Atherosclerosis of the abdominal aorta and its branches

Atherosclerosis is a well-known and common disease that affects the arteries and is accompanied by the formation of cholesterol deposits on the internal vascular walls. If the process involves the abdominal part of the aortic vessel, which passes through the lower abdominal cavity, then the doctor diagnoses "atherosclerosis of the abdominal aorta." The disease can cause serious complications, including disability and death. However, it is not so easy to suspect a pathology, which is associated with an indistinct symptomatology and a frequent latent course.

Epidemiology

In every second patient with aortic circulation disorder, it is the abdominal part of the vessel that is affected. This department is responsible for the supply of blood to the organs of the abdominal cavity, lower limbs and small pelvis.

Over the past few years, the incidence of atherosclerosis has increased significantly, and the death rate from this disease has exceeded the rates due to injuries, infectious pathologies and oncology. Most often, atherosclerosis of the abdominal aorta is found in men aged 45-55 years. Women get sick about 3-4 times less often, and the risk of getting sick increases significantly with the onset of the menopausal period. [1]

The disease is quite common: it is diagnosed in about every twentieth person over 65 years of age.

In European countries and the United States of America, atherosclerosis of the abdominal aorta is much more common than in African countries. The greatest spread of the disease is noted in the USA, Canada, Great Britain, Finland, Australia. The lowest incidence is registered in Japan. [2]

Atherosclerosis and the complications caused by it currently remain the main cause of morbidity and mortality in many countries of the world, including the post-Soviet space. The defeat of the abdominal aorta is found in more than 75% of cases of autopsy of patients who died from coronary heart disease. [3] In more than half of the cases, the pathology is determined only against the background of the development of an acute disorder of the mesenteric circulation.

Causes of the atherosclerosis of the abdominal aorta

Atherosclerosis of the abdominal aorta is a chronic pathology. The disease is characterized by a specific lesion of the vessel, connective tissue proliferation against the background of fatty infiltration of the inner wall, which generally leads to organ and general circulatory disorders.

There are several theories of the appearance of pathology - in particular, the theory of lipoprotein infiltration, as well as the most common one - due to the appearance of pathological changes due to damage to the vessel wall. Such damage is not the result of mechanical trauma to the endothelium, but a violation of its function. We are talking about an increase in permeability, adhesiveness, an increase in the synthesis of procoagulant and vasoconstrictor factors. [4]

Violation of endothelial function can be triggered by infection (for example, herpesvirus), intoxication (tobacco smoking, etc.),  [5] hormonal imbalance (hyperinsulinemia), hemodynamic disorders (hypertension), etc. But the main link scientists unanimously consider hypercholesterolemia.

The main reason for the development of atherosclerosis of the abdominal aorta is impaired lipid-protein metabolism, which provokes the appearance of typical atherosclerotic plaques. Nutritional disorders entail metabolic disorders, damage to the vascular walls, and a change in their structure. [6] Regular hypothermia, weakened immunity, frequent stress and psychoemotional stress, infectious and inflammatory processes, hormonal changes, trauma, together lead to damage to the internal vascular wall. The situation can be aggravated by: improper lifestyle with a lot of bad habits, excess weight, endocrine pathologies, taking certain medications. Concomitant diseases also play a significant negative role: hypertension, obesity, diabetes mellitus,  [7] coronary pathologies.

Experts identify the following main reasons for the development of the disease:

• alimentary (food) violations;
• neurogenic factors (stress, emotional instability, neuroses);
• endocrinopathy;
• prolonged increase in blood pressure, hypoxic conditions;
• autoimmune pathologies;
• hereditary predisposition; (the influence of maternal hypercholesterolemia during pregnancy on the progression of early atherosclerotic lesions in childhood has been proven)  [8];
• overweight, different degrees of obesity; [9]
• lack of physical activity;
• alcoholic, nicotine, drug addiction.

Risk factors

The factors that can lead to the development of atherosclerosis of the abdominal aorta can be divided into several groups: intransient factors, transient and potentially transient.

Permanent factors are permanent and cannot be eliminated:

• age over 40-45 years old;
• male sex (men suffer from atherosclerosis more often than women);
• hereditary predisposition (often the disease is found in people whose relatives also suffer from atherosclerosis of the abdominal aorta). The formation of fatty streaks occurs in the aorta of the human fetus and is significantly enhanced by maternal hypercholesterolemia. [10]
• ethnic risk factors. [11], [12]

Experts point out that hereditary predisposition contributes to an earlier onset of the development of pathology.

