Stratification of an aorta
Stratification of an aorta results from a rupture of an intima with blood penetration podintimalno and forming of a false gleam. Usually blood otslaivat an intima from an average cover, peeling of an average cover from an adventitia is less often observed. Diameter of a false gleam (channel) at a large number of the aorta of blood which streamed in a wall can approach diameter of an aorta, causing sometimes full occlusion of a true gleam of an aorta. Breakthrough of false channel in a gleam of the basic can happen in any place, a thicket — in one of ileal arteries. At the long (chronic) course of a disease the false channel can become covered by an epithelium.
In most cases (nearly 95%) stratification happens in the ascending aorta site (proximal stratification, or type A), at the same time the anguish of an intima comes usually at distance about 2,5 cm from an aorta ring. Stratification in the descending department of an aorta (distal stratification, or type B) is much less often observed, and the anguish of an intima is usually observed below the place of an otkhozhdeniye of a subclavial artery. Time having arisen, stratification usually extends distally and often reaches ileal arteries, and any of aorta branches can be involved in process of stratification. Less often stratification is limited only to the ascending part of an aorta — usually it happens in the absence of hypertensia or at timely purpose of anti-hypertensive therapy.
Factors which contribute to stratification of an aorta are arterial hypertension (accompanies stratification almost in 70% of cases), the disturbances of structure of connecting fabric hereditarily caused (media necrosis), inborn heart diseases (a dvustvorchatost of the aortal valve) and vessels (aorta coarctation). Stratification of an aorta is a basic reason of death of patients with Marfan's syndrome, can meet also at atherosclerosis, aortites. It is reported about cases of stratification of an aorta at patients after aorta catheterization, after operation of prosthetics of the aortal valve.
Proximal stratification happens against arterial hypertension, Marfan's syndrome, a dvustvorchatost of the aortal valve more often; distal — at arterial hypertension, atherosclerosis, aorta coarctation.
Stratification of an aorta can happen at pregnant women on late durations of gestation.
Clinical picture of stratification of an aorta
Stratification of an aorta is most often observed at persons of advanced and senile age, mainly at men, however in certain cases (Marfan's syndrome, aortites, pregnancy) this morbid condition can arise also in young pl mature age.
It is accepted to divide stratification on acute — about two weeks from the beginning of symptoms (during this term in the absence of treatment 3/4 patients die), and chronic which duration happens about several months and even years. Usually if the patient endures the acute period, the disease gets a chronic current. However also latent development of a disease as some patients with the proved picture of stratification of an aorta cannot point to time of developing of a disease is possible.
At proximal stratification (type A) there are strongest stethalgias reminding a painful attack at a myocardial infarction; pains irradiate on the aorta course. The blood which arrived subintimalno often otslaivat an intima not only aortas, but also its branches that leads to ischemia of upper extremities, a head and spinal cord.
At distal stratification (type B) there are sharp pains in epigastriums, to back with irradiation in a neck, extremities; pains and in a thorax can be observed. Stratification distribution distally leads to ischemia of abdominal organs, kidneys and lower extremities. The condition of patients in an initial stage of a disease always very heavy, is observed the picture reminding shock though arterial pressure in many cases is increased. At stratification of branches of an aortic arch syncopal states, a vision disorder, a hemiplegia are possible; at ischemia of a spinal cord — paralysis of the lower extremities. The pulsation of peripheral arteries can be lowered or is absent. At proximal stratification quite often there is aortal regurgitation, is frequent with a picture of an acute left ventricular failure. Besides, at localization in the ascending aorta stratification can extend not only distally, but also proksimalno that leads to a hemopericardium, a lead of the aortal valve, occlusion of coronary arteries.
The death of patients is caused by a rupture of an aorta with hemorrhages in a pericardium, a pleural cavity, or owing to acute heart failure (a hemopericardium, acute aortal insufficiency). At stratification of the descending aorta the death can be caused by acute ischemia of abdominal organs or kidneys.
Chronic stratification of an aorta often proceeds asymptomatically or is shown by signs which happen at an aortic aneurysm. Patients to a chronic current can have an acute stratification or a rupture of an aorta.
Diagnosis of stratification of an aorta
Still acute stratification of an aorta in practice is distinguished not often. Suddenly arising sharp stethalgias with irradiation in hands, a back have to cause suspicion not only on an acute myocardial infarction, a thromboembolism of large branches of a pulmonary artery or an acute pericardis, but also on stratification of an aorta. Quite often on an ECG signs of a hypertrophy of a left ventricle of heart — result of arterial hypertension which almost always precedes stratification of an aorta are found. Symptoms of acute ischemia on an ECG are absent, and it allows to exclude an acute myocardial infarction. Only in rare instances when stratification extends to coronary arteries (usually right), on an ECG observe symptoms of acute ischemia of the lower wall of a left ventricle. In diagnosis of acute stratification of an aorta transesophageal EhoKG has crucial importance.
Chronic stratification of an aorta is quite often distinguished at inspection in other occasion or by purposeful search of the reason of pains or other symptoms (a prelum, ischemia of bodies) by means of EhoKG, a computer tomography or a magnetic and resonant tomography.
Treatment of patients with stratification of an aorta
At patients with arterial hypertension urgent measures for lowering of arterial pressure are necessary: systolic pressure has to be reduced to 100 mm of mercury. or is slightly lower. It is reached by means of intravenous administration of Sodium nitroprussidum to which, for the prevention of undesirable effects of Sodium nitroprussidum (increase in ChSS, increase of force of reductions of a left ventricle), intravenous administration within 5 min. propranolol before achievement of ChSS about 60 one minute has to precede.
At lowering of arterial pressure to the planned level continue treatment by β-adrenoblockers in individually picked up doses.
At stratification of the ascending aorta urgent surgical intervention with prosthetics of part of an aorta, and if necessary — and its branches is carried out. In cases of stratification of the descending aorta waiting tactics is possible. The indication to operation in these cases are incessant pains, stratification increase, symptoms of ischemia of abdominal organs, kidneys, lower extremities or a rupture of aneurism.
At chronic stratification of an aorta by the patient appoint anti-hypertensive drugs (it is desirable — in the absence of contraindications, β-adrenoblockers)))))))))) with maintenance of level of systolic arterial pressure not higher than 100 mm of mercury.; to lindens with normal arterial pressure also appoint β-adrenoblockers with a reference point to the same level of systolic arterial pressure.
At chronic stratification of the ascending aorta the issue of operation has to be resolved soon; at chronic stratification of the descending aorta waiting tactics, especially at elderly people is possible.