Aortic dissection in the elderly
Introduction
Introduction to the separation of aortic dissection in the elderly The aortic dissection is an intramural hematoma formed by the infiltration of circulating blood into the middle layer of the aortic wall due to destruction of the intima or middle layer of the aorta, also known as aortic dissection. This exfoliative hematoma of the aortic wall can expand along the artery, invade the branches of the aorta, and can cause massive hemorrhage caused by destruction of the adventitia of the arterial wall. Sometimes the distal endometrium breaks into the aortic lumen, and the condition can be temporarily relieved. The disease has a sharp onset, complex symptoms, rapid changes and easy misdiagnosis. If not treated in time, the mortality rate is extremely high. basic knowledge Sickness ratio: 0.05% Susceptible people: the elderly Mode of infection: non-infectious Complications: pericardial effusion, sudden death, acute myocardial infarction, abdominal pain
Cause
Etiology of aortic dissection in the elderly
(1) Causes of the disease
In elderly patients, the cause is mostly essential hypertension and arteriosclerosis. The incidence may be due to the long-term aortic pressure in the aorta. The aortic wall is persistently contracted and hardened, resulting in the middle layer of the aortic wall. Degenerative changes in elastic fibers and smooth muscle, history of hereditary disease, horse-square syndrome, age of onset, congenital vascular disease, such as aortic coarctation, bicuspid aortic valve malformation, aortic dysplasia, aortic stenosis Acute aortic dissection can also occur.
(two) pathogenesis
Aortic cystic necrosis, mucoid degeneration, elastic fiber rupture, smooth muscle cell destruction, chronic inflammation granulation tissue hyperplasia, arterial intimal tear, arterial wall peeling and hematoma spread between arterial walls are the basic pathology of aortic dissection development process.
Prevention
Prevention of aortic dissection in the elderly
1. For asymptomatic old age, avoid extreme cold, warm clothes in winter, do not bathe with cold water, avoid strong sun exposure on feet and calves, often walk to promote blood circulation, soak your feet with warm water and dry thoroughly, especially toes. To avoid skin rupture and infection, shoes and socks need to be loose and comfortable. Do not wear socks with elastic bands.
2. Intermittent claudication for the elderly, the effect of medical treatment is limited, but some cases have a certain effect, during the treatment period, to advise to quit smoking, obese people encourage weight loss, and as much activity as possible, walk to a certain time after the limp, should rest immediately, Then continue to walk, such as drug treatment is not satisfactory, the only method is surgical treatment, for arterial bypass grafting, or percutaneous transluminal angioplasty.
Complication
Complications of aortic dissection in the elderly Complications, pericardial effusion, sudden death, acute myocardial infarction, abdominal pain
If the aneurysm ruptures, hemorrhage, pericardial effusion, acute pericardial tamponade can be sudden death, the lesion involving the coronary artery caused acute myocardial infarction involving the aorta, the renal artery is abdominal pain, involving the paravertebral artery caused by paraplegia.
Symptom
Symptoms of aortic dissection in the elderly Common symptoms Persistent pain, hoarseness, dyspnea, nausea, blood in the stool, skin, cold, dizziness, heart failure, blood pressure, decreased blood pressure
1. Pain: It is the most common symptom in the initial stage of the disease. It is found in 80% to 90% of patients. The pain is characteristic and it is tear-like persistent pain. It is often extremely intense and intolerable from the beginning of the pain. There is a sense of suffocation or sudden death. The pain is mostly in the front chest and extends to the back, especially in the interscapular region. As the meridian hematoma spreads, the pain can be released to the head and neck, abdomen, groin and lower limbs, and strong pain relief. Agents such as morphine or crown-expanding drugs often do not relieve pain. If the distal endometrial rupture of the dissection causes the blood in the dissected hematoma to return to the aortic cavity, the pain can often be relieved. If the pain disappears after the disappearance, the mezzanine should continue to expand and The risk of rupture of the outer membrane, a small number of patients without pain may be covered by fainting or neurological symptoms.
2. Shock: 1/3 to 1/2 patients have pale face, sweating, wet skin, high blood pressure, fast and weak pulse, but the blood pressure and shock performance are not parallel, but often Increased, this is another feature of this disease, early onset due to severe pain, irritability, blood pressure generally higher than usual, after a slight decrease in blood pressure, but still maintained at a certain height, a small number of patients with significant hypotension may be due to rupture bleeding caused by blood volume Reduce or tamponade, caused by heart failure.
3. According to the affected parts, the following various symptoms and signs can appear, resulting in complex and variable clinical manifestations.
