Chronic aneurysm

A chronic aneurysm is a long-lasting and dynamically developing localized protrusion of a thinning tissue zone of the cardiac or vascular wall. As a rule, the pathology is characterized by intense symptoms of cardiovascular insufficiency, sometimes developing thromboembolic syndrome, strokes, gangrene of the extremities, heart attacks and other complications, among which the most dangerous is considered the rupture of a chronic aneurysm. The disease is not amenable to treatment with conservative methods, so when symptoms of heart failure or other complications appear, doctors raise the question of surgery. In general, the prognosis of the pathology is not optimistic. [1]

Epidemiology

A chronic aneurysm forms more than two months after exposure to a triggering factor, such as trauma or myocardial infarction. Often the problem is detected accidentally, during ultrasound or X-ray examination. If the pathology is detected, urgent treatment measures may be prescribed, since a complicated bulge can pose a threat to the patient's life.

In men, chronic aneurysms occur about 6 times more often than in women. In patients under 40 years of age, the pathology is found in 13% of cases. Congenital cardiac aneurysms formed from ventricular diverticula, as well as posttraumatic chronic aneurysms are rare.

Aortic aneurysms come in the following localizations:

• 37% of cases involve the abdominal segment;
• in 23% of cases, the ascending branch is affected;
• 19% of cases involve the aortic arch;
• 19% involve the thoracic segment.

Thoracic aneurysms are in many cases combined with other malformations, such as aortic insufficiency or coarctation.

Causes of the chronic aneurysm

A chronic aneurysm is an enlargement (bulging) of the wall of an arterial or venous vessel or the heart due to its thinning or excessive stretching. Due to pathological processes, an aneurysmal bursa is formed, exerting pressure on nearby structures. Aneurysms can be congenital, although in newborn children this pathology often goes undetected and is discovered many years later. Acquired chronic aneurysms develop as a result of other conditions and diseases that cause thinning of the vessel or heart walls. This can be infection, hypertension, atherosclerotic processes, trauma, etc.

Chronic aneurysm may not bother for years, the patient often does not realize the existence of the problem. In the meantime, pathologic enlargement increases, the condition worsens, and the risk of complications grows.

In the vast majority of cases, the cause of cardiac chronic aneurysm formation is transmural myocardial infarction, which literally destroys the structure of muscle fibers. Favors the development of complications failure to comply with the rules of the postinfarction period (strict bed rest, lack of exercise), increased blood pressure, tachycardia, increasing angina pectoris. Other most likely causes include trauma, infectious processes (syphilis, etc.).

The occurrence of congenital aortic aneurysms is mainly associated with hereditary diseases, such as Marfan, Erdheim or Ehlers-Danlos syndromes, fibrous dysplasia, elastin deficiency, etc. The occurrence of congenital aortic aneurysms can be post-inflammatory (due to mycoses, syphilis, syphilis, postoperative infectious complications, etc.). Acquired chronic aortic aneurysm can be post-inflammatory (due to mycoses, syphilis, postoperative infectious complications), degenerative (atherosclerotic, postoperative), traumatic (due to mechanical damage to the vessel). In rare cases, idiopathic origin of chronic aneurysm is spoken about: such a disease occurs as a result of medionecrosis of the aorta.

Risk factors

Dangerous factors that provoke the development of chronic aneurysms are considered:

• atherosclerotic processes;
• age-related changes;
• smoking and other bad habits, drug addiction;
• hereditary predisposition;
• infectious and inflammatory diseases, most often tuberculosis, syphilis;
• regular heavy physical activity;
• chest, abdominal injuries, head injuries (especially road traffic accidents).

Chronic cardiac aneurysm in the vast majority of cases is formed as a result of extensive transmural infarction of the heart muscle. Additional factors include:

• Non-compliance with bed rest in the postinfarction period;
• arterial hypertension;
• arrhythmias and prolonged palpitations;
• repeat heart attacks;
• increasing heart failure.

A common cause of chronic aneurysm formation is considered to be postinfarction cardiosclerosis, in which under the influence of blood flow pressure there is an expansion of the heart wall in the area of the formed connective tissue scar.

