Aneurysm in women

In general, an aneurysm is a locally dilated segment of the vessel, with a tendency to gradual thinning of its wall. This pathology refers to irreversible processes: over time, under the influence of functioning blood flow, the enlarged segment increases, increasing the risk of rupture and intense arterial bleeding. According to statistics, aneurysms in women are somewhat less common than in men, but proceed with a higher frequency of complications. Without timely medical intervention, such complications are inevitably fatal.

Epidemiology

Over the last few years, there has been a slight decrease in vascular pathologies in women over 65 years of age. However, despite this, mortality from aneurysms remains quite high, and the mortality rate in female patients is about 5-10% higher than in men, although the incidence rate is lower.

Vascular pathologies are considered the most frequent cause of mortality in women, and over the last two decades, scientists have made significant progress in the study of the effects of atherosclerosis and cardiovascular disease. In European countries, more than 50% of all fatalities in the female population are due to cardiovascular pathologies (in men, the figure is about 43%). Some risk factors are specific to women: in particular, there are disorders during pregnancy, gestational hypertension and diabetes mellitus, endocrine disorders closely associated with accelerated development of vascular pathologies.

Lethality from aneurysms in women is higher than in men: almost every second patient dies, after rupture a person lives on average up to 11 hours. Among the female population, aneurysms are the most vulnerable to aneurysm development:

• women between the ages of 45 and 80;
• smokers;
• patients with uncontrolled high blood pressure, excessive body weight, atherosclerosis, impaired cholesterol metabolism;
• women who have relatives with an aneurysm (in this situation, the risks are doubled).

Despite the fact that there are fewer women smokers than men, the risk of aneurysm development due to smoking is 20-30% higher in the female population compared to men. Combining nicotine with oral contraceptives is considered particularly dangerous.

The impact of obesity is much more unfavorable. Thus, overweight increases the relative risks of aneurysm development in women by about 64% (in men this figure is about 46%).

Dyslipidemia in terms of risks of aneurysm development is much more important after the onset of menopause.

Causes of the aneurysms in women

The main root causes of aneurysms in women are various diseases and conditions that lead to weakening and loss of elasticity of the arterial wall. Such conditions are often:

• Atherosclerotic changes in the vascular wall (this cause is recorded in 70-90% of cases);
• inflammatory processes in the vessel (in particular, aortitis) of syphilitic, mycotic, gigantocellular origin;
• trauma, mechanical damage to the vascular wall;
• Congenital abnormalities affecting connective tissue structures (e.g., Marfan or Ehlers-Danlos syndromes);
• autoimmune pathologies (in particular, nonspecific aortoarteritis);
• iatrogenic root causes associated with medical manipulations (such as reconstructive interventions on the artery and its branches, coronary catheterization, aortography).

Atherosclerosis of the vascular wall is clearly considered by experts to be the main cause.

Risk factors

Despite the fact that in men aneurysm occurs more often than in women, for the weaker sex there are also a number of factors that can lead to the development of this pathology. Such factors include:

• smoking (thanks to a study, it was found that almost 100% of aneurysm patients had a long smoking history (more than 25 years), and the development of life-threatening complications in smokers is 4 times more common than in nonsmokers);
• Age greater than 45-55 years (menopause and postmenopause periods in women);
• aggravated hereditary history;
• Long-standing arterial hypertension (blood pressure values exceeding 140/90 mmHg);
• sedentary lifestyle, lack of physical activity;
• overweight, obesity of any degree;
• high blood cholesterol.

Hypertension, excessive body weight, and dyslipidemia increase the risk of aneurysm development in women to varying degrees. With regard to specific factors for women, there is data on the involvement of preeclampsia, gestational diabetes, the onset of menopause in the development of pathology. Studies have shown that cardiovascular disorders are often the cause of death in both women and men, but their prevalence is still higher among women.

Pathogenesis

Aneurysms in women can be single, multiple, single-chamber or multichamber, and depending on the configuration, sac-shaped or spindle-shaped. A dissecting aneurysm requires a special description, which is characterized by the ingress of blood between the vascular layers, which gradually leads to their divergence and layer-by-layer thinning of the artery.

It is also necessary to distinguish between false and true aneurysms: false aneurysms are distinguished by the fact that the appearance resembles a bulge of the vascular wall, but in fact is a perivascular hematoma (the wall is not disturbed).

Aneurysms in women can be congenital - such pathologies make themselves known at an early age.

