Thoracic and abdominal aortic aneurysm rupture: chances of survival, treatment

The cardiovascular system, in which the scarlet fluid (blood) circulates, which maintains the vitality of the entire human body, consists of a heart and many vessels of various sizes. The largest of these is the aorta. It is in the aorta that the maximum blood pressure is noted, and if the walls of the blood vessel weaken, become less elastic, this causes their irreversible overstretching with the formation of an aneurysm. By itself, an aneurysm may not let you know about itself for a long time, and not interfere with a person's normal life, but you need to know that in some cases dissection or rupture of the aortic aneurysm may occur, and this is already an extremely dangerous condition for a person's life and requiring urgent professional vascular care. Surgeon.

Useful information from anatomy

In connection with the above, the expression "rupture of the aorta or aneurysm formed on it" sounds intimidating. Therefore, it is not surprising if the reader is interested in the question of where the aorta is located, what it is, as well as what an aneurysm is and what factors can provoke its rupture.

The human circulatory system originates from a rhythmically contracting hollow muscle organ, which acts on the principle of a pump. This organ was called the heart and its purpose is to provide continuous blood circulation, which delivers oxygen and nutrients to all human organs.

The large blood vessels that communicate with the heart are divided into arteries and veins. The former take blood away from the heart, the latter are responsible for supplying blood to the central organ of the circulatory system. The largest human artery is the aorta, which is part of the systemic circulation, which supplies blood to the entire body, while the small one is responsible only for the blood supply to the pulmonary system.

The aorta, which emerges from the left ventricle of the heart and is a kind of its continuation, can be compared to a pump hose. This large artery is long and extends along the entire human body.

It is customary to distinguish between 3 main sections of the aorta:

• ascending (originates in the left ventricle of the heart and debuts from an expanded part, called the bulb),
• the aortic arch (begins somewhere in the seventh centimeter of the vessel, has a curved shape),
• descending (in the region of the 4th thoracic vertebra, the arc passes into a straight line).

The ascending part of the aorta is hidden behind the pulmonary trunk - an artery that begins the small (pulmonary) circle of blood circulation, and is covered with a pericardial sac (pericardium). The diameter of the artery in this part is about 2.5-3 cm.

At the junction of the second costal cartilage and the sternum (the main bone of the chest), the aorta narrows to 2 cm and takes the form of an arc, turning slightly to the left and back. Reaching the fourth thoracic vertebra, it forms a small isthmus, after which its location becomes almost vertical.

The descending part of the aorta, in turn, is divided into 2 sections:

• the thoracic region, which is located in the thoracic cavity in the posterior mediastinum,
• the abdominal region, which is considered a continuation of the thoracic vertebra and begins at the level of the 12th thoracic vertebra.

The initial section of the thoracic aorta is located antero-left from the esophagus. Further, in the region of the 8th vertebra, it bends around the esophagus on the left side and rushes down along the posterior wall of the esophagus.

The beginning of the abdominal region is the aortic opening of the diaphragm. Diving into this opening, the aorta stretches up to 4 lumbar vertebrae.

In the course of the passage of the aorta, branches of various sizes - arteries - depart from it. In the ascending section, these are the right and left coronary arteries. In the area of the aortic arch originate:

• brachiocephalic trunk, which in turn is divided into the right carotid and subclavian arteries,
• left common carotid and subclavian arteries.

The descending part is divided into the thoracic region, in which the intercostal, tracheal and many other types of arteries begin, and the abdominal. From the abdominal section leave:

• celiac trunk, which after a couple of centimeters is divided into the left gastric, common hepatic and splenic arteries,
• mesenteric blood vessels, which are responsible for the blood supply to the intestines and pancreas,
• low phrenic artery feeding the diaphragm and adrenal glands,
• adrenal artery,
• lumbar arteries,
• renal artery.

In the region of the 4-5 lumbar vertebra, the abdominal part of the aorta is divided into 2 parts (its bifurcation occurs): the right and left common iliac arteries, the continuation of which is the femoral arteries.

Weakening of the walls of large blood vessels experiencing maximum blood pressure can occur in any part of the aorta or arteries extending from it. Overstretching of the walls of the aorta leads to the fact that in this place they become weaker and prone to rupture. Rupture of an aortic aneurysm or arteries extending from it is dangerous in any case. But the prognosis in this case depends on many factors: the location of the aneurysm, its shape and size, the degree of damage to the arterial walls.

Aneurysm and its consequences

The aneurysm of the aorta and other large arteries is usually called the area where the vessel undergoes a pathological change in shape and size. In this area, an unusual expansion is formed with an increase in the lumen of the arterial vessel. The diagnosis of aneurysm is made in the case of an increase in the lumen of the vessel by 2 or more times.

Distinguish between fusiform and saccular aneurysms. The spindle-shaped form is said to be when there is a diffuse protrusion of the walls of an artery along its entire diameter. The saccular form of an aneurysm is characterized by the appearance of such a protrusion in a limited area of the vessel and its shape resembles a sac protruding from the side of the artery.

The aorta, like all blood vessels, has a three-layer wall. Under blood pressure, in the presence of risk factors for damage to the aorta, both individual layers of the vessel and all 3 layers can rupture. In the first case, they speak of aortic dissection. Usually this situation is observed at the site of the aneurysm and the aneurysm is called exfoliating.

