. Coarctation of the aorta is manifested in childhood anxiety, cough, cyanosis, shortness of breath, malnutrition, fatigue, dizziness, palpitations, nosebleeds. When diagnosing coarctation of the aorta, ECG data, chest x-ray, echocardiography, probing of the heart cavities, ascending aortography, left ventriculography, coronary angiography are taken into account. The methods of surgical treatment of aortic coarctation are transluminal balloon dilatation, isthmoplasty (direct and indirect), resection of aortic coarctation, and shunting.

ICD-10

Q25.1

General information

Coarctation of the aorta is a congenital anomaly of the aorta, characterized by its stenosis, as a rule, in a typical place - distal to the left subclavian artery, at the point of transition of the arch into the descending aorta. In pediatric cardiology, aortic coarctation occurs with a frequency of 7.5%, while it is 2-2.5 times more common in males. In 60-70% of cases, aortic coarctation is combined with other congenital heart defects: patent ductus arteriosus (70%), ventricular septal defect (53%), aortic stenosis (14%), mitral valve stenosis or insufficiency (3-5%), less often with transposition of the great vessels. In some newborns with aortic coarctation, severe extracardiac congenital anomalies of development are detected.

Causes of coarctation of the aorta

In cardiac surgery, several theories of the formation of aortic coarctation are considered. It is generally accepted that the basis of the defect is a violation of the fusion of aortic arches in the period of embryogenesis. According to Skoda's theory, coarctation of the aorta is formed due to the closure of the patent ductus arteriosus (PDA) with simultaneous involvement of the adjacent part of the aorta. Obliteration of the Batallian duct occurs shortly after birth; while the walls of the duct collapse and scar. When the aortic wall is involved in this process, it narrows or completely closes the lumen in a certain area.

According to the Anderson-Becker theory, the cause of coarctation can be the presence of a falciform ligament of the aorta, which causes narrowing of the isthmus during obliteration of the PDA in the area of its location.

In accordance with the hemodynamic theory of Rudolf, coarctation of the aorta is a consequence of the peculiarities of the intrauterine circulation of the fetus. During prenatal development 50% of the ejection of blood from the ventricles passes through the ascending aorta, 65% through the descending aorta, while only 25% of the blood enters the aortic isthmus. This fact is associated with the relative narrowness of the isthmus of the aorta, which, under certain conditions (in the presence of septal defects), is preserved and aggravated after the birth of a child.

Features of hemodynamics in coarctation of the aorta

A typical location of stenosis is the terminal section of the aortic arch between the ductus arteriosus and the orifice of the left subclavian artery (aortic isthmus region). In this place, coarctation of the aorta is detected in 90-98% of patients. Outside, the narrowing may look like hourglass or constrictions with a normal aortic diameter in the proximal and distal aorta. External narrowing, as a rule, does not correspond to the value of the internal diameter of the aorta, since in the lumen of the aorta there is an overhanging crescent-shaped fold or diaphragm, which in some cases completely overlaps the internal lumen of the vessel. The length of coarctation of the aorta can range from a few mm to 10 cm or more, but more often it is limited to 1-2 cm.

A stenotic change in the aorta at the point of transition of its arch into the descending part causes the development of two modes of blood circulation in a large circle: there is arterial hypertension proximal to the place where blood flow is obstructed, and hypotension distally. In connection with the existing hemodynamic disorders in patients with aortic coarctation, compensatory mechanisms are activated - left ventricular myocardial hypertrophy develops, stroke and minute volume increase, the diameter of the ascending aorta and its branches expands, and the network of collaterals expands. In children older than 10 years, atherosclerotic changes are already noted in the aorta and blood vessels.

Hemodynamic features in coarctation of the aorta are significantly affected by concomitant congenital malformations of the heart and blood vessels. Over time, changes occur in the arteries involved in the collateral circulation (intercostal, internal thoracic, lateral thoracic, scapular, epigastric, etc.): their walls become thinner, and the diameter increases, predisposing to the formation of prestenotic and poststenotic aortic aneurysms, aneurysms cerebral arteries, etc. Usually, aneurysmal vasodilatation is observed in patients older than 20 years.