Transient risk factors include those that can be eliminated:

• smoking, its negative effect on the elasticity of blood vessels;
• unhealthy diet, eating a lot of animal fats;
• physical inactivity, passive lifestyle, excess weight.

Potentially transient factors include diseases that can be corrected, controlled and prevented from further development:

• hypertension, which favors the deposition of lipids in the vascular wall and the formation of atherosclerotic plaques; [13]
• dyslipidemia, impaired fat metabolism, which is accompanied by an increase in cholesterol, lipoprotein and triglyceride levels;
• diabetes mellitus, obesity increase the risks of developing atherosclerosis of the abdominal aorta several times, which is due to the simultaneous violation of lipid metabolism; [14]
• infectious and intoxication processes contribute to damage to the vascular walls.

If you know and take into account the main provoking factors, then you can determine the basic rules for the prevention of the disease. [15]

Pathogenesis

The development of atherosclerosis of the abdominal aorta is due to a combination of factors - in particular, endothelial dysfunction, inflammatory reaction, immunological process, dyslipidemia, plaque rupture, external negative influences (for example, smoking).

The endothelium produces substances necessary to control blood coagulation and metabolic brain processes, regulate vascular tone and blood pressure, filter renal function and contractile cardiac activity. The first stage in the development of atherosclerosis is provoked by a violation of the endothelial vasodilator function, which, in turn, becomes a consequence of the loss of nitric oxide by the endothelium. Dysfunction of the endothelium is also caused by an increased content of cholesterol in the blood, diabetes mellitus, prolonged hypertension, and nicotine addiction. The disorder occurs under the influence of low density lipoprotein oxidation. [16]

• Inflammatory processes in atherosclerosis were observed in almost all cases. They involved macrophages, cytokines, monocyte chemotaxis protein, growth factors, interleukin-1, -3, -6, -8, -18, tumor necrosis factor α, CD40 ligand. Atherosclerotic development is also associated with serum C-reactive protein. An increased level of lipoprotein-associated phospholipase increases the likelihood of complications; the involvement of cytokines, which induce cell proliferation and stimulate the production of active oxygen forms, activate matrix metalloproteinases and the expression of tissue factor, is not excluded.
• Lipid disorders are an important factor in the development of atherosclerosis of the abdominal aorta. The risk is especially increased with serum cholesterol levels above 3.9 mmol / liter.
• Increased pressure in the cerebral and coronary arterial vessels increases the tension of the vascular wall, which negatively affects the regenerative processes and contributes to the formation of pathological protrusions. [17]
• Nicotine dependence has a negative effect during all stages of atherosclerosis development, and this effect is quite intense: endothelium-dependent vasodilation worsens, pro-inflammatory factors increase (including C-reactive protein, interleukin-6 and tumor necrosis factors α), platelet NO availability decreases, the oxidative modification of LDL increases and the plasma activity of paraoxonase decreases.
• An increased level of insulin entails an increase in the content of cytokines (-6 and MCP-1), which contribute to the growth of atherosclerotic processes.

An increase in LDL cholesterol and a decrease in HDL cholesterol are considered to be particularly important underlying factors. The former accumulate in atherosclerotic plaques (foam cells), which entails mitochondrial dysfunction, apoptosis and necrosis, with the release of cell proteases, pro-inflammatory cytokines and thrombotic molecules. Oxidation of LDL provokes inflammatory and immune changes, platelet aggregation increases, and plaques become unstable. [18]

High-density lipoproteins promote the inclusion of the reverse transition of cholesterol, support endothelial function, and protect against increased thrombus formation.

The main pathogenetic links in the development of atherosclerosis are:

• Disorder of fat metabolism.
• Extra-fat changes (hemodynamic disturbances, deterioration of the rheological properties of blood, primary pathologies and damage to the vascular wall, genetic predisposition).

There is evidence that myostatin (a skeletal muscle growth inhibitor involved in metabolic disorders and cardiac fibrosis) can be considered as a new player in the progression of atherosclerosis. According to research, myostatin mediates the progression of atherosclerosis of the abdominal aorta, causing dysfunction of vascular smooth muscle cells. [19]

Symptoms of the atherosclerosis of the abdominal aorta

In most cases, atherosclerosis of the abdominal aorta proceeds without certain symptoms, but the pathology can be detected during diagnostic measures. Nonspecific signs appear as the disease progresses:

• uncomfortable sensations in the abdomen and lower back;
• regular abdominal pain, worse after eating (especially after a hearty meal);
• digestive upsets for no apparent reason (diarrhea, constipation, bloating);
• unpleasant belching, regular heartburn after eating;
• progressive emaciation.

