It branches like a tree, first into large branches (trunks), then into smaller branches and twigs, and is conventionally divided into several parts or sections:
- 1. The ascending aorta is the area from the aortic valve to the brachiocephalic trunk.
- 2. The aortic arch is a short section from which all the vessels supplying the arms and head (brachiocephalic arteries) depart. They anatomically form an arch connecting the ascending and descending aorta.
- 3. The descending (thoracic) aorta begins from the mouth of the left subclavian artery and continues to the diaphragm.
- 4. Below the diaphragm and before the bifurcation of the aorta (bifurcation) is the abdominal aorta.
Dividing the aorta into sections is very important for assessing risk and choosing optimal treatment tactics in patients with aortic aneurysms.
An aortic aneurysm is an area of local expansion.
Causes of aortic enlargement
Congenital systemic connective tissue diseases: Marfan syndrome, Ehlers-Danlos syndrome, caused by genetic changes in which the aortic wall has an abnormal structure, can cause the development of an aneurysm.
Acquired diseases that cause aneurysmal changes in the aortic wall: most often this is atherosclerosis. About 80% of all complicated aortic aneurysms are aneurysms caused by an atherosclerotic process, which leads to weakening of the vessel wall and the inability to withstand normal blood pressure, and as a result, to its expansion.
Less commonly, an aortic aneurysm develops in inflammatory diseases caused by external agents (syphilis, fungal infection, tuberculosis) or in autoimmune diseases (nonspecific aortoarteritis).
Symptoms of aortic aneurysm
Unfortunately, the diagnosis of aortic aneurysm cannot always be established during the “cold period” (before complications develop), since this disease is usually asymptomatic. Most often, it is discovered accidentally during fluorography, ultrasound or tomography studies performed in connection with other diseases. Treatment of an aneurysm of the ascending aorta before complications develop is much safer for the patient, therefore, in the early diagnosis of an aortic aneurysm, routine medical examination is important.
It is worth noting that every hundredth patient who died suddenly dies from aortic dissection.
Complaints usually appear when the aneurysm begins to stratify or, enlarging, compresses surrounding organs and tissues. Pain or dysfunction of those organs located in the area of the aneurysm appears. At first, this is not of a bright nature and, therefore, does not alarm either the patient or the doctor.
However, the pain intensifies as these deadly complications of an aortic aneurysm develop—it is some of the most severe pain a person can experience. It is localized in the chest if the aneurysm is located in the ascending, descending sections or in its arch, or in the abdomen if it formed in the abdominal section. Characterized by severe weakness, pallor, and often the person loses consciousness.
Impaired blood supply to organs located in the area of aneurysm rupture or aortic dissection (brain or spinal cord, kidneys, intestines, upper or lower extremities) leads to loss of function of these organs, and a large volume of blood loss during aortic rupture represents the most serious danger. To save a life, minutes count. If early surgical treatment is not available, the first-day mortality rate for aortic dissection is 1% per hour (one person in a hundred dies every hour). Within the first 24 hours, 33% of patients die from aortic dissection, 50% of patients within 48 hours and 75% within two weeks. Only early surgical intervention makes it possible to save a significant proportion of patients.
Why does vice occur?
Any malformation is formed in the fetus if a woman is influenced by negative environmental factors during pregnancy - smoking, alcoholism, drug addiction, ecology and unfavorable background radiation. However, genetic (hereditary) factors play an important role in the development of the child’s heart, as well as existing chronic diseases in the mother or past infectious diseases, especially in the early stages of pregnancy (influenza, herpes infection, chickenpox, rubella, measles, toxoplasmosis and many others) .
But, in any case, when any of these factors influence a woman in the early stages of pregnancy, the normal processes of ontogenesis (individual development) of the heart and aorta, formed during evolution, are disrupted.
So, in particular, the period of pregnancy of approximately 2-6 weeks is especially vulnerable to the fetal heart, since it is at this time that the formation of the aorta occurs.
