Allergic processes, systemic collagenoses. The disease is chronic and manifests itself painful sensations behind the sternum, expansion of the aorta. Prevention and treatment come down to active treatment of the underlying disease.
Aortitis is an inflammation of the aorta, often of infectious origin. The main cause of aortitis is syphilitic infection; Streptococcal, rheumatic, septic, and tuberculous aortitis are less common. Sometimes the aorta is involved in the process due to inflammation of neighboring organs (pulmonary tuberculosis, mediastinitis). Isolated cases of aortitis with systemic thrombangitis have been described. The listed forms of aortitis do not have a clear clinical picture. Aortitis is suspected when dilatation of the aorta is detected against the background of rheumatic, septic or other diseases.
Aortitis is a late manifestation of syphilis. The first clinical symptoms of aortitis appear several years after infection, much more often in men. The main clinical symptom of aortitis is pain. Patients usually complain of prolonged dull, pressing and aching pain behind the sternum, which intensifies with physical activity and excitement. With damage to the ostia of the coronary arteries and insufficiency of the aortic valves, the pain can take on a severe anginal character.
Syphilitic aortitis is divided into uncomplicated and complicated (narrowing of the mouths of the coronary arteries, aortic insufficiency, aneurysm). With uncomplicated syphilitic aortitis, objective data are scarce. Sometimes it is possible to note increased pulsation of the aorta in the jugular fossa, and with percussion in the upper part of the sternum - expansion of the aorta. When listening in the second intercostal space to the right of the sternum, a change in the second tone is characteristic, acquiring a ringing metallic character. Often a soft systolic murmur is heard in the same place, in contrast to the rough systolic murmur with aortic stenosis. Often, systolic murmur in syphilitic aortitis occurs or intensifies when raising the arms (Sprotinin's symptom). When large vessels extending from the aortic arch are affected, a difference occurs in the intensity of pulsation of both carotid arteries, pulse frequency and height blood pressure on the right and left hands. The electrocardiogram is usually unchanged. Positive reaction Wasserman is observed in 74-95% of patients with syphilitic aortitis. The most important thing for diagnosing syphilitic aortitis is careful X-ray examination(fluoroscopy, teleradiography, X-ray kymography and electrokymography, contrast aortography). Characterized by expansion of the aorta, an increase in the amplitude of its pulsation, uneven contours and an increase in the shadow of the aorta.
When syphilitic aortitis is complicated by narrowing of the coronary artery ostia or aortic insufficiency, a picture of slowly progressive chronic coronary insufficiency develops, followed by cardiosclerosis and circulatory failure. Differential diagnosis carried out with atherosclerosis of the aorta (see Atherosclerosis), atherosclerotic cardiosclerosis (see), subacute septic endocarditis (see), mediastinal tumors (see).
The prognosis for syphilitic aortitis depends on the activity and extent of the process, and the presence of complications. Prevention and treatment come down to active, comprehensive therapy for syphilis. Treatment is carried out in a hospital setting, starting with bismuth, mercury, iodine and active penicillin therapy (see Syphilis, treatment). In case of severe coronary insufficiency, heart failure, antisyphilitic treatment must be carried out more carefully, combining it with effective coronary dilation therapy, the administration of cardiac glycosides, saliuretics, oxygen therapy [see. Angina pectoris, Blood circulation (insufficiency)]. V. Soloviev.
Pathological anatomy. The term “aortitis” refers to both an inflammatory process in the wall of the aorta, predominantly of an infectious nature, and reactive changes in the aorta of an immunoallergic nature, whose morphological picture resembles inflammation. Based on the localization of the process, endaortitis, mesaortitis, periaortitis and panaortitis are distinguished, but isolated damage to the intima or adventitia is extremely rare (with brucellosis, rheumatism). According to the distribution, aortitis can be diffuse, ascending and descending.