The pressure of the tortuous and dilated intercostal arteries on the ribs contributes to the formation of uzurs (notches) on the lower edges of the ribs. These changes appear in patients with aortic coarctation over the age of 15 years.

Classification of aortic coarctation

Taking into account the localization of the pathological narrowing, coarctation is distinguished in the isthmus, ascending, descending, thoracic, and abdominal aorta. Some sources distinguish the following anatomical variants of the defect - preductal stenosis (narrowing of the aorta proximal to the confluence of the PDA) and postductal stenosis (narrowing of the aorta distal to the confluence of the PDA).

According to the criterion of the multiplicity of anomalies of the heart and blood vessels, A. V. Pokrovsky classifies 3 types of aortic coarctation:

1 type- isolated coarctation of the aorta (73%);
type 2- combination of coarctation of the aorta with PDA; with arterial or venous discharge of blood (5%);
3 type- a combination of coarctation of the aorta with other hemodynamic significant anomalies vessels and CHD (12%).

In the natural course of coarctation of the aorta, 5 periods are distinguished:

I (critical period)- in children under 1 year old; characterized by symptoms of circulatory failure in a small circle; high mortality from severe cardiopulmonary and renal failure, especially when aortic coarctation is combined with other CHD.
II (adjustment period)- in children from 1 to 5 years; characterized by a decrease in the symptoms of circulatory failure, which is usually presented increased fatigue and shortness of breath.
III (compensatory period)- in children from 5 to 15 years; characterized by a predominantly asymptomatic course.
IV (period of development of relative decompensation)- in patients 15-20 years old; during puberty, signs of circulatory failure increase.
V (decompensation period)- in patients 20-40 years old; characterized by signs of arterial hypertension, severe left and right ventricular heart failure, high mortality.

Symptoms of coarctation of the aorta

The clinical picture of coarctation of the aorta is represented by many symptoms; manifestations and their severity depend on the period of the defect and associated anomalies that affect intracardiac and systemic hemodynamics. In children early age with coarctation of the aorta, there may be growth retardation and weight gain. The symptoms of left ventricular failure predominate: orthopnea, shortness of breath, cardiac asthma, pulmonary edema.

At an older age, due to the development of pulmonary hypertension, complaints of dizziness are characteristic, headache, palpitations, tinnitus, decreased visual acuity. With coarctation of the aorta, nosebleeds, fainting, hemoptysis, numbness and chilliness, intermittent claudication, cramps in the lower extremities, and abdominal pain caused by intestinal ischemia are not uncommon.

The average life expectancy of patients with aortic coarctation is 30-35 years, about 40% of patients die in the critical period (up to 1 year of age). The most common causes of death in the period of decompensation are heart failure, septic endocarditis, ruptured aortic aneurysms, and hemorrhagic stroke.

Diagnosis of coarctation of the aorta

On examination, attention is drawn to the presence of an athletic body type (predominant development of the shoulder girdle with thin lower extremities); increased pulsation of the carotid and intercostal arteries, weakening or absence of pulsation on femoral arteries; increased blood pressure in the upper extremities with a decrease in blood pressure in the lower extremities; systolic murmur over the apex and base of the heart carotid arteries etc.

In the diagnosis of coarctation of the aorta, instrumental studies play a decisive role: ECG, echocardiography, aortography, chest radiography and cardiac radiography with esophageal contrast, sounding of the heart cavities, ventriculography, etc.

Electrocardiographic data indicate overload and hypertrophy of the left and / or right heart, ischemic changes in the myocardium. X-ray picture is characterized by cardiomegaly, bulging of the arc pulmonary artery, change in the configuration of the shadow of the aortic arch, usuration of the ribs.

Echocardiography allows direct visualization of coarctation of the aorta and determine the degree of stenosis. For older children and adults, a transesophageal echocardiogram may be performed.

During catheterization of the heart cavities, prestenotic hypertension and post-stenotic hypotension, a decrease in the partial pressure of oxygen in the post-stenotic aorta are determined. With the help of ascending aortography and left ventriculography, stenosis is detected, its degree and anatomical variant are assessed. Coronary angiography in aortic coarctation is indicated in case of episodes of angina pectoris, as well as when planning an operation in patients older than 40 years to rule out coronary artery disease.