An aneurysm is a pathological protrusion of the walls of the aorta, which can be either acquired or congenital. The reasons for the acquired aneurysm are:

• inflammatory pathologies of the vascular wall caused by an infectious factor (aortitis, which develops against the background of syphilis, tuberculosis, postoperative infections),
• degenerative changes in the tissues of the aorta (atherosclerosis of the vessels, defects in the structure of the aortic wall that have arisen after operations on the vessels),
• medionecrosis of the aorta (pathology, the causes of which are unknown, manifests itself in the formation of cystic cavities (necrotic foci) in the inner layer of the aortic wall),
• mechanical damage and trauma to the largest blood vessel

Congenital aneurysms can occur with such hereditary pathologies as Marfan syndrome, Ehlers-Danlos syndrome, congenital elastin deficiency and other pathologies of the connective tissue that make up the blood vessels.

It must be said that the risk of aneurysm occurrence is higher in people with high blood pressure (arterial hypertension) and a hereditary predisposition. At risk are smokers, fans of alcoholic beverages. As for sexual preferences, this pathology is more characteristic of men. And it is most often found in older people (60 years or more).

By itself, a small aneurysm may not remind of itself until it enlarges and begins to squeeze nearby organs. Then the person begins to experience pains of varying intensity, plus symptoms appear, indicating malfunctions in the squeezed organs. If the aneurysm is located in the chest region, coughing and shortness of breath appear, the voice becomes hoarse, and the pain is localized in the sternum, back, neck. With an abdominal aneurysm, a person feels pain in the epigastric region, as well as a feeling of severe bloating, nausea. He may be tormented by belching, urinary disorders, and constipation.

This is an unpleasant, but not the most dangerous condition. The greatest danger is the rupture of the aortic aneurysm. But in this place the walls of the vessel turn out to be the least strong, therefore, the violation of the integrity of the aorta usually occurs in such areas. This complication of the aneurysm is considered deadly and is treated strictly with surgery.

It is believed that the rupture of the aorta in the chest area is preceded by the dissection of the vessel walls, when only the inner layers undergo rupture. But in the abdominal part of the aorta, ruptures in most cases occur unexpectedly, while all 3 layers of the aortic wall are damaged. In this case, severe bleeding occurs, and patients in the vast majority of cases die. We can say that aneurysm of the abdominal aorta is a potentially very dangerous condition that requires treatment even in the early stages of development.

[1], [2], [3], [4], [5], [6], [7], [8],

Epidemiology

According to statistics, fusiform aneurysms are most often formed. Moreover, in 37 percent of cases, such protrusions occur in the abdominal part of the blood vessel. Slightly less often, an aneurysm is diagnosed on the ascending part of the aorta (about 23 percent). Pathological areas on the arch and the descending branch of the largest artery are detected in less than 20% of cases. Much less often, an aneurysm is diagnosed in the area of the inguinal and femoral arteries.

A rupture of a dissecting aortic aneurysm is diagnosed much more often than damage to an aneurysm, the integrity of the walls of which is not violated. It is clear that a three-layer wall is able to withstand higher loads than one in which the inner or both inner and middle shells are damaged. A dissecting aneurysm, which is an incomplete rupture of the aortic wall, has the highest risk of rupture and the worst prognosis.

The most dangerous is the rupture of the aorta in the abdominal region, which has a more severe course and certain difficulties in diagnosis.

[9], [10], [11], [12], [13], [14]

Risk factors

Risk factors for rupture of an aneurysm of any large vessel can be considered:

• vascular atherosclerosis, because the formation of cholesterol plaques on the walls of arteries makes them less elastic,
• high blood pressure, which causes the formation of an aneurysm, and subsequently further increases the tension in this area,
• physiological age-related changes, i.e. Wear and tear of various body tissues,
• congenital diseases of the connective tissue, as a result of which its underdevelopment is observed, which means that it cannot perform the functions assigned to it qualitatively,
• inflammatory pathologies of the vessels, which additionally weaken the internal tissues of the vascular wall (progressive syphilis, for example, can provoke the development of a chronic inflammatory process in the arteries, and this increases the risk of damage to the walls at the slightest tension),
• increased thrombus formation, because a harder thrombus will exert higher pressure on the wall of the aneurysm than liquid blood (and thrombi are literally drawn into the cavity of the aneurysm, where they subsequently accumulate, reducing the lumen and increasing pressure on weak walls)
• alcoholism and smoking (these bad habits create a high load on the heart, increase blood pressure and, accordingly, can become a risk factor for rupture of the walls of the heart and blood vessels)
• autoimmune and endocrine diseases, leading to rapid destruction of blood vessels (most often aortic ruptures occur in patients with diabetes mellitus, especially if the pathology is combined with vascular atherosclerosis, which is characteristic of diabetes).

