Gerashchenko A.V., Kucherenko V.S., Fedotov P.A., Borshchev G.G., Gorokhovatsky Yu.I.

Dissecting aortic aneurysm — sudden formation due to various causes of a defect in the inner wall of the aorta with subsequent penetration of the blood flow into the degenerately altered middle layer, the formation of intra-wall hematoma and longitudinal stratification of the aortic wall mainly in the distal or less often in the proximal direction.

The first attempt to correct aortic dissection was undertaken by D. Gurin et al. in 1935 by creating a distal fenestration at the level of the external iliac artery. The first successful resection of the aneurysm of the thoracic portion of the aorta with replacement of the graft was reported in 1953 by M. DeBakey, D. Cooley. 1955 was marked by two new victories in the surgical treatment of aneurysms of the thoracic part of the aorta — D. Cooley et al. reported a complete replacement of the aneurysm of the aortic arch, and F. Ellis et al. and independently S. Etteredge performed successful operations for thoracoabdominal aneurysms. The first successful operation of separate aortic valve replacement and ascending aorta was carried out in 1964 by R. Wheat. Further, M. Bentall (1968), J. Edwards (1974) and S. Cabrol (1981), considering the involvement of the fibrosus ring, Valsalva sinuses and coronary arteries in the pathological process, proposed various modifications of simultaneous aortic valve and aortic valve replacement “Conduit” with reimplantation of the coronary arteries.

In the USSR, the first successful operation of resection of posttraumatic aneurysm of the thoracic part of the aorta in correctional colony conditions was performed on April 17, 1962. by M.N. Anichkov. On December 28 of the same year, a successful resection of the saccular aneurysm of the ascending part of the aorta with the imposition of a marginal aortic suture under AI conditions was performed by A. V. Pokrovsky. The first successful operations of supracoronary resection of an aneurysm of the ascending part of the aorta with separate aortic and aortic valve replacement, as well as interventions using the Bental and Kabrol method in the Marfan’s syndrome were performed by G.I. Tsukerman in 1973, 1978 and 1983 respectively.

In 18-22% of cases, the cause of the development of aneurysm of the aorta is the traumatic nature of the lesion. Less common aortic aneurysms occur with aortites (4.3%) — syphilitic, giant cell and mycotic. With the increase in the number of invasive instrumental methods of examination, as well as surgical interventions, the frequency of iatrogenic (2.5-7%) aortic aneurysms is increasing: after reconstructive operations on the aorta and its branches, at the sites of postoperative aortic injury, as well as cardiac catheterization, aortography.

The ratio of aortic aneurysms of different localization was as follows: aneurysms of the ascending part of the aorta — 22.9%, aortic arch — 18.9%, descending part of the aorta — 19.5%, abdominal aorta — 37.2%. Thus, aneurysms of the thoracic aorta account for almost 2/3 of all cases of aortic aneurysms.

Classifications of dissecting aortic aneurysms are usually based on the localization of the proximal rupture of the inner aortic membrane and the extent of the aortic wall stratification. In clinical practice, to modify the prognosis of the disease and develop conservative and operational tactics, it is more convenient to modify this classification, which was proposed in 1984 by F. Robicsek:

Type I — the rupture of the inner shell is localized in the ascending part of the aorta, and the stratification of its walls extends to the ventral part of the aorta. The pathological process has two options:

  • the dissection of the wall ends with a blind sac in the distal aorta;
  • there is a second — distal aortic rupture (distal fenestration).

Type II — the rupture of the inner membrane is localized in the ascending part of the aorta, the bundle ends with a blind pouch proximal to the brachiocephalic trunk.

Type III — rupture of the inner aortic membrane is localized in the initial section of the descending part of the thoracic aorta distal to the mouth of the left subclavian artery. The process of stratification has 4 options:

  • the dissection ends with a blind bag above the diaphragm;
  • the dissection ends with a blind sack in the distal parts of the abdominal part of the aorta;
  • the dissection is directed not only distally, but also extends retrograde to the arch and the ascending part of the aorta, ending with blind sacks;
  • the aortic dissection extends to the abdominal part of the aorta with the development of distal fenestration.