Diagnosis of aortic aneurysm
In the diagnosis of aortic aneurysms, the so-called imaging techniques (ultrasound, MRI, CT, AG) are of greatest importance. In the ascending aorta, its arch and in the abdominal section, an aneurysm can be detected using ultrasound methods (ultrasound). To diagnose an aneurysm of the descending (thoracic) aorta, X-ray methods (x-ray, computed tomography) are required. To establish a final diagnosis and select a treatment method, contrast research methods are performed. Currently, the optimal diagnostic method, which provides the most complete information about the location, extent, diameter of the aneurysm and its relationship to nearby organs, is multislice computed tomography - aortography.
Treatment methods for aortic aneurysm
The main method of treating an aneurysm of any part of the aorta is surgical. The point of the method is to replace the dilated section of the aorta in order to prevent its further stretching and rupture. To replace the aorta, two methods are used - the endovascular (intravascular) method using a special intravascular prosthesis (stent graft), and open surgery - aortic replacement.
Each method has its own indications, and each of them has its own advantages and disadvantages.
The advantages of the surgical method lie in its versatility, that is, the ability to correct all disorders associated with an aortic aneurysm, regardless of the department and nature of the lesion. For example, in case of an aneurysm of the ascending aorta and damage to the aortic valve, aortic and aortic valve replacement is performed in combination with coronary bypass surgery.
To perform surgery on the ascending aorta and its arch, it is necessary to use artificial circulation, systemic hypothermia, and often complete circulatory arrest.
Indications for surgical treatment
- transverse size of the aneurysm,
- aneurysm growth rate;
- the formation of complications of this disease.
For each section of the aorta, there is a cutoff limit for the transverse size of the aorta, after which the risk of aortic rupture statistically significantly increases. Thus, for the ascending and abdominal aorta, the transverse diameter of the aneurysm is 5 cm dangerous in terms of rupture, for the thoracic aorta - 6 cm. If the diameter of the aneurysm increases by more than 6 mm in 6 months, then this is also an indication for surgery. Also threatening in terms of rupture and dissection of the aorta are the saccular form of the aneurysm and expansion of the aorta, which is smaller than the diameter that is the indication for surgery, but accompanied by pain at the site of expansion and dysfunction of the presenting organs. Dissections and completed ruptures of aneurysms are absolute indications for emergency surgery.
Catalog
Cardiac surgeon, scientist, teacher and organizer of science, Doctor of Medical Sciences (1973), Professor (1982), Academician of the Russian Academy of Medical Sciences (1994), Academician of the Russian Academy of Sciences (2011), Honored Scientist of the Russian Federation (1994) , laureate of the Lenin Prize (1976), State Prize of the USSR (1986), State Prize of the Russian Federation (2002), Prize of the Government of the Russian Federation (2003).
In 1994, L.A. Bockeria was elected through a competition to the position of director of the National Research Center for Agricultural Sciences named after. A.N. Bakuleva. In 1998, he simultaneously became director of the Center for Surgical and Interventional Arrhythmology of the Ministry of Health of the Russian Federation.
Since 1994, he has been the head of the Department of Cardiovascular Surgery at the Russian Medical Academy of Postgraduate Education (RMAPO) of the Ministry of Health of the Russian Federation. Since 1995, he has been the head of the Department of Cardiovascular Surgery No. 2 of the Moscow Medical Academy (now the First Moscow State Medical University), which he created. THEM. Sechenov Ministry of Health of the Russian Federation.
Since 2003, he has headed the Department of Cardiovascular Surgery and Interventional Cardiology at the Moscow State Medical and Dental University. A.I. Evdokimov Ministry of Health of the Russian Federation.
On the initiative of L.A. Bokeria at the National Medical Research Center for Agricultural Sciences successfully operates an educational and research center that annually conducts 4–6 courses of postgraduate advanced training for senior specialists.
L.A. Bokeria performs the entire known arsenal of heart surgeries for a wide variety of pathologies: from 3 to 6 operations per day, that is, from 700 to 900 operations using artificial circulation per year.
Since 1996, he has been the chief cardiac surgeon of the Ministry of Health of the Russian Federation.
L.A. Bockeria is the author and co-author of over 3,700 scientific publications, including more than 250 books, more than 100 inventions and utility models, more than 300 computer programs and databases, a number of which are registered abroad, on various problems of cardiovascular surgery, cardiology, medicine education and organization of medical science.