It must be said that any increased stress on the heart can provoke a rupture of the walls of the aorta. Such a negative effect on the work of the heart can be exerted by:

• strong feelings and stress,
• excessive physical exertion (in the case of an aneurysm, even moderate, slightly increasing vascular tension is often enough for them to rupture in a weak spot),
• pregnancy and childbirth (in this case, increased stress is experienced not only by the heart, but also by other organs of the woman, therefore, expectant mothers with cardiovascular pathologies are registered separately, while aneurysm can form both before conception and in the last months and days of pregnancy, and burst at the time of childbirth),
• overweight, obesity, physical inactivity, which negatively affect the heart and blood vessels, gradually weakening them.
• injuries of the chest and peritoneum (for example, rupture of an aortic aneurysm quite often occurs in an accident as a result of a sharp impact on the steering column or at the time of a fight, when the blow falls into the zone of passage of various parts of the aorta). If the blow is strong, then even an intact section of the vessel can rupture. In this case, usually all 3 layers of the aorta are damaged, which leads to the death of the victim.

Why are pathological foci formed, which subsequently become a risk factor for rupture of the aortic walls? The pathogenesis of this process is based on multifactoriality. Inflammatory and degenerative processes in tissues, the formation of cholesterol plaques on the walls, traumatic injuries cause pathological changes in the structure of the vascular wall.

Structural and geometrical changes in collagen and elastin fibers, which make up the choroid, lead to the destruction of the artery walls imperceptible from the side, so it is not surprising that when stretched, they cannot return to their normal position. At the same time, once the broken shape of the wall is not subject to natural correction, but it may well progress, i.e. The size of the aneurysm can gradually increase, and the larger the area of damage to the vessel, the higher the risk of rupture, and the more difficult it is to save the patient's life.

The diameter of the aneurysm is directly proportional to the pressure on the vessel walls and the breaking force. With an aneurysm diameter less than 5 cm, the risk of wall rupture approaches 1%, while a 7-centimeter aneurysm increases the risk of tissue rupture by up to 30 percent or more.

[15], [16], [17], [18]

Pathogenesis

It is believed that the appearance of a focus of pathological stretching of the blood vessel wall itself is one of the main risk factors for rupture of the aorta, because in this place the tissue becomes thinner and less elastic, therefore it can rupture with any increase in pressure on it. It is clear that the causes of rupture of the aorta will be closely related to the factors causing the appearance of the aneurysm itself, which most often occurs in the zone of increased tension of the vessel walls.

[19], [20], [21], [22], [23]

Symptoms of the ruptured aortic aneurysm

It must be said that a person may not even guess for a long time about such a pathology as an aortic aneurysm, because the pronounced symptoms of the disease usually appear when the pathological area already reaches a large size and begins to have a negative effect on the work of other organs. But the rupture of the aneurysm cannot be asymptomatic.

The first signs of a ruptured aneurysm are pain of high intensity. True, the localization of pain may differ depending on the location of the aneurysm. A ruptured thoracic aortic aneurysm will debut with bouts of pain in the sternum, while the symptom may radiate to the back, shoulders or neck, much less often to the abdomen, upper and lower extremities.

A similar situation is observed with rupture of the aneurysm of the ascending aorta, its arch or descending section.

Most often, in this case, we are not talking about a complete rupture, but about an exfoliating aneurysm, the symptoms of which are considered:

• migratory pain (pain syndrome with a hard-to-define localization caused by hemorrhage into the lumen between the aortic membranes), they are observed along the course of hematoma formation),
• tachycardia (rapid pulse, and it is different on the upper and lower extremities),
• fluctuations in blood pressure upwards and then downwards,
• neurological symptoms caused by ischemia of the brain and spinal cord (weakening of the muscles of half of the body, decreased sensitivity or paralysis of the limbs), impaired consciousness, dizziness, damage to peripheral nerves,
• shortness of breath
• hoarse voice
• severe weakness and sweating,
• pale or bluish skin color
• the formation of edema, etc.

In severe cases of blood leakage outside the aorta, it is possible to develop hemopericardium, myocardial ischemia, heart failure, cardiac tamponade.

If aneurysm dissection occurs in the descending part of the thoracic or abdominal aorta, symptoms of acute renal failure, ischemia of the digestive system or lower extremities may appear.

Abdominal aneurysm rupture is characterized by abdominal pain. The clinical picture of this pathology is characterized by symptoms of an acute abdomen: severe pain in this area and tension of the abdominal wall. Most often, we are talking about a complete rupture of the aortic membranes with symptoms characteristic of it:

• the appearance of acute, unbearable pain in the epigastrium (if the rupture occurred in the thoracic part of the aorta, the localization of pain will be different),
• severe dizziness up to loss of consciousness and coma,
• nausea with bouts of vomiting,
• drying out of the mucous membranes of the mouth,
• bluish skin color
• pulse is weak, threadlike,
• cold sweat,
• heavy intermittent breathing
• the heart rate is increased,
• there is a sharp decrease in blood pressure, possibly the onset of collapse.

The intensity and localization of symptoms of aortic aneurysm rupture is influenced by the location of the site of tissue integrity violation and the size of the resulting hematoma. Retroperitoneal aortic rupture is characterized by severe, persistent abdominal and lower back pain. The larger the hematoma, the more it presses on the nerve trunks. This causes excruciating pain that cannot be controlled with analgesics.

If the rupture of the vessel tissues occurs in the upper part of the abdominal region or the descending part of the thoracic aorta, pain can radiate to the heart, resembling the clinical picture of rupture of a heart aneurysm. The spread of hematoma to the pelvic area will cause pain not only in the lumbar region, but also in the groin and perineum. Irradiation to the thigh is possible.