We present a clinical demonstration of the surgical treatment of the dissecting aneurysm of the ascending aorta.

Patient O. 28 years old entered the department on October 7, 2010 with complaints of moderate pain behind the sternum

From the anamnesis it is known that on 06.10.10 pain behind the sternum appeared, then temperature has risen and headaches took place, after taking anti-inflammatory drugs the symptoms decreased. 07.10.10 in the morning, pain behind the breastbone appeared again, the patient called the Ambulance team, after nitro drugs, a syncopal condition was noted, inotropic support was prescribed.

The general condition at admission was heavy. Consciousness was clear. The patient was active. The constitution of normostenic Skin and mucous membranes were of normal color and moisture. There was no pastosity of the shins and feet. Musculoskeletal system without pathology. Lymph nodes are not enlarged, painless on palpation. At the lungs percussion: clear pulmonary sound. BH 17 min. At auscultation: breath vesicular, was spent above all departments. There were no whips. The boundaries of relative and absolute cardiac dullness of the heart were not expanded. Heart sounds were muffled, rhythmic. HRC 105 per minute, blood pressure 120/70 mm Hg. Pulsation on the main peripheral arteries was preserved (pulsation is determined on the carotid, radial, femoral arteries without changes). Symptoms of varicose veins of the lower extremities were not revealed. The appetite was preserved. Tongue was moist, clean. The abdomen was of a regular shape, soft, palpation painless. Symptoms of irritation of the peritoneum were not revealed. The kidney area was not changed. Pasternatsky sign was negative. There was no dysuria. Focal and meningeal neurologic symptoms were not revealed.

Instrumental research data

ECG sinus rhythm with heart rate 95 (Fig. 1).

Echo-KG: The systolic function is not reduced, the zones of akinesis were not revealed. There were no pathological changes in the valvular apparatus. The expansion of the ascending aorta up to 6.4 cm is revealed. The aortic valve is consistent

Chest X-ray: In the lungs without focal and infiltrative changes. (Fig. 2).

CT of thoracic organs: An expansion of the ascending aorta up to 72 mm was revealed with the formation of a false path from the sinotubular junction. (Figures 3a and 3b, indicated by arrows)

Diagnosis: Dissecting aneurysm of the ascending aorta, type II.

On October 11, 2010 the operation was performed:

Closure of the defect of the posterior-lateral wall of the ascending aorta by a xenopericardial patch, linear plasty of the ascending aorta under conditions of artificial extracorporal blood circulation and cold pharmacological cardioplegia

Operated by academician Shevchenko Yu.L.

Intraoperative: Under the endotracheal anesthesia, a median sternotomy was performed. Parallel, the superficial femoral artery is isolated. At revision, the heart is not enlarged in size. The ascending aorta is enlarged for 15 cm to 8 cm across (Figures 4a and 4b). Artificial extracorporal blood circulation device connected to upper and lower hollow veins and left femoral artery. Transverse aortotomy. Selective cardioplegia of the coronary artery entrance. A defect of the intima on the posterior surface of the aorta was detected for 5-6 cm (Fig. 5) with a cavity filled with thrombotic masses. A sealing seam with a puncture on the external surface of the aorta was used to close the defect of intima of the aorta with a patch of xenopericardium (Fig. 6) and fix the patch with a suture from the inside of the aorta to the outer wall on teflon gaskets. Linear plastic of the ascending aorta is linearized with the formation of a duplication from the left edge of the aortotomic incision on felt liners (Fig. 7). After stabilizing the parameters of central hemodynamics, the extracorporeal blood circulation was gradually stopped. The time of artificial circulation was 113 min, the clamp on the aorta — 83 min.

The patient was discharged in good condition 14 days after surgery.


Fig. 1. Electrocardiogram

Fig. 2. Radiograph
 

Fig. 3a. Computed tomography of chest organs

Fig. 3b. Computed tomography of chest organs
 

Fig. 4a

Fig. 4b
 

Fig. 5

Fig. 6
 

Fig. 7