(1) Circulatory system: sudden diastolic murmur accompanied by systolic murmur in the aortic valve auscultation area, which is a diagnostically significant sign. The noise is caused by aortic root mesentesis, aortic valve displacement, prolapse, and flap Ring expansion, rupture of the intima, bulging into the lumen caused by blood flow vortex, chest pain associated with the emergence of aortic regurgitation, is an important sign of ascending aortic dissection, pulse pressure widening and edema Peripheral signs such as veins, severe aortic regurgitation can lead to progressive congestive heart failure, left ventricular enlargement can cause relative mitral regurgitation, systolic murmurs in the apex, aortic dissection can affect coronary arteries, more common in Right coronary artery, causing acute myocardial infarction, ruptured into the pericardial cavity caused by pericardial hemorrhage, causing acute pericardial tamponade, the condition can be rapidly deteriorated, is the main cause of death, the dissection of the hematoma or the main branch of the aorta can occur Arterial occlusion, manifested as bilateral neck, paralysis of the ankle and femoral artery or asymmetry, significant difference in blood pressure between the upper limbs, Limb blood pressure to reduce the difference, changes in arterial pulse common type patients, the abnormal beat is one specific type patient signs appear sternoclavicular joint, few patients performance superior vena cava obstruction.
(2) The nervous system: due to the involvement of the cerebral hemisphere in the meridian hematoma, the arteries of the spinal cord or cerebral hypoperfusion due to hypotension, can cause a series of neurological symptoms, invasive arteries or carotid arteries, dizziness, confusion or Syncope, but also hemiplegia, blindness, aphasia and other strokes, fundus examination of the retina pale, lesions involving the intercostal artery or lumbar artery, can lead to spinal cord ischemia, delayed or spastic paraplegia, dissection of the hemorrhage caused by dissection of the diaphragmatic hematoma, Then the lower extremity arterial pulsation can disappear, peripheral nerve ischemic necrosis, limb paresthesia or loss, limb chills, skin spots purple, muscle tension weakened or paralyzed, and the recurrent laryngeal nerve can be hoarse.
(3) Respiratory system: The meridian hematoma compresses the trachea, the bronchus or rupture to the thoracic cavity causes pleural hemorrhage, and both may have difficulty breathing and coughing. The dissection of the dissection to the thoracic cavity is generally seen on the left side. If it is directly broken into the lungs, it may cause hemoptysis.
(4) Digestive system: As the abdominal aorta and its branches are involved, affecting the blood supply to the abdominal organs, there may be similar manifestations of various acute abdomen, which may be misdiagnosed as acute abdomen, and upper abdominal pain is seen in 10% to 50%. Patients, often accompanied by nausea, vomiting symptoms, meridian hematoma compression of the trachea can cause difficulty breathing, such as breaking into the esophagus can cause hemoptysis, the superior mesenteric artery invasion can lead to paralytic intestinal necrosis and blood in the stool.
(5) Urinary system: When the meridian hematoma invades the renal artery, it can cause acute renal ischemia and renal failure. There is oliguria and no urine. When the blood pressure is significantly increased, hematuria can be seen. The kidney can touch the mass and can appear at the waist or Pain at the rib angle.
1 According to the course of the disease, the disease is divided into 3 types: A. Acute type: acute and dangerous onset, more than 24h to penetrate the outer membrane, causing hemorrhagic shock and death, B. subacute type: survival after the disease for several days to In a few weeks, most of the clinical features are acute, C. Chronic: slow onset, the course of the disease can be extended to more than 6 weeks, often due to the distal end of the aortic dissection into the endometrium to form a pseudo-aortic channel and the symptoms are relieved. Or heal itself due to blood coagulation or fibrosis in the interstitial hematoma.
In 21965, DeBakey divided the disease into three types according to the lesion: type A.I. The lesion occurred in the ascending aorta and expanded beyond the aortic arch to the descending aorta. This type is the most common type, B.II type, and the lesion is limited to liter. The aorta, type C.III, begins at the distal end of the descending aortic left subclavian artery and includes or exceeds the thoracic aorta.
Examine
Examination of aortic dissection in the elderly
Increased white blood cell count, red blood cells, anemia or hemolytic jaundice; red blood cells in the urine, and even gross hematuria.
X-ray inspection
For common examination methods, common mediastinal widening and aortic arch enlargement and deformation of chest radiographs are performed. The follow-up shows an increase in short-term. Sometimes, the aortic arch constricted to a localized hump-like shape or a double shadow of the aorta. The internal image is true. In the arterial cavity, the external shadow is a pseudo-arterial cavity. If the aortic calcification is seen, and the internal limit of the artery wall is determined, the distance from the outer edge of the aortic shadow is greater than the normal 2 to 3 mm. Aneurysm.