For example, a rupture of an aneurysm of the splenic artery leaving the abdominal aorta, with a retroperitoneal rupture, is manifested by pain in the left half of the abdomen and lower back. The formation of a hematoma somewhat stops bleeding, but is accompanied by the appearance of bruises on the side, abdomen, thighs and groin (depending on the size and extent of the hematoma). Patients have a decrease in blood pressure and signs of anemia. Symptoms from the abdomen in this case are not so intense, which is associated with a small amount of blood flowing from the aorta (no more than 1 glass).

The outflow of blood into the abdominal cavity is accompanied by the development of collapse, loss of consciousness, cold sweat, pallor of the skin, weakness of the pulse and other dangerous symptoms, while soreness is felt throughout the abdomen. The penetration of blood from an artery into the digestive tract is accompanied by pain in the stomach, intestines or pancreas. In the latter case, the pain will be girdle in nature.

Symptoms of intraperitoneal rupture of aneurysm are more pronounced, they are accompanied by the development of hemorrhagic shock and manifestations of internal bleeding. There is severe bloating and soreness of the abdomen, the pulse becomes frequent, but very weak, the skin is pale, covered with cold sweat. The clinical picture may resemble acute appendicitis or peritonitis. In addition, the pathology is characterized by the Shchetkin-Blumberg symptom, when the pain increases when the hand is pressed and taken away from the abdomen.

The symptomatology of an intraperitoneal rupture grows with lightning speed, so there is usually no time left for diagnostic measures.

If an aortic aneurysm ruptures into the vena cava, there is a gradual progression of symptoms: weakness, shortness of breath, heart palpitations, pain in the abdomen and lumbar region, edema that spreads to the lower trunk and legs. In the area of the peritoneum, you can easily feel the pulsating area, listening will show the appearance of a systolic-diastolic murmur above it.

A rupture of an aortic aneurysm or large arteries extending from it can also occur in the duodenum or other organs of the gastrointestinal tract. In this case, there are symptoms of gastrointestinal bleeding: black stools formed by a mixture of blood with gastrointestinal contents, vomiting of blood, rapidly advancing collapse (a sharp drop in blood pressure). Pain syndrome with localization in the epigastric region is not decisive here, although these pains cannot be called weak.

It should be understood that an aneurysm, most often localized in the area of large vessels with high blood pressure, can also form in smaller arteries extending from the aorta. So from the abdominal part of the aorta, the iliac arteries depart, which smoothly pass into the femoral area. In this zone, aneurysm does not occur so often, and rupture of an aneurysm of the femoral artery can be considered a rare pathology. But this is possible, as indicated by the following symptoms: pain in the legs, numbness of the lower extremities, cramps, a feeling of coldness in the feet and white color of the skin of the feet, the appearance of bleeding ulcers and bruises in the anterior abdominal wall, groin of the thigh, the appearance of weakness, a decrease in pressure, tachycardia.

Despite the fact that the femoral artery is not such a large blood vessel as the aorta, bleeding in the event of its rupture can be quite severe, foci of necrosis and gangrene can appear at the site of the hematoma.

Forms

We have already noted that aortic aneurysm rupture can occur anywhere in this large blood vessel, and the prognosis of not only health, but also human life depends on the location of the rupture. Quite often, doctors use a simplified classification, dividing the aorta into 2 large sections:

• rupture / dissection of the upper (proximal) or thoracic aorta,
• rupture / dissection of the lower (distal) or abdominal aorta.

As you can see, doctors consider 2 types of damage to the aortic wall, which are considered fatal:

• complete rupture, when the integrity of all layers of the vessel wall is violated and blood flows out of the artery,
• incomplete rupture or stratification with damage to 1-2 inner layers and penetration of blood into the space between the layers of the blood vessel.

According to the classification of the American cardiac surgeon Michael DeBakey, incomplete damage to the walls of the aorta can be viewed from this angle:

• dissection of the aortic walls simultaneously in the ascending and descending sections (generalized form or type 1)

• rupture of the inner membranes of the vessel with localization mainly in the ascending section and the aortic arch (type 2),
• dissection localized in the descending aorta (type 3).

The Stanford classification considers only 2 types of bundles:

• dissection of the ascending part of the aorta (type A),
• rupture of the inner shells of the vessel in the area of the arch and the descending section (type B).

Since the wall of the aorta consists of a three-layer connective tissue, its rupture is considered as a sequential violation of the integrity of the layers, starting from the inner and ending with the outer, which is ruptured last. A violation of the inner layer leads to the fact that blood begins to seep into the space between it and the middle layer. Individual blood components and increased pressure begin to destroy the middle layer, which can also be damaged, releasing blood further into the space between the subendothelium and the outer membrane. The dissection intensifies and, in the end, does not withstand the outer layer, which, like others, ruptures, and the blood flows out of the aorta.

All these stages go sequentially one after another, but the interval between them can be different. A person with a dissecting aorta can die in the first minutes after rupture or live with this pathology for several years.

There is such a classification of stages, or rather forms of rupture of the aorta:

• An acute form, when a sequential change in the stages of rupture occurs during the first 2 days. There is practically no hope that a person will survive with this form of rupture, since 9 out of 10 patients do not even have time to be taken to the hospital (death occurs at home or on the way to a medical facility).
• Subacute form. The duration of the change in the stages of aortic dissection in this case can reach 2-4 weeks, which gives the person some time to recognize the disease and seek help.
• Chronic form. In this case, the breaks are small and there is a large interval between the stages of separation. The process can last from several months to several years, which allows saving a person's life with an operation, which is necessary regardless of the form of the disease.