As other organs become involved in the process, other symptoms appear:

• pain in the kidney and / or groin area;
• swelling of the limbs;
• swelling on the face in the morning;
• urinary disorders;
• increased blood pressure.

Since these symptoms are nonspecific, the patient may be misdiagnosed and treated incorrectly. Moreover, atherosclerosis of the abdominal aorta often coexists with other pathologies, including chronic ones, which also complicates the correct diagnosis.

First signs

In most patients, atherosclerosis of the abdominal aorta begins to develop at a young age, progressing over the years. Moreover, for a long time, the patient does not complain about anything at all, and the first signs begin to appear only when a large artery is significantly narrowed or clogged.

Among the most typical pathological signs are the following:

• epigastric pain, not associated with diseases of the stomach, radiating to the lower back, groin;
• digestive disorders, heartburn, not associated with pathologies of the gastrointestinal tract;
• cold feet;
• tingling sensation, numbness in the legs;
• male impotence;
• decreased muscle tone of the lower extremities;
• lethargy or absence of arterial pulsation in the feet, knees, groin;
• the appearance of intermittent claudication (with the spread of the lesion to the vessels of the lower extremities).

If atherosclerosis affects not only the abdominal, but also the thoracic part of the aorta, then chest pain appears after physical exertion or stress, with irradiation to the back or neck, as well as heartburn, a feeling of chest discomfort, without connection with cardiac pathology. [20]

If the pathology extends to the renal arteries, then arterial hypertension develops. [21] In the study of urine, proteinuria, erythrocyturia, cylindruria are found. The defeat of the cerebral arteries reveals itself as a deterioration in memory and intellectual activity, dizziness, sleep disturbance, and in severe cases, the risks of stroke and thrombosis increase.

With atherosclerotic changes in the mesenteric arteries, the blood supply to the intestines deteriorates, severe pain appears a few hours after eating - with localization in the umbilical zone or epigastrium. The pain can last for several hours (usually 1-3 hours), in many cases it disappears after taking Nitroglycerin.

Stages

In its development, atherosclerosis of the abdominal aorta goes through the following stages:

1. For the deposition of lipids in the wall of the aorta, vascular microdamages, focal slowing down of blood flow are favorable. The duration of the lipid stage can be different: the deposition of fat and diffuse thickening of the intima and proteoglycans of the extracellular matrix  [22] can only be viewed microscopically. 
2. The stage of liposclerosis is accompanied by an increase in the areas of fat deposition in the areas of connective tissue. An atherosclerotic plaque is gradually formed, the composition of which is represented by fats and connective tissue fibers. At this stage, plaques can still be eliminated, since they are amenable to drug dissolution. However, fragments of these deposits can clog the vessels, and the aortic wall in the area of the attached plaque loses its elasticity and is damaged: in this place, the risk of thrombus formation increases.
3. The stage of atherocalcinosis is characterized by the compaction of plaques and the deposition of calcium salts in it. The plaques increase in size, narrowing the lumen of the vessel, impairing the blood supply to the organs. The risk of occlusion or aneurysm increases.

The clinical stages of development of atherosclerosis of the abdominal aorta are as follows:

1. A person leads a normal life, does not have any associated symptoms, and pathology can be detected only with the help of Doppler research.
2. The patient begins to complain of abdominal pain after a heavy meal.
3. Abdominal pain appears even after a normal, poor meal.
4. The pain becomes constant, and after eating it increases.

Forms

There are several options for the classification of atherosclerosis of the abdominal aorta. So, in the course of the inflammatory process, the disease is divided into complicated and uncomplicated. The type and location of the pathological process also differ: atherosclerosis can affect the proximal segment of the abdominal aorta, the infrarenal section, or the entire section of the abdominal part of the vessel.

• Atherosclerosis of the abdominal aorta and its branches is most often accompanied by a clinical picture of abdominal ischemic disease, which is otherwise called the syndrome of chronic abdominal ischemia, or abdominal toad. The patient may complain of a feeling of heaviness and fullness in the abdomen, epigastric pain without obvious irradiation, dysfunction of the stomach and intestines, stable emaciation. There is a functional systolic murmur in the epigastric zone. [23]
• Atherosclerosis of the abdominal aorta and iliac arteries is called Larish syndrome. We are talking about a clinical symptom complex that develops against the background of severe narrowing or complete blockage of the abdominal aorta. Symptoms such as intermittent claudication, lack of pulse on the dorsum of the foot, as well as in the popliteal and femoral arteries, the formation of trophic ulcers on the toes and feet, a decrease in systolic blood pressure on the legs, a constant feeling of chilliness in the legs, and impaired libido are characteristic. Outwardly, muscular hypotrophy of the lower extremities is noted, signs of trophic disturbances on the skin and nails, systolic murmur is traced in the abdominal aorta and femoral artery.
• Obliterating atherosclerosis of the abdominal aorta is caused by the overlap of the vessel lumen by an atherosclerotic plaque and can be noted near the branching zone of the base trunk, or in the area of its division into branches of the I and II orders. The pathology is predominantly one-sided, although bilateral lesions also occur.
• Stenosing atherosclerosis of the abdominal aorta is caused by stenosis of the vessel and is characterized by the appearance of abdominal attacks, which have a poor prognosis and may result in ischemic disorders, reversible intestinal dystrophy or thrombosis and intestinal infarction.