Pathogenesis

In addition to the direct defect in the vascular wall, mechanics and hemodynamic factors are involved in the formation of chronic aneurysms. Thus, pathologic bulges appear mainly in areas of functional stress, increased load and high blood flow velocity, exposure to pulse fluctuation. Chronic trauma, high activity of proteolytic enzymes lead to destructive changes in the elastic framework and nonspecific degeneration in the vascular wall.

The formed bulge gradually increases in volume as the wall stress in it grows in accordance with the expansion of the internal diameter. Blood flow within the lumen of the aneurysm slows down and turbulence occurs. Less than half of the blood filling the aneurysm sac enters the distal arterial flow. This is due to restrained turbulent mechanisms and the presence of multifocal thrombi in the sac. Subsequently, blood flow worsens, and there is a risk of tromoembolism of distal arterial branches.

In cardiac chronic aneurysms, a fibrous bursa is also formed, including three layers: endocardial, intramural, and epicardial. Fibrous and hyalinized overgrowths are noted in the endocardial layer. The wall of the affected section is thinning, the formation of wall thrombi is possible, which fragment and significantly increase the risk of thromboembolic complications.

Symptoms of the chronic aneurysm

Chronic cardiac aneurysm is more often formed in the postinfarction period: patients begin to notice discomfort behind the sternum, the heart seems to "freeze", "flushes" regularly bother them. There is severe weakness, shortness of breath, sometimes - dizziness. A paradoxical pulsation in the chest is clearly manifested, there is a "symptom of the head", which consists in the non-simultaneity of the cardiac and apical tremor in the precardiac zone.

Chronic left ventricular aneurysm is accompanied by deposition in the dilated cavity of up to 30% of the shock volume of blood. At the initial stage, the insufficiency of cardiac activity is compensated by palpitations. Gradually, the ventricular walls expand, all cardiac dimensions increase. Somewhat later, complications make themselves known, although ruptures in chronic cardiac aneurysms are relatively rare.

Chronic aortic dissecting aneurysm is accompanied by symptoms in accordance with the localization of pathological dilation. Many such pathologies initially proceed latently, or have a scanty clinical picture, but with the development of dissection, the condition deteriorates sharply, symptoms characteristic of an angina attack are noted. The leading first signs are acute pain associated with damage and stretching of the aortic wall and/or compression of other organs. When the abdominal segment is affected, digestive disorders may occur, and sometimes increased pulsation in the abdominal cavity is palpable. When the thoracic segment is affected, cardiac or chest pain, head pain, swelling of the face and upper half of the body are typical. In aortic arch aneurysm, compression of the esophageal tube, hoarseness of voice, dry cough are observed.

Chronic postinfarction aneurysm is formed by a long-standing acute aneurysm. The general condition of the patient is unsatisfactory, there is blood stasis in the atrium, pulmonary and arterial pressure increases, the small circle of blood circulation suffers. Dull cardiac pain is typical, with intensification during physical activity, not eliminated by analgesics and nitroglycerin. Localization of pain: behind the sternum, with spread to the anterior surface of the chest. The skin is pale grayish, there is coughing, noisy breathing.

Chronic cardiac aneurysm with wall thrombus is manifested by increasing weakness, increased sweating, frequent palpitations, subfebrile. In the blood there is a neutrophilic leukocytosis and accelerated sedimentation. Thrombosis is dangerous because of the probable development of embolism to internal organs (lungs, spleen, kidneys, brain structures, etc.).

Stages

The formation of an arterial aneurysm occurs in stages:

• there's a defect in the muscle layer;
• the inner elastic membrane is damaged;
• starts the process of intimal hyperplasia;
• the collagen fibers of the arterial vessel are damaged;
• increases the stiffness of the vascular wall, it thins.

Forms

Chronic cardiac aneurysms come in several types:

• muscular;
• fibrous;
• muscular-fibrotic.

Most often, cardiac aneurysms are single, but sometimes there are 2 or more dilations.

Pathology can be true (involving all three layers), false (formed by rupture of the myocardial wall and limited by pericardial fusions) and functional (formed by an area of viable muscle tissue with low contractility and bulging in ventricular systole).

Chronic aneurysms can be diffuse (flattened), sac-like, or mushroom-shaped in terms of configuration and extent of the lesion. Heart damage can occur as an "aneurysm within an aneurysm": there are several dilations that are enclosed in each other. The risk of rupture of such pathology is particularly high.