2. Ultrasound examination
Ultrasound can clearly show the location of the aortic dissection of the ascending aortic dissection, the width, the echo of the intima of the intima and the size of the aortic valve, but the function of the aortic valve in the lungs. Ultrasound application in the esophagus shows that the relationship between the ascending aorta and the heart chamber is more intuitive and clear, and it is helpful for the evaluation of the diagnosis and treatment results.
3. CT or MRI examination
It is a non-invasive examination, safer and easier than aortic angiography, and has important value in determining the location, extent and shape of the lesion. In recent years, many units have listed it as a routine examination item.
4. Aortic angiography and DSA: It is the most reliable method for diagnosing aneurysms. It can not only fully display the location, size, shape and extent of aneurysms, but also show the upper and lower arteries, branch distribution and the relationship between the tumor and the heart chamber and valve. The contrast agent enters the dissection tumor and forms a shadow associated with the aortic tube, which has important reference significance for guiding surgery.
Diagnosis
Diagnosis and differential diagnosis of aortic dissection in the elderly
Diagnostic criteria
The cause of aortic dissection, extension range, aortic branch involvement and comorbidities, resulting in complex clinical changes, easily misdiagnosed, must improve the understanding of the disease, a detailed understanding of the occurrence and development of symptoms, close Observing changes in physical signs can form a correct diagnosis.
The diagnosis points of this disease:
1. The pain reaches a peak at the beginning of the attack, which is a tear-like pain and has a migration.
2. Although there is shock performance in the clinic, the blood pressure drop is often not parallel with it, and the blood pressure is increased in the early stage of the disease.
3. Sudden aortic regurgitation or pericardial tamponade.
4. Neck, limb arterial pulsation disappeared or bilateral asymmetry, the blood pressure of the arms was significantly different.
5. Sudden onset of acute abdomen or nervous system ischemic disorder.
6. X-ray films may provide diagnostic clues. Doppler two-dimensional echocardiography detected by chest wall and esophagus can show the intimal tear site and the functional state of the true and false cavity and valve, combined with the morphological changes of CT or MRI. Accurate diagnosis and classification can be performed, and a small number of diagnoses or aortic angiography can be performed in patients with coronary artery conditions before surgery.
Differential diagnosis
Acute myocardial infarction
(1) The pain at the beginning of the pain of the dissecting aneurysm is the peak of tearing, which is a wide-ranging tear. It can be seen in the head, neck, back, abdomen, waist and lower limbs. It can not be relieved by analgesics. Acute myocardial infarction pain Generally, the drama is gradually increased, showing dull pain or cramping, and there is a feeling of tightness. The pain relief or crown-expanding drugs can alleviate or alleviate.
(2) When the dissection of the aneurysm is accompanied by shock, the blood pressure does not necessarily decrease, but often increases, the myocardial infarction is accompanied by shock, and the blood pressure is decreased.
(3) myocardial infarction caused by cerebral artery or peripheral arterial embolism, usually several days or weeks after the onset of the disease, while the dissection of the surrounding artery caused by peripheral arterial occlusion or cerebrovascular symptoms more than within hours after the onset.
(4) Myocardial infarction has typical ECG changes and increased serum enzyme activity. In addition to a small number of invasive coronary artery-induced myocardial infarction, there is no specific ECG change.
(5) X-ray chest and echocardiography can provide a diagnostic clue for dissection aneurysms.
2. Acute abdomen: When the dissection lesion invades the aorta and its main branches, various manifestations of acute abdomen may occur, which may be misdiagnosed as mesenteric artery embolism, acute cholecystitis, pancreatitis, ulcer disease and intestinal obstruction. Abdominal symptoms generally have tenderness or rebound tenderness in the abdomen. The degree of pain in dissecting aneurysms is often inconsistent with abdominal signs. Abdominal pain is often migratory. Signs of vascular obstruction can occur in other parts of the body. Ultrasonography, CT or aortic angiography can be used to identify.
3. Cerebrovascular accidents: In addition to the signs of the nervous system, dissecting aneurysms often have signs of vascular obstruction in other parts of the body or sudden signs of aortic regurgitation.
4. Pulmonary infarction: manifested as sudden chest pain, difficulty breathing, cough and hemoptysis, similar to the symptoms of dissection aneurysms, but the chest pain is not as extensive as the latter, chest X-ray is helpful to identify.
5. Other diseases that cause sudden aortic regurgitation: Aortic sinus aneurysm rupture, infective endocarditis, etc. Aortic regurgitation can also occur after chest pain, and progressive congestive heart failure occurs, but The chest pain is less than that of the mezzanine artery, and echocardiography and aortic angiography can be identified.