Infectious aortitis is a particular manifestation of the underlying disease (syphilis, rheumatism, sepsis, malaria, brucellosis, gonorrhea, etc.). Mesaortitis and panaortitis are more common. In acute infectious aortitis (septic, streptococcal, gonorrheal, rickettsial, malarial), the aorta is swollen and poorly elastic. Microscopically, its membranes are infiltrated with polymorphonuclear leukocytes. In chronic infectious aortitis (syphilitic, rheumatic, tuberculous), the aortic wall is compacted, brittle, with calcifications. The intima is thickened, wrinkled, with abundant lime deposits (syphilitic aortitis), sometimes with the formation of folds like “valve” (rheumatic aortitis). The adventitia is spotted and sharply plethoric. Microscopically, in the intima of rheumatic aortitis, foci of mucoid swelling and fibrinoid necrosis are detected: in the media - phenomena of metachromatic edema, sometimes rheumatic granulomas are found. Syphilitic aortitis is characterized by multiple foci of necrosis with ruptures of elastic fibers, infiltrates of lymphoid, plasma, histiocytic cells and extensive fields of sclerosis. The microscopic picture of brucellosis and chronic fibrous rheumatic aortitis differs from that indicated by the absence of plasma cells in the infiltrates. Characteristic of tuberculous, syphilitic and actinomycotic aortitis is the presence of specific granulomas in the adventitia.
Immunoallergic diseases include the so-called juvenile and giant cell aortitis. The first is observed in young people, more often in women. The pathogenesis and etiology of the disease are not clear; the term “aortitis” is purely arbitrary here. The process is characterized by a predominant lesion of the ascending thoracic aorta. The aortic wall is diffusely thickened, inelastic, sometimes with calcified dense adventitia. Microscopically - uneven development connective tissue under the endothelium, swelling and fragmentation of elastic membranes with the deposition of lipoids and infiltrates of lymphoid and plasma cells. Necrosis of the type of microinfarction is often observed in the aortic wall. In the adventitia against the background of sclerosis, there is an abundance of vasa vasorum, either obliterated throughout, or with extensive proliferation of their endothelium. The lesion from the ascending aorta spreads to its branches with the development of the clinical picture of the “pulseless” disease (Takayasu’s disease).
Giant cell “aortitis”, or idiopathic necrosis of the aortic media, is accompanied by aneurysmal dilatations and ruptures of its wall. The process begins, like rheumatic aortitis, with focal lymphoid cell infiltration of the adventitia with an admixture of Langhans-type giant cells. Infiltrates penetrate into the media, where foci of necrosis appear, surrounded by giant cells. The final stage of the process is fibrosis of all membranes of the aorta and the development of secondary atherosclerosis.
Aortitis is a complex polyetiological disease characterized by inflammation of individual layers or the entire thickness of the aorta. The main cause of the pathology is infection - syphilitic, tuberculosis, streptococcal. Among others etiological factors the most common are considered allergic reactions and autoimmune processes. With such vasculitis, the affected area of the aorta expands until an aneurysm forms.
Aortitis is manifested by pain, increased blood pressure, chills, fever, dizziness, and fainting. Aortalgia is difficult to distinguish from pain with. With this disease, attacks of aortalgia are longer, they are not stopped by taking medications from the nitrate group.
With aortitis, the thoracic or abdominal part of the aorta can become inflamed. With inflammation of all layers of the vessel, panaortitis develops; with inflammation of the inner layer, endaortitis develops. medium – mesaortitis, external - periaortitis.
Aortitis often becomes a complication of pulmonary tuberculosis, sepsis, mediastinitis, or systemic. Diagnosis and treatment of pathology is carried out by doctors of various specialties: cardiologists, rheumatologists, venereologists, pulmonologists, phthisiatricians, traumatologists.
If heart problems are not detected in time and you do not contact experienced specialists, Severe complications may develop.
Etiology and pathogenesis
Aortitis can be infectious or non-infectious.