Aortic chronic aneurysms are subdivided according to localization:

• aneurysms of the ascending, descending, abdominal aorta;
• aneurysm of the sinus of Valsalva, aortic arch;
• combined aneurysm (thoracoabdominal).

A separate variety is a dissecting chronic aneurysm, in which blood enters between the layers of the arterial wall through damage to the inner sheath, gradually dissecting the vessel.

Classification of cerebral aneurysms according to the size of pathologic enlargement:

• Miliary aneurysm (less than 3 mm);
• regular (4 to 15 mm);
• large (16 to 25 mm);
• Giant (greater than 25 mm in size).

Complications and consequences

Aortic chronic aneurysm can be complicated by rupture of the pathologic dilation with subsequent development of massive bleeding, collapse, shock, acute heart attack. The rupture is directed into the system of the superior vena cava, the cavities of the pericardium or pleura, the esophageal tube, the abdominal cavity. The consequence is the occurrence of superior vena cava syndrome, cardiac tamponade, severe internal bleeding, hemothorax or hemopericardium.

With the separation of the thrombus from the aneurysmal wall, acute occlusion of peripheral vessels develops. The patient's feet turn blue, become sharply painful. If the renal arteries are thrombosed, there is a sharp increase in blood pressure, signs of renal failure are noted. The lesion of cerebral arteries is manifested by the clinical picture stroke.

Cardiac chronic aneurysm can be complicated by fibrinous pericarditis, development of adhesions. If thromboembolism forms, acute peripheral vascular occlusion is noted: the brachial trunk, cerebral and renal arteries, pulmonary and intestinal vessels are affected. There is a possibility of complications such as leg gangrene, strokes, renal infarctions, recurrent myocardial infarctions, pulmonary embolism.

Rupture of a cardiac chronic aneurysm is relatively rare: such a complication is more common in acute aneurysms.

Diagnostics of the chronic aneurysm

After collecting complaints and anamnestic information, as well as a thorough examination, the doctor can assume that the patient has a chronic aneurysm. However, to confirm the diagnosis, a complete laboratory and instrumental diagnosis should be performed.

The tests include determination of blood creatinine levels with calculation of creatinine clearance and CKF, total hemoglobin, hematocrit, and platelet and red blood cell counts. Low total hemoglobin, platelet and red blood cell counts indicate increased hemorrhagic risk, and elevated platelet counts are associated with a risk of thrombosis. Additionally, it is recommended to assess the amount of electrolytes in the blood (potassium, sodium, magnesium), correct the values and further repeat the study.

Instrumental diagnosis in chronic cardiac aneurysm primarily includes ECG: manifestations of myocardial infarction are recorded. During EchoCG visualizes the aneurysm cavity, you can assess its size, shape, detect the presence of blood clots. Stress EchoCG and PET make it possible to assess the viability of the heart muscle.

Chest X-ray helps to detect congestion of the small circle of blood circulation, signs of cardiomegaly. In addition, it is possible to use X-ray contrast ventriculography, magnetic resonance imaging and multispiral computed tomography. If indicated, a cardiac cavity probing, coronarography, electrophysiologic study are prescribed.

Chronic cerebral vascular aneurysm is diagnosed with:

• angiography - an x-ray of the blood vessels using a contrast agent;
• computerized tomography and/or magnetic resonance imaging.

To diagnose pathologies of the aorta, ultrasound and echocardiography are most often used to detect even small morphological and functional disorders of the main artery and heart.

Differential diagnosis

Chronic cardiac aneurysm is differentiated with these pathologies:

• Pericardial coelomic cyst (a thin-walled fluid element associated with the pericardium);
• Mitral heart defect (stenosis or insufficient mitral valve function);
• mediastinal tumor process (tumors localized in the mediastinal part of the chest).

Chronic aortic aneurysm is distinguished by:

• from angina attack, myocardial infarction (perform ECG, echocardiogram, blood tests);
• from a heart defect (do an EKG, echo);
• from attacks of musculoskeletal pain (appoint electrocardiography, ultrasound of the abdominal aorta, consultation with a cardiologist);
• for pericarditis (EKG, echo);
• for pancreatitis, biliary colic (abdominal ultrasound, blood tests);
• for pulmonary embolism (EKG, echo, blood work).