In addition, to understand the pathogenetic features, it is necessary to know where the aneurysmal enlargement may be located:

• Aortic aneurysm [1] in women may involve the following compartments:
  • ascending section;
  • arch;
  • descending;
  • abdominal;
  • sinus of Valsalva.
• Cerebral aneurysm [2] can affect:
  • internal carotid artery;
  • the anterior cerebral artery;
  • the middle cerebral artery;
  • the vertebrobasilar system.
• A hamstring aneurysm is a bulge of the main artery that runs from the lower third of the thigh to the upper third of the tibia. Thus, the hamstring arterial vessel is a continuation of the superficial femoral artery, which below the knee joint diverges into the anterior and posterior tibial vessels and the peroneal artery. This network supplies blood to the ankle area, so if an aneurysm develops in this area, there is a deficit of blood supply to the limb and acute ischemia occurs. [3]

Loss of elasticity and weakening of the vascular wall predispose to the development of aneurysms in women. Such unfavorable processes may be associated with congenital individual characteristics, or with the influence of external factors. So, in the vast majority of cases, the trigger mechanism is atherosclerosis, accompanied by the formation of cholesterol deposits on the walls of the arteries. Other less common causes include inflammatory processes (bacterial, fungal), autoimmune pathologies, connective tissue disorders (cystic fibrosis, Marfan syndrome, etc.), trauma (including injuries due to therapeutic and diagnostic manipulations).

Symptoms of the aneurysms in women

The clinical presentation of aneurysms differs slightly, but not significantly, between the sexes. For example, men are more likely to present with pressing or compressive chest pain and respiratory difficulties similar to those of ischemic heart disease. In women, abdominal pain, dizziness, shortness of breath, unmotivated fatigue, and digestive disorders are more common. Moreover, female patients are more likely to develop microvascular dysfunction.

Symptomatology is often slow to detect itself, but the first signs are more likely to appear in patients who suffer from arterial hypertension, overweight and obesity, dyslipidemia, other cardiovascular pathologies. The initial symptoms of aortic aneurysm in women may be as follows:

• feeling of pressure on internal organs (in the chest, abdomen);
• a feeling of heaviness in the abdominal or heart area;
• dizziness, systematic headaches;
• bulging neck veins;
• shortness of breath;
• dull pain in the area of localization of the aneurysm.

If it is a lesion of the cerebral vessels, then there are often such signs of cerebral aneurysm in women:

• Disorder of muscle tone on one side of the facial musculature;
• headaches (frequent, sudden, quite severe);
• dilated pupils;
• eye pain, foggy eyes;
• zonal numbness, impaired sensation;
• intermittent nausea, vomiting;
• visual disturbances, double vision, photophobia;
• a feeling of fatigue, general weakness, depression of consciousness.

In abdominal aortic aneurysm patients pay attention to the appearance of a feeling of heaviness in the abdomen (like overeating), periodic vomiting (has a reflex connection), belching, decreased urination. Palpatorially, you can determine the presence of a pulsating formation in the abdominal cavity. Symptoms of abdominal aortic aneurysm in women are often mistaken for pathology of the reproductive organs or digestive system, so to make the correct diagnosis it is necessary to consult doctors as early as possible and conduct a comprehensive diagnosis, involving various specialists - including gynecologist, urologist, gastroenterologist, infectious disease specialist. [4]

If we consider the symptoms of a cardiac aneurysm, symptoms in women are more often manifested by intrathoracic pain and a feeling of internal pressure, increased fatigue, frequent dizziness and pallor of the skin. Heart pain is more often pressing, cyanosis, swelling of the face and extremities are noted. [5] In the long-term course of aneurysms are characteristic:

• frequent pneumonias;
• difficulty swallowing;
• hoarseness of voice;
• heart rhythm disturbance.

The symptoms of a hamstring aneurysm in women are:

• coldness of the affected limb;
• pallor and lividity of the skin on the side of the lesion;
• numbness and loss of sensation in the affected limb;
• pain;
• trophic disorders.

A pulsating and protruding tumor-like mass in the hamstring area can be palpated. There may be swelling of the foot and ankle and, less frequently, shooting pains in the leg.

It is important to realize that an aneurysm of the hamstring artery is often combined with a lesion of the femoral artery (inguinal ligament area), and the aneurysm zones may be multiple. In such a case, the probability of complete loss of limb function increases significantly, up to the development of flaccid paralysis. In the absence of treatment, tissues undergo irreversible changes, gangrene develops. Thrombosis and thromboembolism are also frequent complications.

Complications and consequences

In uncomplicated aneurysms, most women complain only of periodic pressing pains in the area of localization of pathology, as well as the sensation of pulsation and the presence of a palpable pulsating mass (for example, in the abdominal cavity).