Bacteria and viruses that cause infectious aortitis:
- Hemolytic streptococcus,
- Treponema pallidum (the causative agent of syphilis),
- tuberculosis bacillus,
- Gonococci,
- Rickettsia,
- The causative agent of brucellosis.
Pathogenic biological agents penetrate the aortic wall through the blood or lymph flow. The spread of infection is possible from tissues and organs adjacent to the aorta. Acute inflammation is characterized by swelling of the aortic walls, its rigidity, and infiltration of the membranes with polymorphonuclear leukocytes. In chronic aortitis, the walls of the vessel become denser, calcified, and become wrinkled and folded.
Non-infectious aortitis is caused by allergic and autoimmune causes. Vasculitis is a manifestation of collagenosis, ankylosing spondylitis, rheumatism, thromboangiitis obliterans, Cogan's syndrome, and inflammatory keratitis. Juvenile aortitis occurs in young women and girls. The wall of the ascending part of the thoracic aorta thickens and becomes denser, connective tissue fibers grow under the endothelium, and lymphoid and plasmatic infiltrates appear.
According to the course, aortitis is divided into acute and chronic. Acute aortitis usually occurs in a purulent or necrotic form, while chronic aortitis occurs in a productive or granulomatous form. At the same time, the pathogenetic and pathomorphological processes occurring in the patient’s body depend on the etiology of aortitis.
Symptoms
Aortitis does not have specific symptoms. The clinical picture of inflammation of the aortic walls consists of the symptoms of the underlying disease - syphilitic or tuberculosis infection, rheumatism, endocarditis. The acute form of the pathology is manifested by severe intoxication: fever, chills, weakness and general malaise, hyperhidrosis, insomnia, loss of appetite.
The symptoms of aortitis are caused by ischemia of organs that are supplied with blood through the branches of the aorta:
- Brain damage is manifested by headache, blurred vision, presyncope,
- Inflammation of the kidneys – development of malignant hypertension,
- Myocardial hypoxia - cardialgia, arrhythmia,
- Intestinal ischemia – paroxysmal abdominal pain.
Aortitis manifests itself as pain. When the thoracic aorta is inflamed, pain occurs in the affected area. In patients it has a pressing, burning, cutting character. Unbearable and constant pain radiates to the upper limbs, back of the head, shoulder blades, and epigastrium. Aortitis of the thoracic aorta is accompanied by shortness of breath, dry and painful cough, tachycardia. These symptoms are caused by compression of the trachea by an inflamed vessel.
Inflammation of the abdominal aorta manifests itself as pain in the abdomen or lower back. It subsides periodically or is constant. Experts detect an enlarged aorta by palpation. In severe cases, a picture of an acute abdomen develops.
Asymmetry of the pulse in the peripheral arteries is the main factor of the disease. With aortitis, the pulse becomes asymmetrical or disappears completely on one side.
Allergic aortitis is clinically manifested by signs of pericarditis. Patients experience chest pain, low-grade fever, fatigue, tachycardia, and heart murmurs are heard.
Syphilitic mesaortitis - features of the course
Syphilitic mesaortitis - special shape pathology characterized by a long asymptomatic course and the development of severe complications. Vasculitis is a late manifestation of tertiary syphilis. Clinical signs of pathology appear 5-10 years after infection. Dull, pressing and It's a dull pain localized behind the sternum. It occurs after stress, mental and physical strain. Then signs of heart failure appear: arrhythmia, shortness of breath, whooping cough, asthma attacks. Over time, collateral circulation develops.
The uncomplicated form of the pathology is often asymptomatic, objective data are scanty or absent. In some patients, the boundaries of the aorta expand. On ECG changes are missing.
Aortitis of syphilitic origin usually develops in the ascending aorta. In more rare cases, the aortic arch becomes inflamed or descending department aorta. Patients' body temperature rises abruptly throughout the day.