Treatment of the chronic aneurysm

To date, experts strongly recommend surgical treatment of chronic aneurysms. This approach allows optimizing the prognosis and preventing the development of complications of the disease.

At the same time, the therapeutic tactics are determined after performing the entire diagnostic complex, determining the size of pathologic dilation and the presence of complications (valve insufficiency, dissection, compression of nearby organs, etc.). Possible conservative treatment may consist in controlling blood pressure indices, reducing blood cholesterol levels, monitoring in dynamics by vascular surgeons. It is recommended to perform diagnostic control studies (CT, ultrasound) every 6 months.

If the pathological dilation increases rapidly, there is a risk of rupture, the doctor will strongly recommend surgical treatment, the essence of which is to remove the problematic segment of the artery and install a synthetic implant instead. Traditional or endovascular intervention is possible. The right to choose a surgical method remains with the doctor, after evaluating all diagnostic results.

Surgical treatment

With regard to cardiac aneurysms, the use of surgical intervention in this situation is strongly recommended. Currently, there is no single approach of the most effective type of surgery for ventricular pathology. At the preoperative stage, the surgeon calculates the permissible area of disconnection of the dilated area. During the preoperative modeling of the affected ventricle, the estimated area of disconnection is determined based on the results of echocardiography. Among the possible surgical methods used are:

• Palliative surgery (Carpentier mitral valve support-ring plasty).
• Radical operations (aneurysm resection, septoplasty for aneurysm of the interventricular septum, resection with reconstruction according to Jaten-Dohr for large aneurysm, suturing of rupture of the damaged ventricular wall, coronary bypass).

Among the most likely postoperative complications are:

• arrhythmias;
• low ejection syndrome;
• failure of respiratory function;
• bleeding;
• acute circulatory disorders in the brain, acute vascular insufficiency.

Intervention may be postponed in asymptomatic chronic aneurysms, high anesthetic risk, inability to restore functional capacity of the heart muscle after resection, and in increasing mitral insufficiency.

Surgical treatment of aortic chronic aneurysms can be presented:

• aneurysmectomy with bifemoral aortoprosthesis;
• with an aorto-femoral bypass;
• bifurcation aorto-femoral bypass.

If it is a detected but potentially not dangerous chronic aneurysm of the peripheral arteries or aorta, the patient is offered a planned operation, or dynamic monitoring of the problematic vessel is established. Cerebral aneurysms are usually a direct indication for emergency surgery.

Prevention

Doctors offer a few tips that in many cases can help avoid the onset of a chronic aneurysm:

• blood pressure readings need to be monitored;
• If the doctor has prescribed hypotensive drugs, you should not neglect to take them;
• It is imperative that you stop smoking, eliminate alcohol and drugs from your life;
• It is necessary to follow a healthy diet, avoiding fatty meat, lard, smoked products and large amounts of salt;
• It is important to monitor cholesterol and blood sugar levels;
• physical activity should be maintained, and both hypodynamia and excessive overloading of the body should be avoided;
• It is necessary to avoid stressful situations in every possible way, to develop stress resistance.

In addition, if suspicious symptoms of pathology do not try to self-treat with folk remedies or over-the-counter drugs. It is important to visit doctors in a timely manner, undergo a full diagnosis and, if indicated, carry out treatment prescribed by a medical specialist.

Forecast

Chronic aneurysm can lead to sudden death of the patient almost at any moment. Pathology is also dangerous in that it often proceeds without pronounced clinical symptoms until the development of complications. Patients only sometimes voice complaints of pain, a feeling of heaviness in the area of pathological vascular expansion. But most often they learn about the problem accidentally, in the process of undergoing routine or background X-ray or ultrasound examination.

Different locations of chronic pathology are possible - from the arteries of the brain and peripheral vessels to the aorta and heart. However, regardless of the localization, the danger to the patient's health and life is approximately the same.

Chronic aneurysm is a life-threatening disease. Its timely diagnosis is a chance to eliminate the problem and the possibility of leading a normal life without adverse effects and recurrences.