We can say that the faster the stage changes, the less chance a person has for life. With a strong blow to the heart or abdomen, for example, during an accident or a fight, the aorta ruptures so rapidly that the victim can die within a few minutes due to heavy bleeding.

[24], [25], [26], [27], [28]

Complications and consequences

If you hit a leg or arm hard, a large hematoma forms on them, which hurts a lot when pressed and swells due to hemorrhage in this area. If the bruise is small, it does not pose a particular danger, but a large, gradually increasing in size hematoma can present a serious problem, which is fraught with tissue necrosis, the development of purulent processes under the skin, and limitation of limb mobility.

When there is a violation of the integrity of the tissues, the blood begins to ooze out, and the longer this happens, the worse the patient's well-being will be. Even with a little bleeding, we first try to stop the bleeding.

An identical situation is observed with a ruptured aortic aneurysm, but it must be understood that the aorta is not a peripheral vessel, the diameter of which is insignificant, and the blood pressure in it is much higher. That is, we will not talk about a small hemorrhage, but about serious bleeding, when about 200 ml or more of blood accumulates in the internal cavities.

By itself, aortic dissection does not always lead to severe bleeding, but circulatory disorders are evident, which over time can lead to ischemic myocardial infarction or cerebral stroke. The fact is that aneurysm creates conditions for the formation of blood clots, which in turn can clog the vessels, preventing the flow of blood that carries oxygen to the tissues of the body. And from hypoxia, the brain and heart first of all begin to suffer. Ischemic disorders make the tissues of organs weak and unable to perform their functions.

Often, there is a blockage of smaller vessels, usually responsible for the nutrition and respiration of the tissues of the lower extremities. The legs begin to freeze more often, the risk of frostbite and the development of ulcerative processes increases.

The penetration of blood between the layers of the aortic wall also causes necrotic processes in the tissues, which weaken them and lead to rupture, which is considered a fairly frequent and most dangerous complication.

The penetration of blood into the chest or abdominal cavity has its unpleasant consequences. In the first case, the lung tissue is compressed and the mediastinal organs are displaced, respiratory failure increases, the risk of hemorrhagic shock caused by internal bleeding increases. Coagulated blood becomes the cause of the development of purulent processes in the pleura. Hemothorax is considered a medical emergency that can lead to the death of the patient.

Penetration into the abdominal cavity of various substances and fluids, including blood, becomes a risk factor for the development of purulent-inflammatory processes there. Peritonitis is one of the most life-threatening conditions that can be fatal in a short time. Especially if there is severe blood loss with a drop in blood pressure and acute signs of anemia. Why is intra-abdominal rupture of an aneurysm considered the most dangerous condition, which in the overwhelming majority of cases ends with the death of the patient.

It turns out that, whatever one may say, the rupture of the aortic aneurysm does not pass without a trace and the death of a person is a matter of time, if he is not provided with timely assistance. And it is better if this help is provided even at the stage of aneurysm formation, and not when the rupture of its membranes is diagnosed.

[29], [30], [31], [32], [33], [34]

Diagnostics of the ruptured aortic aneurysm

An aneurysm itself is a potentially dangerous condition that greatly increases the risk of rupture of the tissues of the largest blood vessel. Therefore, the sooner such a pathologically stretched section of the vessel wall is identified, the more chances there are to prevent its rupture.

Aortic aneurysm is a condition that can be detected both during a preventive examination (for example, with an asymptomatic course), and when a patient seeks a doctor for pain in the heart or epigastrium during chest and abdominal X-rays. It is possible to detect an aneurysm in the ascending part of the aorta during transthoracic or transesophageal echocardiography, on descending - by means of Doppler ultrasonography of the vessels of the thoracic or abdominal cavity.

Magnetic resonance computed tomography and aortography help to clarify the various parameters of the aneurysm. Although the latter is considered an invasive method, it allows us to detect the localization of the initial section of the rupture, to estimate the length of the exfoliated section, various disturbances in the structure of the vessel, leading to exfoliation of the tissues of the aortic wall, the size of the lumen and other diagnostically important parameters. While the tomogram allows you to determine the direction of the dissection, the involvement of the aortic branches in the process, the state of the aortic valve.

But if for the diagnosis of ordinary and dissecting aortic aneurysm, patients in most cases come with their own feet, then when it ruptures, an ambulance usually brings a person, and diagnostic measures are carried out directly on the operating table.

The task of the doctor in this case is to assess the localization of the rupture and the size of the hematoma as soon as possible in order to orientate about the further treatment regimen. In this case, computer and magnetic resonance imaging, ultrasound examination, laparoscopy, aortography and other available methods come to the rescue. The fact is that when the aorta ruptures, time goes by for minutes, so there is often no time left to transport patients to centers equipped with MRI and CT equipment.

It is clear that there will be few complaints of the patient and pallor of the skin for making a presumptive diagnosis. On palpation, the doctor can detect a pulsating seal in the peritoneal region, which indicates the presence of an aneurysm in the abdominal aorta (although the pulsation is not always felt). Listening to the sounds of the heart will show the presence of systolic murmurs in the projection of the enlarged section of the aorta. Blood tests will indicate signs of anemia (anemia).