The main complication that threatens the life of a woman with an aneurysm may become a rupture of the pathologic enlargement, [6] which is accompanied by such symptomatology:

• the appearance of sharp pain in the area of localization of the aneurysmal focus, or a sharp increase in the already existing pain;
• Irradiation of pain to the back, groin, jaw, shoulders (depending on the localization of the aneurysm);
• lowering blood pressure;
• clinical picture of myocardial infarction, peritonitis, stroke (depending on localization);
• intense increase in signs of anemia;
• signs of internal bleeding.

When a cerebral vessel aneurysm ruptures, a hemorrhagic stroke develops, the nervous system is damaged, and the patient quickly dies.

The main risks of a hamstring aneurysm are a high probability of embolization - blockage of downstream arterial vessels by clot particles, or occlusion of the aneurysmal cavity. Both the first and the second complication can cause the development of acute ischemia and gangrene of the limb, which is caused by a sharp loss of blood supply.

Diagnostics of the aneurysms in women

The diagnostic algorithm when an aneurysm is suspected in a woman is as follows:

1. History taking.
2. Physical examination.
3. Depending on the findings identified:

• electrocardiography;
• chest x-ray;
• chest CT scan;
• an examination of the abdomen, digestive system;
• X-rays of the spinal column, shoulder joints, ribs;
• Echocardiogram;
• angiography;
• MRI of the brain.

Lab tests:

• Blood biochemistry (cholesterol, triglycerides, lipoproteins, lipoprotein fractions, atherogenicity level, total protein);
• general blood and urine tests;
• coagulogram;
• creatinine, potassium, urea;
• glucose, glucose tolerance;
• hormonal status.

To detect asymptomatic aneurysms in women is often helped precisely by instrumental diagnostics, which consists in performing magnetic resonance or computed tomography, performed for other reasons. Optimal methods of visualization are considered:

• MRI and CT scans;
• cerebrospinal examination, cerebral angiography.

Differential diagnosis

If a woman seeks help for chest pain, the doctor should clarify all the characteristics of the pain syndrome, find out the factors that increase or relieve pain.

• Increased pain sensation at the moment of respiratory movement or coughing indicates the involvement of the pleura, mediastinum or pericardium in the pathological process. It is also possible that intrathoracic structures are affected, which are typically associated with motor activity.
• Pathologies of the upper digestive tract are characterized by the connection of the pain syndrome with the consumption of food.
• If a positive effect is noted after taking a nitroglycerin tablet, anginous pain, cardiospasm, esophageal disease can be assumed.
• Swallowing difficulties are seen in esophageal pathologies, cardiospasm, but may also be present in aortic aneurysm in women.
• If pain is combined with a sharp drop in blood pressure and dyspnea, it is possible to suspect not only aneurysm dissection, but also myocardial infarction, pulmonary embolism. And the combination of pain with dyspnea and cyanosis may indicate the presence of pneumothorax, cardiac malformation, pleuropneumonia, pulmonary hypopneumonia.
• If there is an elevated body temperature, one may suspect the presence of infectious inflammatory or tumor processes, as well as pulmonary infarction, mediastinitis, acute pericarditis.

If different pressure readings are noted in both arms, you should think about the possibility of aortic dissecting aneurysm!

Treatment of the aneurysms in women

If the diagnosis of aneurysms in a woman, but the pathology is not considered prone to progression, then doctors try to adhere to conservative tactics: put on the record to the cardiologist and vascular surgeon, regularly monitor the general condition, blood pressure and pulse, perform ECG, systematically tracing possible changes in the aneurysm and preventing the development of complications.

On indications, antihypertensive therapy is prescribed, which is necessary to normalize blood pressure values and prevent excessive pressure of blood flow on the thin wall of the pathological enlargement.

The need for anticoagulant drugs is due to the prevention of the formation of blood clots and further thromboembolism. And the reduction of cholesterol levels is achieved by combining drug therapy and nutritional correction.

Surgical intervention for aneurysms in women is indicated:

• when the aneurysm lumen is severely dilated;
• at high risk of complications;
• in cases of severe symptoms that severely limit the patient's quality of life.

Drug treatment

Medications are not able to eliminate aneurysms in women, but they alleviate the general well-being of patients, reduce the likelihood of complications. It is possible to prescribe such medications:

• Calcium channel blockers (Nimodipine) promote vasodilation, improve blood circulation, and prevent vascular spasms.