Complications and consequences

The most common adverse consequences of atherosclerosis of the abdominal aorta are the development of an aortic aneurysm, or dissecting hematoma of the aorta. We are talking about a local expansion of the vascular area associated with the increasing weakness of its walls, or about an intramural hematoma, leading to a dissection of the vessel. A pulsating tumor-like formation appears in the abdominal cavity, located at the level of the navel or slightly below it, on the left. For an aneurysm, a rupture is dangerous when a vessel breaks into the abdominal cavity or retroperitoneal space. With dissecting hematoma due to progressive blood loss, it can be fatal. The patient has severe pain, collapse may develop, symptoms of acute blood loss appear; typically there are no signs of a heart attack on the electrocardiogram. Aneurysm may present with a rough systolic murmur. [24]

Additional signs of the appearance of an aneurysm can be:

• pressing, pulling, aching pains in the abdomen and lower back for no apparent reason;
• a feeling of pulsation, a feeling of the presence of a pulsating formation inside the abdomen.

Signs of the development of complications in the form of rupture of the abdominal aorta:

• a sharp appearance or intensification of pain syndrome;
• severe lumbar pain radiating to the groin, inner thighs, genitals;
• symptoms resembling myocardial infarction
• decrease in blood pressure indicators;
• signs of growing anemia;
• vomiting blood, etc.

Due to the lack of specificity of the clinical picture, complications are often mistaken for other diseases. Therefore, a qualified and comprehensive approach to each patient is very important: according to statistics, in 70% of cases with complications of an aneurysm, an incorrect diagnosis is made, which leads to extremely unfavorable consequences. If medical assistance is not provided on time, the patient with a rupture dies within a few hours. [25]

However, aneurysm and abdominal aortic dissection are not the only possible complications. Atherosclerosis eventually leads to cellular hypoxia, necrotic processes in tissues. Vascular walls lose elasticity, become dense and fragile, prone to damage. Intravascular plaques increase in size, can break off and clog smaller vessels. The main such complications are:

• the spread of the atherosclerotic process to the vascular branches, including capillaries;
• insufficient oxygen supply to the myocardium and brain, to the organs of the abdominal cavity;
• vascular stenosis, the beginning of the development of necrotic processes;
• detachment of atherosclerotic plaques, blockage of blood vessels;
• development of necrosis, gangrene (for example, intestines);
• myocardial infarction, cardiac ischemia, stroke, renal failure;
• Cases of penetrating atherosclerotic ulcers of the abdominal aorta have been described. [26]

An early competent diagnosis allows you to identify existing violations and promptly carry out appropriate treatment. Atherosclerosis of the abdominal aorta in the early stages can be stopped if all medical recommendations are followed. 

Left ventricular hypertrophy, aortic wall thickness, may be a predicted lifelong risk of cardiovascular disease. [27]

Diagnostics of the atherosclerosis of the abdominal aorta

Physical examination should include mandatory palpation of the abdomen, with further percussion and listening to the abdominal cavity using a phonendoscope. Pulse and blood pressure are measured separately.

Tests often include determination of total cholesterol, LDL, HDL, triglycerides.

A blood test helps determine the general condition of the aortic bed and assess the likelihood of developing atherosclerosis. The most indicative are the following evaluation criteria:

• total cholesterol indicator at a rate of 3.1-5.2 mmol / liter;
• HDL (good cholesterol) index at a rate of 1.42 (women) and 1.58 (men);
• LDL (bad cholesterol) index at a rate of up to 3.9 mmol / liter;
• triglyceride index at a rate of 0.14-1.82 mol / liter;
• atherogenic index (good cholesterol in relation to bad) at a rate of up to 3.