L.A. Bockeria owns unique works on the theoretical substantiation and clinical use of the hyperbaric oxygenation method in heart and vascular surgery. He is a leading specialist in the field of diagnosis and surgical treatment of cardiac rhythm and conduction disorders (especially tachyarrhythmias), including various combinations of cardiac arrhythmias with congenital and acquired heart defects and anomalies, coronary disease.
L.A. Bokeria is the initiator of the development of another new section of cardiac surgery in our country - minimally invasive heart surgery. L.A. made a great contribution. Bockeria in solving the problem of surgical treatment of coronary artery disease.
The role of L.A. is great. Bockeria in the development of new approaches to surgical treatment of terminal heart failure. His merit is the development of new operations in a severe category of cardiac surgical patients with various forms of cardiomyopathies. He was the first to develop the concept of dynamic cardiomyoplasty, including in children. L.A. Bockeria performed the first implantation of an artificial heart ventricle in our country and, after a long break, initiated the resumption of heart transplant operations at the Center.
On the initiative of L.A. Boqueria introduced advanced technologies for diagnosis and reconstructive surgery of diseases of the ascending aorta and arch into clinical practice.
He generated the development of another direction of modern medical science - creative cardiology, which determines the need for creative cooperation between doctors of different specialties: cardiologists, cardiac surgeons, specialists in functional diagnostics, fundamental and applied disciplines.
Under the leadership of L.A. At the Boqueria Center, new high-tech principles for the prevention and treatment of patients with cardiovascular pathology are being developed and introduced into clinical practice - the use of gene and cell therapy methods.
Academician L.A. Boqueria is conducting priority research on the creation of bioprosthetic heart valves for the correction of valve defects - a low-profile, curved bioprosthesis of the mitral and tricuspid valves, reproducing the natural shape of the fibrous ring, on an elastic frame. The study of the effectiveness of myocardial protection in children of the first year of life with the use of the new intracellular cardioplegic solution “Bokeria-Boldyreva”, created at the National Medical Research Center for Cardiovascular Surgery under the leadership of L.A., continued. Boqueria.
L.A. Boqueria is actively involved in the methodology of medical science and teaching activities. He is the founder of the country's largest cardiac surgery school, having trained more than one generation of doctors - cardiac surgeons, cardiologists, resuscitators and specialists in other related specialties.
L.A. Bockeria is the scientific supervisor of 350 candidate dissertations and a consultant of more than 100 doctoral dissertations. He is the founder of the publishing house NMITSSSH named after. A.N. Bakuleva with the printing house, founder and editor-in-chief of the journals “Annals of Surgery”, “Bulletin of the National Medical Center for Cardiovascular Surgery named after. A.N. Bakulev “Cardiovascular diseases”, “Childhood diseases of the heart and blood vessels”, “Clinical physiology of blood circulation”, “Annals of Ari, information collection “Cardiovascular surgery”; Editor-in-chief of the journal "Thoracic and Cardiovascular Surgery".
Active work of L.A. Boqueria and his contribution to domestic healthcare have been awarded titles and awards of the highest value. He is a laureate of the Lenin Prize (1976), two State Prizes (1986 - USSR, 2002 - Russian Federation), and the Prize of the Government of the Russian Federation (2003). For outstanding achievements of L.A. Bockeria was awarded the Order of Merit for the Fatherland, III (1999), II (2004) and IV (2010) degrees, the Order of Dignity and Honor (Republic of Georgia, 1999), the Order of St. Sergius of Radonezh, II degree (2001). The Russian Biographical Institute has repeatedly recognized L.A. Bokeria “Person of the Year”, and in 2000 - “Person of the Decade” in the “Medicine” category. In 2002, he was awarded the title “Legend Man”, the all-Russian “Russian National Olympus” award, established by the Government, the Union of Industrialists and the Third Millennium Foundation. As one of the leading cardiac surgeons in the world in 2003, L.A. Bokeria was awarded the international Golden Hippocrates award. In 2004, he was awarded the RAS Triumph Prize in the Life Science – Medicine category. In 2004, he was awarded the Order of Patron, which is awarded by the Patrons of the Century Charitable Foundation for his outstanding contribution to the revival and prosperity of the world, for the greatness of the soul, for selfless generosity; in 2004 and 2005 – the Golden Badge of Honor “Public Recognition”, which is awarded by the National Foundation for “Public Recognition”, the National Civil Committee for Interaction with Law Enforcement, Legislative and Judicial Bodies and the independent organization “Civil Society” for great personal contribution to the development of the domestic medicine, conducting unique cardiac surgery using the latest medical technologies that saved the lives of hundreds of children and newborns, many years of fruitful scientific, practical, pedagogical and educational activities, active citizenship.