Diagnostics
Diagnosis of pathology consists of a general examination and palpation, percussion, auscultation, and laboratory and instrumental techniques. These methods will allow you to assess the degree of damage to the aorta, detect areas of ischemia, and determine the etiological moments of inflammation.
- General and biochemical analysis blood.
- Immunogram.
- Bacteriological blood culture.
- Serodiagnosis of syphilitic, brucellosis and tuberculosis infections.
In the blood of patients with rheumatoid aortitis it is determined C-reactive protein, circulating immune complexes, signs of inflammation. In tuberculous aortitis, PCR examination of sputum and X-ray of the lungs are positive. To determine the etiology of bacterial aortitis, it is necessary to carry out bacteriological research blood. Electrocardiography, tomography, and X-ray contrast examination can confirm or refute the suspected diagnosis.
computed tomography: thickening of the aortic wall and aneurysm of the ascending aorta
Treatment
Treatment of aortitis is etiotropic, consisting in eliminating the main cause of the pathology. Patients are hospitalized in a cardiology hospital or venereology clinic.
An inflammatory process that involves individual layers or the entire thickness of the aortic wall. Depending on the etiology and location of the lesion, aortitis can manifest itself as the development of aortalgia, abdominal angina, vasorenal hypertension, and limb ischemia; chills, fever, attacks of dizziness and fainting. Aortitis is diagnosed based on laboratory (biochemical, immunological) and instrumental studies(aortography, ultrasound, CT). Treatment of aortitis, first of all, involves treatment of the underlying disease (infectious, allergic, autoimmune lesions).
General information
Aortitis - vasculitis, special case aortoarteritis with exclusive or predominant damage to the aorta. Due to the variety of causes leading to the development of aortitis, the disease is in the field of view not only of cardiology, but also of rheumatology, venereology, allergology, pulmonology and phthisiology, and traumatology.
Typically, aortitis affects the thoracic aorta, less commonly the abdominal aorta. If inflammation affects individual layers of the aorta, they speak of endaortitis, mesaortitis, periaortitis; if the entire thickness of the arterial wall (intima, media and adventitia) is affected - panaortitis. According to the distribution, aortitis can be ascending, descending and diffuse.
Causes of aortitis
Depending on the etiology, there are 2 groups of aortitis: infectious and allergic. The development of infectious aortitis is associated with the penetration of an infectious pathogen into the aortic wall by hematogenous or lymphogenous route or spread inflammatory process onto the aorta from the tissues adjacent to it. Specific infectious aortitis most often develops with syphilis, tuberculosis, and less often with brucellosis. Nonspecific aortitis is usually bacterial in nature and is usually associated with previous streptococcal infection and rheumatic fever. The aorta can be involved in inflammation due to lung abscess, mediastinitis, and infective endocarditis.
Allergic aortitis is most often caused by autoimmune diseases, collagenosis, systemic vasculitis (Takayasu's disease). Cases of aortitis have been described in ankylosing spondylitis (ankylosing spondylitis), rheumatoid arthritis, and thromboangiitis obliterans. Aortitis may be a component of Cogan's syndrome, also characterized by inflammatory keratitis, vestibular and auditory dysfunction.
Classification and pathogenesis
Taking into account the predominance of certain pathological processes, purulent, necrotic, productive, and granulomatous forms of aortitis are distinguished. Purulent and necrotizing aortitis have an acute or subacute course, the rest have a chronic course. Pathological changes in the arterial wall differ in aortitis of various etiologies.
With aortitis of a syphilitic nature, the intimal layer of the aorta undergoes inflammatory and sclerosing processes, as a result of which it becomes wrinkled, scarred, with rough folds resembling tree bark. IN pathological process estuaries are involved coronary arteries, as well as semilunar valves of the aortic valve, contributing to the occurrence of aortic insufficiency. IN late period Syphilitic aortitis forms saccular or diffuse aortic aneurysms. Syphilitic gummas are sometimes found in the aortic wall.