Coarctation of the aorta should be differentiated from other pathological conditions that occur with symptoms of pulmonary hypertension: renovascular and essential arterial hypertension, aortic heart disease, nonspecific aortitis (Takayasu's disease).

Treatment of coarctation of the aorta

With coarctation of the aorta, there is a need for drug prophylaxis infective endocarditis, correction of arterial hypertension and heart failure. Elimination of the anatomical defect of the aorta is carried out only by surgery.

Cardiac surgery for coarctation of the aorta is performed in early dates(with a critical defect - up to 1 year, in other cases at the age of 1 to 3 years). Contraindications to surgical treatment of aortic coarctation are irreversible degree of pulmonary hypertension, the presence of severe or uncorrectable concomitant pathology, end-stage heart failure.

The following types of open surgeries are currently proposed for the treatment of coarctation of the aorta:

I. Local plastic reconstruction of the aorta: resection of the stenotic section of the aorta with end-to-end anastomosis; direct isthmoplasty with longitudinal dissection of stenosis and suturing of the aorta in the transverse direction; indirect isthmoplasty (using a flap from the left subclavian artery or a synthetic patch, with the imposition of a carotid-subclavian anastomosis).

The natural course of aortic coarctation is determined by the variant of aortic narrowing, the presence of other CHDs, and generally has an extremely unfavorable prognosis. In the absence of cardiac surgery, 40-55% of patients die in the first year of life. With timely surgical treatment of aortic coarctation, good long-term results can be achieved in 80-95% of patients, especially if the operation was performed before the age of 10 years.

Operated patients with coarctation of the aorta are under the supervision of a cardiologist and a cardiac surgeon for life; they are advised to restrict physical activity and loads, regular dynamic examinations to exclude postoperative complications. The outcome of pregnancy after reconstructive surgery for aortic coarctation is usually favorable. In the process of pregnancy, antihypertensive drugs are prescribed to prevent aortic rupture, and infective endocarditis is prevented.

ICD-10 code

With the development of the arch from the right, and not from the left branchial arch, a right-lying aorta is obtained. With the development of the aortic arch, a double arch is formed from the left and right primary gill arches. The right aorta, passing behind the esophagus to the left side of the spine, can cause compression of the esophagus, and the double arch can cause compression of the esophagus and trachea. Abnormal origin of the right subclavian artery directly from the aorta also causes compression of the esophagus (Fig. 2).

Surgical treatment of these anomalies in each case individually, based on accurate diagnosis(based on radiopaque examination of the aorta and arteries) and consists in ligation and intersection of formations that compress the esophagus and trachea, and in the transfer of the mouth of the vessels (for example, the right subclavian artery) to another place (new anastomosis with the aorta).

Narrowing of the isthmus - coarctation of the aorta (Fig. 3). According to Bonnett's classification, coarctations of infantile and adult types are distinguished. The first is located proximal to the arterial (botallian) duct (preductal type), the second is distal to it (postductal type).

Adult coarctation is usually shorter, while infantile coarctation is longer. In about 10% of cases with coarctation of the aorta, the arterial duct functions, and then the clinical picture of the disease depends on whether this duct is located in front of the narrowed area or after it. In the latter case, the clinical picture is due to the discharge venous blood from the pulmonary artery to the distal aorta. Coarctation of the aorta is always accompanied by a significant development of collaterals that provide arterial blood around the narrow area. These are anastomoses of the internal thoracic artery with the intercostal arteries and the superior epigastric artery with the inferior epigastric. Overdevelopment and aneurysmal dilatation of the intercostal arteries lead to the usuration of the ribs, which is characteristic of coarctation. Hypertension is determined upper divisions body (up to 200 mm Hg or more) and hypotension distal to the site of coarctation. A sharp systolic murmur is heard on the aorta and in the interscapular space. Treatment is operative.

In young children, as a rule, it is possible to make an aortic resection with an end-to-end anastomosis (Fig. 4). In adults, either replacement of the resected portion of the aorta (Fig. 5) with a plastic prosthesis, or expansion of the narrowed portion of the aorta with a “patch” of synthetic tissue is used.