Instrumental diagnostics includes such studies:

• Aortic X-ray - helps to detect changes in the size of the vessel, the presence of calcium deposits or aneurysm. The enlarged aorta is manifested by an increase in the transverse size of the shadow, an increase in the protrusion of the aortic arches into the fields of the lungs. From the antero-left oblique projection, the shadow becomes unfolded, the aortic window increases in size. The elongated vessel changes dimensions up and to the right and forms the upper right contour of the vascular shadow, strongly going out into the shadow area of the upper hollow venous vessel. With fluoroscopy of the aneurysm, increased pulsation is noted.
• Contrast-enhanced X-ray aortography can help determine the location and size of existing aneurysms or areas of vasoconstriction. A sign of wall dissection is a doubled contour of the abdominal aorta.
• Two-dimensional ultrasound allows you to notice such pathological changes as thickening, induration, parietal calcification, roughness of the inner vascular wall, curvature or lengthening of the artery, the presence of atherosclerotic plaques. An aneurysm is said if there is a limited protrusion of the wall or a diametric increase in the abdominal aorta by two times, compared with the normal rate. 
• X-ray computed tomography and MRI clearly reveal morphological abnormalities in the aorta and large branches. [28] Enables the evaluation of indices to classify the location, severity and progression of calcified abdominal aortic lesions. [29]
• Selective angiography is prescribed if surgery is expected. 

The pathological study of an atherosclerotic plaque demonstrates the following changes:

• protein-fatty detritus in the center;
• in a circle - connective tissue.

Macrodrug for consideration: aorta and large or small arteries of muscular and muscular-elastic type. Lipid spots and stripes, fibrous structures, calcification, less often ulceration, thrombotic masses are found.

Differential diagnosis

Differentiation should be carried out with the following pathologies:

• appendicitis;
• inflammation of the gallbladder;
• inflammation of the pancreas;
• nephrolithiasis, cholelithiasis;
• peptic ulcer and 12 duodenal ulcer;
• pseudo-abdominal ischemia.

It is important to timely distinguish pathology from glomerulonephritis, pyelonephritis, renal amyloidosis, renovascular (vasorenal) arterial hypertension, atherosclerosis of the renal vessels, polycystic kidney disease, fibro-muscular aplasia, nonspecific aortoarteriocytosis, aortoarterocytocyte insufficiency, primary aldostoarthritis, congestive heart failure.

As a rule, to clarify the diagnosis, an ECG, an ECHO cardiogram, and an ultrasound of the abdominal organs are performed. Less commonly, angioscopy, digital subtraction angiography, optical coherence tomography are used.

Treatment of the atherosclerosis of the abdominal aorta

If the patient does not note any pathological symptoms, has a low level of risk (less than 5% according to SCORE), and the total cholesterol value exceeds 5 mmol / liter, then the treatment involves only lifestyle correction:

• exclusion of smoking and other bad habits;
• changing the diet;
• compliance with physical activity.

After normalizing the level of total cholesterol to 5 mmol / liter, and LDL to 3 mmol / liter, a regular preventive examination is prescribed every 3-5 years.

Patients with a high SCORE risk and total cholesterol of more than 5 mmol / liter should also change their lifestyle with laboratory follow-up at 3 months. If after the specified period the situation stabilizes, then further preventive diagnostics are prescribed annually. In case of instability of indicators or in the presence of typical symptoms of atherosclerosis, conservative treatment is prescribed.

Drugs that eliminate hyperlipidemia are represented by several classes of drugs: statins (drugs that inhibit HMG-CoA reductase), Ezetimibe, sequestrants (drugs that bile bile acids), fibrates, nicotinic acid drugs, polyunsaturated fatty acids, lipase inhibitors. [30]

• Statins are drugs that inhibit HMG-CoA reductase: Lovastatin, Simvastatin, Atorvastatin, Pravastatin, Fluvastatin, Rosuvastatin.
• Preparations inhibitors of cholesterol absorption in the intestine: Ezetemib is an active hypocholesterolemic agent.
• Bile acid sequestrants are drugs that enhance the excretion of bile acids from the body - the basic product of cholesterol metabolism (Cholestyramine, Colestipol).
• Funds derived from fibric acid - fibrates - are represented by Gemfibrozil, Bezafibrate, Ciprofibrat, Fenofibrat, Clofibrate.
• Nicotinic acid preparations - niacin - have cholesterol-lowering properties, reduce the content of lipoprotein.
• Omega-3 polyunsaturated fatty acids in sufficiently large dosages (up to 4 g per day) eliminate hypertriglyceridemia.

With atherosclerosis of the abdominal aorta, combination therapy is appropriate, which allows you to stop the development of the pathological process and prevent the occurrence of complications.