Nimodipine

The drug is taken orally without chewing, drinking liquid, regardless of food intake. Intervals between drug intake - at least 4 hours. Dosage is prescribed by a doctor (average daily dosage - 360 mg). It is not prescribed for persons under 18 years of age. Treatment may be accompanied by transient increase in the activity of hepatic transaminases, decrease in blood pressure, headache.

• Anticonvulsants (Fosphenytoin) stabilize the nervous system, inhibit the spread of pathological nerve impulses.

Fosphenytoin (Phenytoin, Diphenin)

It is taken orally immediately after a meal. The average dosage is 1 tablet 3-4 times a day (at the discretion of the attending physician). In some cases, the drug may cause dizziness, nausea, and with prolonged use - osteoporosis.

• Analgesics (Morphine) is used for severe pain that cannot be controlled by conventional painkillers.

Morphine

An opioid analgesic with a pronounced analgesic and antishock effect. It is effective approximately 25 minutes after internal administration or 12-14 minutes after subcutaneous administration. It is prescribed and dispensed only by the attending physician.

• Antihypertensives (Captopril, Labetalol) reduce total arterial tone, preventing aneurysm rupture.

Captopril	The recommended starting dosage is 25-50 mg per day (divided into two doses). It can be combined with thiazide diuretics. In the course of treatment, the dose is adjusted by the attending physician.
Labetalol	Take orally with food 0.1 g 2-3 times a day. If necessary, the dose is increased. The drug is not administered to women with severe heart failure and atrioventricular block.

Surgical treatment

Neurosurgical care usually consists of these standard variations of treatment:

• Aneurysm dissection (clipping) is an open intervention in which a special clamp is used to intercept the affected vascular segment. The operation is effective, but the recovery and rehabilitation period is quite long. [7]
• Endovascular aneurysm embolization is a minimally invasive treatment option that does not involve open access and is characterized by a minimal recovery term. A special spiral-shaped framework is inserted into the damaged artery, blocking blood flow in the aneurysm sac. [8]

The choice of one or another surgical intervention is associated with various individual factors, so it is discussed by doctors separately for each specific case. Scheduled operations increase the survival rate of patients with aneurysms, so it is recommended not to avoid this type of treatment if the size of pathological bulges is large. However, it should be noted that in about 10% of cases, women have not one, but two or more aneurysms of other localizations, which should be taken into account when carrying out complex diagnostic measures.

Prevention

Preventive measures to prevent aneurysms in women are nonspecific and consist of the following:

• Complete elimination of smoking (including secondhand smoke);
• Reducing the consumption of alcoholic beverages, up to complete abandonment of them;
• physical education and sports;
• getting rid of factors that can negatively affect blood pressure (stress, renal pathologies, etc.);
• impact and prevention of conditions that contribute to aneurysm formation in women (atherosclerosis);
• obligatory referral to doctors in case of unexplained arrhythmias, pain in the chest, abdomen, head;
• systematic and complete preventive examinations by cardiologists and vascular surgeons.

If a woman has already been diagnosed with an aneurysm, preventive measures should be directed at preventing the development of complications:

• anticoagulant treatment is competently selected to prevent thrombosis in the dilated lumen;
• corrected physical activity, eliminating activity that can provoke excessive tension of the thin aneurysm wall and, as a consequence, its rupture;
• antihypertensive drugs are prescribed (to normalize blood pressure values);
• provides complete psychological calm (stressful situations - a fairly common factor in the development of complications of aneurysms in women).

In addition, hormonal background control by the attending physician is required.

Forecast

Complications that develop in aneurysms, in most cases become the main indications for urgent surgical intervention. In women with aneurysms, the probability of adverse effects is quite high, which in 20% is due to ignorance of the existing pathology, or false hopes for a cure.

The success rate of elective surgeries is quite high, and after timely surgical intervention in many cases recovery occurs. In operations performed for complications, the results of treatment depend on the urgency and timeliness of intervention. For example, surgery for a ruptured aneurysm of the hamstring artery in the first six hours from the moment of rupture can save the limb in 80% of patients. In all other cases, treatment may consist only in amputation of the affected leg.

In the absence of appropriate treatment measures, the prognosis for women with aortic and cerebral aneurysms is considered unfavorable, as there is an increased risk of rupture or thrombotic complications. If the problem is detected in a timely manner and the patient undergoes surgery, the prognosis is considered more optimistic.

To prevent aneurysms in women from complications, it is recommended to annually, regularly examined by your family doctor, as well as a cardiologist, neurologist. It is equally important to adhere to a healthy lifestyle, control blood cholesterol and blood pressure, completely eliminate smoking, avoid hypodynamia, and adjust nutrition.