From aortic diseases the most common is atherosclerosis (see), aortic aneurysm (see).

Recently allocate as an independent nosological form also aortitis (see). Aortitis is sometimes accompanied by occlusion of vessels extending from the aorta (for example, truncus brachiocephalicus). Surgical treatment for occlusion of vessels (Fig. 6, 7) extending from the aorta consists in restoring their lumen (thrombendarteriectomy), bypass shunting or resection of the obliterated area and replacing it with a graft. see also Blood vessels(operations).

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DOUBLE ARCH WITH THE FORMATION OF A VASCULAR RING AND THE DEVELOPMENT OF TRACHEA AND ESOPHAGUS COMPRESSION SYNDROME: FEATURES OF THE CLINICAL PICTURE, DIAGNOSIS AND SURGICAL TACTICS [Electronic resource] / Arakelyan [et al.] // Thoracic and cardiovascular surgery.- 2016 .- №5. - S. 45-48 .- Access mode: https://site/efd/545827

Double aortic arch is a rare congenital anomaly and is almost always accompanied by symptoms of compression of the trachea and esophagus. The paper presents a clinical observation of a 4-year-old patient with a syndrome of compression of the trachea and esophagus due to the presence of a vascular ring formed by a double aortic arch with an atrezated segment of the left arch distal to the origin of the left subclavian artery and a retroesophageal aortic diverticulum. The patient successfully completed dissociation of the vascular ring by resection of the atretic segment of the left aortic arch, the aortic diverticulum, and the left arterial ligament. Surgical correction of this defect should be performed as early as possible, preventing the development of serious complications in the form of developmental delay, frequent infectious diseases respiratory tract, reflex apneas that were observed in this patient. With early surgical treatment, the functions of the trachea and esophagus are fully restored.

№4 [Radiation diagnostics and therapy, 2011]

The journal is the first and only regularly published periodical scientific and practical peer-reviewed publication officially registered in the Russian Federation, published in the Northwestern Federal District of the Russian Federation and publishes information on the main issues in the field of radiation diagnostics (X-ray diagnostics, ultrasound diagnostics, X-ray computed tomography, magnetic -resonance tomography) and radiotherapy within a large number scientific medical specialties (obstetrics and gynecology, internal illnesses, cardiology, pediatrics, infectious diseases, nervous diseases, oncology, dentistry, traumatology and orthopedics, phthisiology, surgery, neurosurgery, urology, rheumatology, pulmonology, gastroenterology, public health and health care, human anatomy, pathological anatomy, etc.).

Kommerel's aortic diverticulum was first described by the author in 1936. A diverticulum was noted in a patient with a left aortic arch and a right aberrant subclavian artery.

№1 [Thoracic and cardiovascular surgery, 2013]

The operation is performed in one stage, the arterial ligament is transected, the aortic diverticulum is resected and the aberrant subclavian artery is reimplanted. After surgery, dysphagia usually regresses.

Congenital malformation of the subclavian artery is the most common malformation of the aortic arch and its branches. Given the current level of development of diagnostics, the identification of congenital anomalies of development is not difficult for specialists. Indications for surgical treatment and the scope of surgical intervention is determined solely on the basis of diagnostic data and clinical manifestations. At the moment, there is no definite opinion about which way of surgical treatment is the most preferable - classical or hybrid method. The surgeon must take into account all the anatomical and physiological features of the patient before making a decision on the method of surgical treatment. This article presents the historical data of surgical treatment and diagnosis, as well as modern approaches to surgery for anomalies in the development of the subclavian arteries

On barium passage fluoroscopy, he described an aortic diverticulum at the origin of an aberrant right subclavian artery, which would later be called Kommerel's diverticulum.

№2 [Thoracic and cardiovascular surgery, 2013]

The journal covers topical theoretical and organizational issues of thoracic surgery and related specialties. It publishes works related to the etiology, pathogenesis, clinic, diagnosis and surgical treatment of diseases of the heart and blood vessels, lungs, mediastinal organs, etc. The journal also publishes papers on organ transplantation. Founded in 1959. The journal is included in the VAK List

We adhere to the opinion of A.V. Ivanitsky, who proposes to call the aortic diverticulum in his author's version Kommerel's diverticulum, to call all other variants of localization the aortic diverticulum, descriptively 6 cLT.