Instrumental diagnostics allows the doctor to visualize his suspicions and assess the degree of their danger. So, ultrasound angiography allows you to visually assess the size of the aneurysm, the location of the rupture and the size of the hematoma near the passage of the aorta. With the help of spiral computed tomography, it is possible to assess not only the location and size of the rupture, but also its relation to various arteries extending from the largest blood vessel, which is considered the aorta, to differentiate an old hematoma from a new one. The presence of a rupture will also be indicated by the displacement of closely located organs relative to the aorta.

Computed tomography or magnetic resonance imaging helps not only to determine the method of treating a rupture, but, if necessary, stenting of the aorta allows you to determine the size of the stent.

You need to understand that not all clinics are equipped with CT or MRI equipment, so it usually comes down to X-ray and ultrasound. If it is not possible to conduct these studies, and the upper pressure indicator (systolic blood pressure) is not less than 90 mm Hg. Art., endoscopic techniques (laparoscopy) come to the rescue, which is effective in case of rupture of the abdominal aorta. In this case, a rupture of the vessel will be indicated by the detection of a hematoma in the area of the aorta near the small intestine, as well as the presence of blood that stains the serous fluid to a scarlet color.

Laparoscopy can also be useful in the postoperative period to assess the quality of the operation and recovery processes.

Aortography (contrast radiography) is a diagnostic method used in situations where the diagnosis is difficult or the doctor needs more information about:

• the relationship between the aneurysm and the branches of the aorta,
• the spread of the pathological focus to the place of bifurcation (bifucation) of the distal part of the vessel and its transition to the iliac arteries,
• to clarify the nature of the damage to the branches extending from the aorta,
• to identify such a rare pathology as aortocaval fistulas.

It must be said that aortic aneurysm rupture is a diagnostic rather difficult situation. On the one hand, you need to act quickly, because the time spent on diagnostics can cost a person his life, but on the other hand, the symptoms of pathology can resemble many other diseases, and the clinical picture can change markedly depending on the location of the break, its size and nature.

[35]

Differential diagnosis

Differential diagnosis of abdominal aortic aneurysm rupture is the greatest difficulty. Symptoms of an acute abdomen characteristic of it can be observed in pancreatic necrosis, acute cholecystitis, appendicitis, peritonitis caused by perforation of a stomach ulcer or rupture of the cecum, etc. Lower back pain, characteristic of rupture of the aorta in its abdominal region, are also signs of acute kidney disease and urogenital dullness, sciatica, girdle pains are characteristic of exacerbations of pancreatitis. Symptoms of internal bleeding require differentiation of aortic bleeding from gastrointestinal bleeding.

A presumptive diagnosis in this case may be "acute obstruction of the bifucation of the aorta and branches extending from it, feeding the lower extremities." In principle, thrombosis of the vessels that cause obstruction is quite possible, but if you pay attention only to this moment, which causes ischemia of the lower extremities, then you may not notice in time the much greater danger of rupture of the aorta.

When it comes to dissection or rupture of the aorta in the thoracic region, its symptoms, such as coughing and shortness of breath, can be misleading to the doctor, resembling the symptoms of inflammatory airway diseases. Thus, the patient can be examined by a therapist or pulmonologist while he has a cardiac problem.

Such mistakes and delays in making the final diagnosis quite often turn into tragic consequences. At the same time, the doctors' fault is not as great as it seems. A dangerous pathology with such controversial manifestations sometimes causes difficulties in diagnosis even for experienced clinicians with many years of experience, not to mention paramedics and therapists who do not have such knowledge.

[36], [37], [38], [39], [40], [41]

Treatment of the ruptured aortic aneurysm

Even if an experienced doctor cannot always accurately diagnose and assess by eye the degree of danger of this pathology, then what can we say about people who are not privy to medical issues. Nevertheless, patients with ruptures of the aorta, near which such an uninitiated person may be, can only rely on him and the patient's life will depend on the correct actions to provide first aid to the victim.

First aid for aortic rupture

The same should be done if there are symptoms that are part of the clinical picture of rupture of the aortic aneurysm and are life-threatening? First of all, you do not need to panic or try to compare these symptoms with the manifestations of other diseases in the hope of the best, assuming that this is an exacerbation of diseases of the gastrointestinal tract or the respiratory system. Pallor of the skin, a sharp drop in blood pressure, a threadlike pulse, breathing disorders and sudden severe pains of different localization are completely unsafe symptoms, the decoding of which is a matter for a specialist. Therefore, in any case, when they appear, you need to:

• Immediately call an ambulance, not forgetting to mention the extremely serious condition of the patient and suspicion of acute cardiovascular pathology (in this case, resuscitation should arrive, and, moreover, in a short time).
• If a person has previously been diagnosed with an aneurysm, then it is imperative to tell the ambulance operator, and then the paramedic about this diagnosis.
• It is also necessary to ensure free access of the doctor to the entrance and the apartment (to the house) so that help arrives as early as possible.
• The patient must be urgently laid on a flat horizontal surface, slightly raising his head in relation to the legs.
• Clothes on the victim should not pinch the chest and abdominal cavity: you need to unfasten the collar and the top buttons of the shirt (if necessary, you can unfasten the clothes completely or take them off), let the corset or belt go.
• The patient may experience mental and motor excitement, so you need to try to keep him from unnecessary movements and ensure a motionless position, which will affect the intensity of bleeding, because it is heavy bleeding that often becomes the cause of the patient's death.
• Violation of blood circulation caused by rupture of the aorta leads to the fact that the tissues do not receive enough oxygen, therefore, to reduce the symptoms of oxygen starvation, it is necessary to increase the oxygen content in the blood by accessing fresh air into the room where the patient is located (this will also facilitate the breathing of the victim).
• The first thought of many in case of health problems is the desire to alleviate the patient's condition with the help of pills, but since the diagnosis of the disease is unknown, it is difficult to navigate with drugs for first aid. It is not recommended to give pressure medications, analgesics, laxatives and other drugs. The best option to help reduce pain in acute cardiovascular pathologies is a nitroglycerin tablet under the tongue.
• Before the arrival of an ambulance, you must not give the patient any food or drink.
• The occurrence of severe pain, especially in the area of the heart and lower abdomen, is often a reason for panic in the patient himself. In this case, you need to try to calm the person down, because experiences can only increase the pressure in the heart and blood vessels, which will increase the force of bleeding.

Since we do not know exactly what we are dealing with, it is better not to make any other attempt to help the patient. The only thing we can do is to provide him with bed rest and rest, and specialists should be engaged in the treatment of the victim and maintenance of his vital functions, especially since the treatment of aneurysm rupture is operative, because from such a large vessel coming directly from the heart, under pressure can a large amount of blood can flow out and it is impossible to stop this process with the help of drugs.

A ruptured aortic aneurysm is an urgent condition, and it would be great luck if the person can be brought to the hospital alive. Be that as it may, doctors always hope for the best. The struggle for the patient's life begins already in the ambulance and at the emergency room, where the Rh factor and blood group, hemostasis indicators are determined, catheters are installed in the region of the central vein and bladder.

Upon arrival at a medical facility, the patient is often almost immediately sent to the intensive care unit, where diagnostic measures are carried out in a short time, allowing the development of an effective treatment regimen for the victim, the functions of vital organs are assessed: heart, kidneys, lungs. Along with diagnostics, various parameters are measured: blood pressure, heart rate, body temperature, strength and respiration rate, etc. If necessary, life support devices are immediately connected.

The choice of methods for treating aortic aneurysm rupture among doctors is small. This is either an intracavitary operation, or endoprosthetics (stenting) of the aorta, which in any case is an operation. Alas, traditional drug and physiotherapy treatment in this case remains powerless.

Intracavitary surgery involves opening the sternum or abdominal cavity (depending on the location of the rupture site), removing the part of the aorta where the integrity of the vessel wall has occurred (resection of the aneurysm), and installing a synthetic prosthesis in this area. This is a fairly common operation, with the features of which cardiac surgeons are well familiar (you need to understand that only a specialist, i.e. A vascular or cardiac surgeon, can perform an operation on large vessels).

But such operations have many disadvantages: low survival rate due to the high trauma of the intervention and a high risk of developing all kinds of complications. The fact is that most patients with aortic rupture have additional cardiovascular health problems. These are myocardial ischemia, cerebrovascular accidents, arrhythmias, arterial hypertension, carotid artery atherosclerosis, etc., which can become a risk factor for the development of all kinds of complications and even be a contraindication to surgery. The doctor has to assess the risk of such an operation, and it is often extremely high, leading to death.

Unlike abdominal surgery, endoprosthetics is considered a low-traumatic method of performing surgical actions, which makes it possible to perform it in patients with heart and vascular diseases. In this case, transvascular introduction of prostheses (stents) is used, which strengthen the vascular walls and replace the tissues of the damaged area. Usually the stent is inserted in the femoral artery area under local anesthesia, which is much better tolerated than the general anesthesia required for intracavitary surgery. The stent graph is inserted with the folded state by means of a conductive system, which is removed after the stent has been opened at the rupture site. Endoprosthetics is performed under X-ray control.

The first and main task of aortic surgery is to stop internal bleeding, which can be performed in various ways:

• the imposition of special clamps on the arteries,
• introduction of a special balloon catheter into the arterial bed,
• compression of the aorta, etc.

If it is not possible to carry out an urgent operation, and the delay of death is similar, pneumatic compression of the body is performed, which allows you to gain from 2 to 5 hours of time.

But just to stop the bleeding by surgery is not enough. It is also necessary to restore the integrity of the aorta and the normal blood flow in it, which is what synthetic prostheses help to do. In addition, it is necessary to remove the symptoms of the disease: relieve pain, normalize blood pressure, take preventive measures to prevent renal failure and some other measures to improve the patient's condition and speed up recovery after surgery.

Consequences after surgery

Despite the vast experience of vascular surgeons and the widely used low-traumatic methods of treating aortic aneurysm rupture, such operations are far from always successful. It happens that the patient dies simply on the operating table or after the operation. Statistics are especially unfavorable to older people and those who have diseases of the cardiovascular system.

Recovery and rehabilitation after a ruptured aortic aneurysm can proceed in different ways. Depending on the type of operation, the patient must be in the hospital for a certain time. After intracavitary intervention, it is necessary to stay in the hospital for 2 weeks, and after vascular stenting, the patient can return home after 2-3 days. After the traditional intervention, the postoperative period is delayed for up to 14 days, after which the patient can be discharged home, but only if the prosthesis is in a satisfactory condition after suture removal. But endoprosthetics provides for a reduction of the entire rehabilitation period to 14 days.