Tuberculous aortitis develops with corresponding damage to the lymph nodes, lungs, mediastinal organs, and retroperitoneal space. IN vascular wall Specific granulations and foci of caseous necrosis are formed. Tuberculous aortitis is characterized by the presence of ulceration of the edothelium, aneurysms, calcification of the aortic wall, and perforations.
Rheumatic lesions of the aorta occur as panaortitis. In this case, mucoid edema, fibrinoid swelling develops in all layers of the aorta, followed by granulomatosis and sclerosis. Purulent aortitis is accompanied by phlegmonous or abscess inflammation of the aortic wall, its dissection and perforation. Typically, inflammation spreads to the aortic wall from neighboring organs, surrounding tissue, or due to septic thrombosis.
Ulcerative-necrotizing aortitis is usually a consequence of bacterial endocarditis, sepsis, and less often - a complication of operations on the aortic valve or patent ductus arteriosus. At the same time, vegetations, thrombotic masses, areas of ulceration, dissection and perforation of the aortic wall are detected in the aortic endothelium. Nonspecific aortoarteritis (Takayasu's disease) occurs as a type of productive inflammation with overproduction of fibrous tissue.
Symptoms of aortitis
The clinical picture of aortitis unfolds against the background of symptoms of the underlying disease (syphilis, rheumatism, tuberculosis, infective endocarditis, sepsis, etc.).
Aortitis itself is mainly manifested by signs of ischemia of organs receiving blood supply through the main branches of the aorta. Thus, cerebral ischemia is accompanied by dizziness, headaches, visual disturbances, and fainting; ischemia of the heart muscle - angina pectoris, myocardial infarction (often painless); renal ischemia – arterial hypertension; intestinal ischemia - attacks of abdominal pain.
A characteristic symptom of aortitis is aortalgia - pain along the affected area of the aorta associated with the involvement of the para-aortic nerve plexuses. Damage to the thoracic aorta is accompanied by pressing or burning pain in the chest, which can move to the neck, both arms, between the shoulder blades, and epigastric region. Tachycardia, shortness of breath, and whooping cough may occur, the causes of which are unclear. In case of damage to the abdominal aorta, pain is localized in the abdomen or lower back. Pain syndrome in aortitis is expressed almost constantly, the intensity of pain periodically changes.
An early pathognomonic sign of aortitis is pulse asymmetry at the radial, subclavian and carotid arteries or him complete absence on one side. When measuring blood pressure on one arm, it may be noticeably reduced or not detected at all.
Complications of aortitis may include thromboembolism, bacterial embolism, dissecting aortic aneurysm, and aortic rupture. Manifestations of syphilitic aortitis usually develop 15-20 years after infection. Until the development of complications (aortic insufficiency, cardiosclerosis, heart failure), syphilitic aortitis is practically asymptomatic.
Diagnosis of aortitis
To find out the causes of damage to the aorta, patients with suspected aortitis should be consulted by a venereologist, rheumatologist, TB specialist, or cardiologist. To substantiate the diagnosis of aortitis, it is necessary to study clinical, laboratory and instrumental data.
Treatment of aortitis
Treatment of aortitis is inextricably linked with active therapy of the underlying disease. For infectious aortitis, antibiotics are the first-line drugs; for allergic aortitis - glucocorticoids, NSAIDs, immunosuppressants; for syphilitic aortitis - preparations of bismuth, iodine, penicillin antibiotics. The effectiveness of therapy is monitored by the dynamics of clinical and laboratory parameters.
The presence of an aortic aneurysm, especially signs of its dissection, is the basis for consultation with a vascular surgeon and angiosurgical treatment - resection of the aneurysm followed by aortic replacement. During development aortic stenosis Balloon dilatation, stenting, or bypass surgery may be required.
Prognosis and prevention
The severity of the prognosis for aortitis is determined by its form and etiology. The most serious prognosis is for acute and subacute bacterial aortitis. The course of syphilitic and tuberculous aortitis is more favorable the earlier it is started specific treatment. The development of other forms of chronic aortitis depends more on the underlying disease. If left untreated, the disease is prone to progression and complications.