Medicines

Conservative treatment most often consists in the use of such medicines:

• Anticoagulants - for example, Heparin at an initial dosage of 5 thousand units injectable under the control of blood clotting, or Enoxaparin sodium 20-40 mg per day in the form of subcutaneous injections, or Nadroparin calcium 0.2-0.6 ml in the form of subcutaneous injections 1 -2 times a day (depending on the patient's weight).
• Antiplatelet agents - for example, acetylsalicylic acid in the amount of 75-325 mg daily by mouth, or Clopidogrel at 75-300 mg daily by mouth, or Dipyridamole at 50-600 mg per day by mouth. Patients should take such drugs for a long time (sometimes for life), under regular laboratory supervision. Chaotic intake of drugs in large doses can lead to hemorrhagic complications, the appearance of signs of heart failure.
• To eliminate pain, appoint:
  • non-steroidal anti-inflammatory drugs, if there are no contraindications (Ketorol, Ibuprofen), paravertebral blockade;
  • opioids (Morphine, Fentanyl) - in severe cases, if non-steroidal anti-inflammatory drugs do not help.
• Drugs that normalize microcirculation and improve the condition of blood vessels (angioprotectors):
  • Pentoxifylline 100-300 mg by injection;
  • Alprostadil 20-60 mcg injected daily.

Possible side effects when taking angioprotectors can be allergic reactions, abdominal pain, and digestive disorders. [31]

• Anticholesterol-lowering drugs are taken for several months (usually up to a year, depending on blood cholesterol levels). Simvastatin and Atorvastatin are usually prescribed internally. Side effects in the form of allergies, myopathy, dyspeptic symptoms are rare.
• Drugs for pathogenetic treatment are often represented by β-blockers - Propranolol, Bisoprolol, Metaprolol. The dosage is standard, therapy is carried out under regular monitoring of heart rate and blood pressure indicators. Cancellation of these drugs is performed gradually.

Diet for atherosclerosis of the abdominal aorta

Diet correction is an effective way to stop the development of atherosclerosis. And this method is in no way inferior to drug therapy, and often even surpasses it. Many doctors point out that one should not rely only on drugs: without changes in diet, one cannot count on a stable and long-term effect of treatment.

As a rule, patients with atherosclerosis of the abdominal aorta are prescribed dietary table No. 10 - the appropriate dietary food normalizes blood cholesterol and inhibits the progression of the disease. In addition, the diet includes a large amount of plant foods rich in dietary fiber and polyunsaturated fatty acids, which help to increase the amount of "good" cholesterol.

In addition to following a diet, it is important to track food calories. With little physical activity, you should not consume more than 2500 calories per day. And for overweight patients, the doctor will help to choose the daily calorie content.

With atherosclerosis, animals and hydrogenated fats, which increase the level of cholesterol and its deposition on the vascular walls, are prohibited. It is important to exclude such foods from the diet:

• fatty meat, lard;
• butter, margarine, vegetable and fat mixtures, lard;
• offal (including liver);
• broths on meat or bones;
• sausages, sausages, wieners;
• any parts of the poultry, except for skinless fillets;
• milk, hard cheese, fat cottage cheese, cream, condensed milk, sour cream, ice cream;
• fast food;
• potato;
• sauces;
• sugar, baked goods, pastries.

You should also limit the use of alcohol, and it is better to exclude it altogether.

The diet should contain the following foods:

• peeled chicken, turkey fillet;
• dairy veal;
• fish, seafood;
• fermented milk products (low-fat cottage cheese, kefir, yoghurts without additives);
• eggs (no more than 2 per week);
• any vegetables, fruits, herbs, berries;
• durum wheat pasta;
• cereals (buckwheat, rice, barley, wheat, oatmeal, bulgur, couscous);
• legumes (beans, chickpeas, mung bean, lentils, peas);
• dark bread, bran;
• herbal teas, green tea, dried fruit compotes, fruit drinks;
• dried fruits.

In no case should you neglect nutritional correction. Diet plays a fundamental role in the treatment of atherosclerosis, and also serves to prevent the development of complications - in particular, myocardial infarction and other cardiovascular pathologies. [32]

Physiotherapy treatment

Physiotherapy is an effective treatment using natural and physical factors. These are thermal influences, ultrasonic influences, magnetic fields, laser, water, therapeutic mud, massage, etc. The methods are usually simple and at the same time extremely effective: with a minimum of side effects, an intense positive effect is noted, which makes it possible to reduce the dosage of the medications used. A particularly pronounced effect is noted if physiotherapy is used in the early stages of the development of pathology.