№5 [Thoracic and cardiovascular surgery, 2016]

Double aortic arch with an atrezated segment of the left arch distal to the origin of the left subclavian artery. Retroesophageal aortic diverticulum. Vascular ring.

No. 3 [Children's diseases of the heart and blood vessels, 2011]

Peer-reviewed scientific and practical journal. The journal covers the organization of the service "Pediatric Cardiology", publishes articles on the history of the specialty, reviews on the problems of pediatric cardiology and cardiac surgery, materials on topical issues, modern techniques, etc. Founded in 2004

Characteristic.
Persistence of the aortic arch is a congenital (congenital) anomaly. It is caused by a rupture of the canal between the aorta and the pulmonary artery (ductus arteriosis), which thus compresses the esophagus and has an indirect compression effect on the trachea.
In the process of ontogenesis, the transition from the branchial to the pulmonary circulation in the fetus occurs with the formation of six pairs of aortic arches, which then transform into the arteries of the small (pulmonary) and large (systemic) circulations. The formation of the aortic arch is normally associated with the transformation of the left fourth aortic arch.
The main clinical sign is Dysphagia (difficulty swallowing). Often there is also secondary inhalation pneumonia.
Nevertheless Clinical signs may also appear during lactation, and almost all dogs are diagnosed before 2 years of age. There are also dogs in which the development of signs of this disease manifests itself at a later age.

Susceptibility: Dogs, Cats, Horses

Etiopathogenesis.
With an anomaly of development, the aorta develops from the right fourth aortic arch. As a result, the aorta is not located to the left of the esophagus, but to the right. The ductus botalis, which runs from the aortic arch to the pulmonary artery, in this case pulls the esophagus in a ring. When the puppy eats thick bulky food, it will accumulate in the precordial part of the esophagus, which leads to the formation of a diverticulum.

Clinical signs.
Sick puppies lag behind in development, their weight decreases. After almost every feeding, they burp undigested food.

General clinic:
1. Auscultation: abnormal sounds of the upper respiratory tract;
2. Auscultation: Abnormal lung or pleural sounds, rales: wet and dry, whistles;
3. Dyspnoe (difficulty breathing, with open mouth);
4. Distension of the abdomen;
5. Dysphagia (difficulty swallowing);
6. Growth retardation; swelling in the neck;
7. Cough;
8. Fever, pathological hyperthermia;
9. The presence of food in the nasal cavity;
10. Obstruction (blockage) of the esophagus;
11. Polyphagia, extremely increased appetite;
12. Weight loss
13. Weight loss, cachexia, general exhaustion;
14. Precomeric salivation, ptyalism, salivation"
15. Vomiting, regurgitation, emesis;
16. Heart murmurs;
17. Increased frequency of respiratory movements, polypnea, tachypnea, hyperpnea;
18. Oppression (depression, lethargy);

Diagnosis is based on:
- contrast radiography of the esophagus (esophagography),
- aortography,
- pathoanatomically at autopsy

Technique of contrast esophagography.
The animal is allowed to swallow 50 ml of a thick suspension of barium sulfate in water and immediately take two pictures covering the chest and neck in frontal and lateral projections.
On the radiograph in the lateral projection, a precordial dilatation of the esophagus is noticeable. At the same time, the right-sided location of the aorta is visible in the dorsoventral projection.

differential diagnosis.
This developmental anomaly must be differentiated from megaesophagus and esophageal achalasia, which are characterized by the expansion of the esophageal tube all the way up to the diaphragm.

Forecast favorable with timely treatment.

Treatment.
Only surgery is possible. The course of the operation is the same as for the closure of the persistent ductus arteriosus. The arterial ligament that pulls the esophagus is ligated and dissected.
In this case, it is much easier, since the duct is almost always obliterated, and the ligament is longer than usual. The operation is completed by applying tightening serous-muscular plastic sutures to the expanded wall of the esophagus.