Unpleasant consequences after surgery, forcing the patient to remain in the hospital under the supervision of a doctor, are:

• leakage of blood in the suture area,
• blockage of blood vessels with blood clots,
• inflammation of tissues in the area of surgical sutures,
• pulmonary edema,
• distal migration (displacement) of the stent,
• violation of the patency of the prosthesis,
• covering the renal arteries with an awning,
• violation of urination (a poor prognostic sign, indicating progressive renal failure, which, again, can lead to the death of the patient).

Complications with endoprosthetics occur much less frequently than with abdominal surgery (no more than 20% of cases). In order for the patient to be discharged home from the hospital, the X-ray and laboratory data must be normal.

After discharge from the hospital, the patient is obliged to undergo a monthly examination by a cardiologist, and, if necessary, visit a doctor for any unusual symptoms. This prerequisite must be met during the first year.

To avoid possible complications, a person will have to constantly monitor the level of blood pressure and, when it rises, take antihypertensive drugs, avoid heavy physical exertion and stressful situations, and eat right. Doctors do not restrict patients in movement, but overwork in this case is unacceptable, and patients get tired very quickly, even from the simplest work around the house.

If in the future a patient who has undergone a ruptured aortic aneurysm is referred for surgery for any other organs, including dental surgery, a course of antibiotic therapy is required to prevent various complications, antihypertensive drugs and anticoagulants, which will prevent the formation of blood clots.

[42], [43], [44]

Prevention

Prevention of aortic aneurysm rupture before surgery can be called timely treatment of emerging cardiovascular diseases, rejection of bad habits, preventive medical examinations.

Since atherosclerosis of the vessels is to blame in 90% of cases of aortic aneurysm formation, such a dangerous pathology can be avoided by prophylaxis of atherosclerosis: adherence to a diet that includes a minimum amount of fat and bad cholesterol, moderate but regular physical activity, quitting smoking and drinking alcohol, using alternative recipes for cleaning blood vessels from cholesterol plaques.

If an aneurysm has been identified, a person should regularly visit a cardiologist, who will monitor the patient's condition, prescribing the necessary studies (for example, Doppler ultrasound or duplex scanning of blood vessels). Now you have to constantly monitor the level of blood pressure and blood cholesterol.

If a person found out about the aneurysm only during its rupture or simply ignored the requirements for preventing aortic aneurysm rupture, it will no longer be possible to avoid the operation. But even after the operation, the patient will have to comply with certain requirements that will prevent the recurrence of the disease, because the cause of the formation of the aneurysm is not removed surgically:

• complete rejection of bad habits (smoking, drinking alcoholic beverages),
• sparing regimen for at least 1 month after surgery (limiting physical activity, avoiding emotional experiences and nervous overstrain),
• maintaining weight within the age norm,
• regular measurement of blood pressure (2 or more times a day) and its decrease if the values exceed 130/85 mm Hg,
• proper nutrition (fractional diet, food should be sufficiently chopped, strict selection of products and dishes).

As for the diet of patients after aortic surgery. They are prohibited from spicy, fried foods, products containing animal fats, fatty meats and fish, rich broths, offal, strong tea and coffee, cocoa and chocolate in large quantities. The ban also includes products that cause increased gas formation (beans and legumes, fresh and sauerkraut, white bread, etc.), as well as carbonated drinks.

The amount of salt in dishes should be limited to 4-5 g per day, the amount of water you drink - up to 1 liter per day. But products that have a laxative effect will benefit such people. Dried apricots and prunes are considered especially useful, which are good to combine with flax seeds.

For six months after the operation, physical activity should be low, but physical inactivity should be avoided. If the doctor allows, after 4-5 months after treatment, you can practice health walking, swimming, slow running. It is better to start classes under the supervision of specialists as part of rehabilitation programs.

It is worth limiting the lifting of weights. The maximum weight of items to be lifted is 5 kg, otherwise pressure build-up or seam damage cannot be avoided.

Now a person will have to be especially careful, because he may simply not survive the re-formation and rupture of the aortic aneurysm. The lethality of even the first operations is very high, and what can we say about such interventions in the work of an organism weakened by the disease and its treatment.

[45], [46], [47], [48]

Forecast

Aortic aneurysm rupture is a pathology that, without professional treatment, does not leave patients a chance for life. No pills, alternative prescriptions, physical therapy can help in this situation. Only a timely stop of bleeding and an operation to replace the vessel give a person hope, although it is very weak. About 90 percent of patients who have undergone abdominal surgery die soon. The prognosis after vascular stenting is more favorable, although later additional operations may be required (the stent has a limited period during which it can perform its functions well).

It must be said that surgery on the aorta allows 50% of patients to live for another 5 years or more, which is also important. But even in the absence of complications immediately after the operation, long-term consequences may occur, such as:

• thrombus formation and blockage of blood vessels by blood clots,
• the formation of fistulas in the intestine (this is possible in the field of surgery on the abdominal aorta),
• suppuration of tissues in the area of the prosthesis,
• deterioration of sexual function and the work of the urinary system.

[49], [50], [51], [52], [53]