In 2006, L.A. Boqueria was awarded the Honorary Diamond Order “Public Recognition”, awarded a diploma from the Presidium of the Parliament of the Peoples of Russia “for saving numerous lives, outstanding knowledge, ability to lead, for unique personal qualities - nobility, courage, sense of duty, ability to preserve honor and dignity, keep one’s word and do business, also for faith in the great future of the Fatherland,” a Gold Medal for outstanding contribution to the education of Russia and a Gold Star “Honor, Pride and Glory of Russia.”
In 2008, L.A. Bockeria was awarded the medal “For practical contribution to strengthening the health of the nation”, the Order of Honor with the title “Support of Honest Business” and the honorary title “Outstanding Cardiac Surgeon of Our Time”. In 2009, the huge contribution of L.A. Bockeria's contribution to science and domestic healthcare was awarded the A.N. Prize. Kosygin “For great achievements in solving problems of the development of the Russian economy” and the Moscow City Prize in the field of medicine “for the development and introduction into clinical practice of a new biological valve “Bioglis”.
L.A. Bokeria is a full member of the American Association of Thoracic Surgeons (1991), member of the board (1992) and member of the Presidium (since 2003, consul) of the European Society of Thoracic and Cardiovascular Surgeons, member of the board of the European Society of Cardiovascular Surgeons, member of the scientific board of the International Cardiothoracic Center of Monaco (1992), member of the Serbian Academy of Sciences (1997), honorary member of the American College of Surgeons (1998), academician of the Academy of Medical Sciences of Ukraine, honorary professor of Moscow State University. M.V. Lomonosov (2011), foreign member of the National Academy of Sciences of Georgia (2012).
He is the president of the Association of Cardiovascular Surgeons of Russia (1995), president of the All-Russian public organization “League of National Health” (2003), member of the Public Chamber of the Russian Federation of all convocations.
Types of open surgical operations for aortic aneurysms:
- Bentalla-De Bono operation (replacement of the ascending aorta with a valve-containing conduit with a mechanical prosthetic aortic valve);
- David's operation (replacement of the ascending aorta while preserving the native aortic valve);
- Supracoronary aortic replacement;
- Prosthetics of the ascending aorta and its arch (Borst technique, the use of oblique aggressive anastomosis and other techniques);
- Thoracic aortic replacement;
- Abdominal aortic replacement.
Endovascular interventions
They allow you to dramatically reduce the amount of surgical trauma, shorten hospitalization periods and reduce the inevitable suffering of the patient associated with surgical approaches. One of the main disadvantages of the method is the need for repeated interventions.
Types of endovascular operations for aortic aneurysm:
- implantation of a stent graft into the abdominal aorta,
- implantation of a stent graft into the ascending (thoracic) aorta.
The most modern method of treating aortic aneurysm is a hybrid method, which allows achieving optimal treatment results with the least surgical trauma.
Hybrid surgeries combine the advantages of open and endovascular interventions.
To prevent the development of aortic aneurysms, the most important thing is the need to control risk factors, namely arterial hypertension. In addition to arterial hypertension, the most significant risk factors are age (over 55 years), male gender, smoking, the presence of aneurysms in direct relatives, and high cholesterol levels.
Forecast
The prognosis for an isolated right-sided aortic arch is favorable, since in most cases surgical intervention is not even required. So, in general, we can say that an isolated right aortic arch is not life-threatening for the child.
With combined types, the situation is much more complicated, since the prognosis is determined by the type of concomitant heart defect. For example, with tetralogy of Fallot, the prognosis without treatment is extremely unfavorable; unoperated children with this disease usually die in the first year of life. After surgery, the duration and quality of life increase, and the prognosis becomes more favorable.