In atherosclerosis of the abdominal aorta, the following types of physiotherapy are considered the most common:

• Electrophoresis with novocaine, as well as vasodilators, antiplatelet, anti-inflammatory drugs, anti-inflammatory drugs. Potassium iodide, sodium salicylate, heparin, lithium, zinc, multivitamins, magnesium sulfate, nicotinic acid, mezaton, etc. Are often used.
• Darsonvalization has a pronounced antispastic effect on the vascular wall, as a result of which it relieves spasm and improves blood flow. The action is explained by the irritation of nerve receptors by impulse currents.
• Hyperbaric oxygenation is a high pressure oxygenation technique. For the procedure, special hyperbaric pressure chambers are used.

Spa treatment includes balneotherapy and mud therapy. A pronounced positive effect is found after taking hydrogen sulfide, carbon dioxide, iodine-bromine, pearl, turpentine baths.

The application of natural mud is indicated for patients with stages 1-2 of atherosclerosis.

Herbal treatment

Atherosclerosis of the abdominal aorta in the early stages of development responds well to treatment with alternative means, subject to lifestyle correction and getting rid of bad habits. [33] The most common and effective herbal medicine recipes are:

• 1 tbsp. L. Buckwheat flowers are brewed in a thermos in 1 liter of boiling water, infused for an hour, filtered. Take 100 ml three times a day between meals.
• Peel 300 g of garlic, pour it into a container and pour 0.5 l of vodka. It is kept in a dark place for a month, after which it is filtered and taken daily, 20 drops with 100 ml of milk, between meals.
• Take 1 tbsp. L. Birch leaves, brew 300 ml of boiling water, leave to cool, filter. Take 100 ml three times a day for half an hour before meals.
• Pour 1 tbsp. L. Hawthorn color 300 ml of boiling water, insist until it cools, filtered. Take 100 ml three times a day half an hour before meals.
• Take 2 tbsp. L. Rose hips, poured into a thermos, pour 300 ml of boiling water. Insist for 15 minutes, filter. Take 100 ml three times a day 20-30 minutes before meals.
• Drink the juice of one lemon daily, with or after meals.
• Squeeze 200 ml of onion juice, mix with 200 ml of honey. Such a remedy is stored in the refrigerator and taken in 1 tbsp. L. Three times a day between meals, for 8-10 weeks.
• Prepare a collection of 10 g of lemon balm, 10 g of a drop cap, 40 g of hawthorn flowers, 30 g of strawberry leaves. Brew 1 st. L. Collecting 300 ml of boiling water, drink instead of tea during the day (you can add honey for taste).
• Take 100 g of fresh sage herb, pour 500 ml of vodka and insist for a month and a half in a dark place. Next, the tincture is filtered and taken in 1 tbsp. L. With water in the morning and before meals, only 3 times a day.
• Squeeze juice from fresh horseradish root. Mix in half with honey and take 1 tbsp. L. In the morning, one hour before the first meal. The duration of treatment is 1 month.

Surgery

If conservative therapy turns out to be ineffective or inappropriate, the patient is prescribed invasive treatment - therapeutic apheresis - plasmapheresis and LDL apheresis. Surgical treatment may be required when there is a high threat or the development of arterial occlusion - a thrombus or plaque. If atherosclerosis affects the heart vessels and the risk of developing myocardial infarction increases, coronary artery bypass grafting is performed.

Cardiac surgery involves performing open interventions or minimally invasive endovascular surgeries. For example, to eliminate ischemic processes in the lower half of the body and to stabilize hemodynamics, a vascular stenting operation is prescribed. And with aortic aneurysm, prosthetics and endoprosthetics of the abdominal aorta are indicated. [34]

If the diametrical size of the pathological protrusion in the aneurysm is less than 50 mm, then the patient is given drug therapy aimed at normalizing cardiovascular activity with its regular monitoring. If the diameter of the aneurysm is equal to or greater than 50 mm, then surgical treatment is prescribed to prevent rupture of the aorta. Also, an indication for surgery can be a protrusion with a diameter of 30 mm, with an annual rapid increase in size by 6 mm.

Surgical treatment can be performed at any age, if the patient does not have the following contraindications:

• acute disorders of cerebral or coronary circulation with obvious neurological insufficiency;
• circulatory failure II-b or III stage.

Abdominal aorta surgery for atherosclerosis

Prosthetics of the abdominal aorta is performed with an open access (15-20 cm incision) or a mini-access in the form of an incision on the abdominal wall of about 5-7 cm. The surgeon processes the operating field, performs the necessary incisions, and compresses the abdominal aorta above and below the affected area. The aneurysm is excised and a previously prepared vascular implant is sewn in instead of the removed segment. After making sure that the seams are tight, the doctor installs drains and sutures the wound. The most common are vascular implants impregnated with silver: they are more resistant to infection. The intervention lasts about 3.5 hours, then the patient is transferred to the intensive care unit, where his condition is monitored throughout the day. The general term for hospital stay is about a week (assuming no complications).  [35]

Aortic arthroplasty is considered a more modern surgical method. The damaged segment of the abdominal aorta is replaced with a special vascular prosthesis, which is placed directly in the aneurysm cavity under X-ray observation. This technique allows you to prevent a large number of complications, shorten the patient's stay in the hospital, and accelerate rehabilitation. Perhaps the only drawback of such an intervention is its high cost. [36]

Possible contraindications for surgical treatment:

• sepsis;
• severe disorders of vital organs, such as acute hepatic or renal failure, cerebrovascular accident, myocardial infarction, etc.

Prevention

To determine the most effective prevention of the development of atherosclerosis of the abdominal aorta, it is necessary to recall the main risk factors and try to influence them:

• get rid of bad habits - in particular, smoking and drinking alcohol;
• maintain an adequate level of cholesterol in the blood, regularly take blood tests;
• monitor blood pressure indicators;
• normalize body weight, lead an active lifestyle;
• avoid emotional stress, stress;
• eat right and quality.

If you eliminate the main predisposing factors, then you can prevent and slow down the development of the disease, prevent the occurrence of adverse complications.

It is important to correctly formulate a diet, reduce the use of products that contain a large amount of cholesterol. These are animal fats and butter, eggs, fatty dairy products, offal. You should also give up easily digestible carbohydrates, sweets, sugar. Preference in the diet should be given to vegetable oils, fish, white meat, seafood, vegetable products. Fiber and complex carbohydrates should take a special place in the menu. The share of raw vegetables, fruits and greens should be ¾ of the diet, which is due to the high content of pectin in plant products, which inhibits the absorption of cholesterol in the intestines. [37]

Protein is also a very important component of the diet. The body can get them from white meat of poultry, fish, legumes, greens.

It is important to monitor body weight, prevent the development of obesity, quit smoking and not abuse alcohol.

Sufficient physical activity is the key to normal heart function and a sufficient supply of oxygen to the myocardium. In addition, regular exercise prevents excess weight gain and maintains normal vascular tone. Physical activity is measured in relation to age and general health. It is optimal to practice walking for 30-40 minutes daily.

In addition, prevention should be supplemented by the elimination of stressful situations, the prevention of overwork of the body. It is important to train resistance to stress, establish a high-quality regime of work and rest, and normalize night sleep.

Forecast

Today, one of the main areas of activity of cardiologists is the search for solutions for the optimal treatment of atherosclerosis of the abdominal aorta. It should be borne in mind that this pathology is a prerequisite for the development of irreversible pathological processes - in particular, ischemic heart disease, renal artery stenosis, aortic aneurysm, ischemic stroke, etc. [38]

Forecasts for patients differ, they cannot be unambiguous, since they depend on the patient's age and the presence of concomitant diseases, on the stage of the pathological process, etc. If you adhere to all medical recommendations (changes in nutrition, exclusion of bad habits, high-quality and timely drug treatment), then the prognosis can be relatively favorable, since the further development of the disease is often slowed down. If you ignore the adherence to the recommendations, break the diet, smoke, etc., then the risk of complications increases significantly: aortic aneurysm, myocardial infarction, stroke, etc. [39]

Unfortunately, it will not be possible to completely get rid of the disease: atherosclerosis of the abdominal aorta is a chronic disease with a gradual progression of pathological changes.

Disability

Obtaining a disability group with atherosclerosis of the abdominal aorta is possible if, as a result of pathological processes, severe functional disorders of organs have developed, and there has been a loss of working capacity. Despite the fact that the disease is very common, and its complication is often fatal, disability is assigned not due to the direct atherosclerotic lesion, but due to the development of adverse consequences.

A patient can be recognized as disabled if he has the following complications:

• microstroke, stroke;
• acute violation of the coronary circulation;
• aortic stenosis and aneurysm.

Any of the above conditions, as well as paralysis of the limbs, disorders of cerebral circulation can be a reason for disability registration based on the results of a medical and social examination. Atherosclerosis of the abdominal aorta without clinical manifestations or with symptoms amenable to drug correction is not an indication for disability.