To prevent aortitis, timely treatment is of paramount importance. primary diseases, prevention of STDs, active detection of tuberculosis.
AORTITIS (aortitis; Greek aorte aorta + -itis) - inflammation of the walls of the aorta, a special case of arteritis with a predominant or exclusive localization of the process in the aorta.
A unified classification of aortitis has not been developed. Most experts distinguish syphilitic aortitis, designating the remaining inflammatory lesions of the aorta as nonspecific aortitis. At the same time, depending on the nature of the disease, it seems possible to distinguish two groups of aortitis: 1) infectious and 2) allergic.
To infectious aortitis may include syphilitic aortitis, bacterial endaortitis, bacterial thrombaortitis, athero-ulcerative aortitis, bacterial embolic aortitis, aortitis in infectious diseases and that developed as a result of the transition of the inflammatory process from surrounding organs.
Allergic aortitis observed most often with the so-called. systemic vasculitis and collagenosis.
Aortitis is a common manifestation of visceral syphilis. According to sectional data by G. F. Lang and M. I. Khvilivitskaya (1930), aortitis is observed in 70-88% of patients with visceral syphilis.
Pathological anatomy and pathogenesis
Syphilitic mesaortitis: a - changes in the inner lining of the ascending aorta
Aortitis is characterized by an inflammatory process involving individual layers (endaortitis, mesaortitis, periaortitis) or the entire wall of the aorta (panaortitis).
The routes of penetration of pathogens into the aortic wall are different: primarily, hematogenously from the lumen of the aorta, along the vasa vasorum, lymphogenously through the outer lining of the aorta, or secondarily when inflammation spreads from neighboring organs.
Depending on the predominance of purulent, necrotic, productive, granulomatous processes, the corresponding forms of aortitis are distinguished. The first two forms occur acutely or subacutely, the rest are chronic. Many of them are accompanied by mural thrombosis.
Syphilitic aortitis (aortitis syphilitica) is manifested by severe damage to the aorta. The inner shell looks wrinkled with scar retractions, cartilaginous folds that have a radiant arrangement, which gives it the appearance of shagreen leather or tree bark (colored fig. a). The changes involve a section of the aorta of several centimeters or are located circularly, more often in the ascending, less often in other sections, ending abruptly at the level of the diaphragm or orifices renal arteries.
Syphilitic mesaortitis: b - inflammatory infiltrates from plasma cells and lymphocytes in the middle and outer membranes; atherosclerotic changes in the inner membrane (hematoxylin-eosin staining; x 80)
Syphilitic mesaortitis: c - rupture of elastic fibers in areas of inflammatory infiltration (orcein staining; x 80).
The orifices of the coronary arteries are involved in the process, which leads to their narrowing, but the arteries themselves are not affected. Inflammation spreads to the wall of the aortic sinuses, the area of attachment of the semilunar valve flaps to the aorta. The resulting tension and roller-like thickening of the valve edges with simultaneous ectasia of the aortic mouth with a naturally developing aneurysm of its ascending section lead to aortic valve insufficiency. In the late period of aortitis, diffuse or saccular aneurysms are formed, and the associated atherosclerosis, as a rule, significantly distorts the changes characteristic of mesaortitis. Microscopy reveals chronic productive inflammation, mainly of the middle tunic of the aorta, from which the name comes - mesaortitis productiva syphilitica. In the middle and outer membranes of the aorta along the vasa vasorum, less often in the inner membrane, there are infiltrates of lymphocytes, plasma cells (color Fig. b), sometimes with the presence of giant multinucleated and epithelioid cells. Rarely, infiltrates acquire the character of miliary or large gummas, which makes it possible to distinguish the gummous form of aortitis. (aortitis gummosa). The inner shell is always sclerotic. Localization of infiltrates around the vasa vasorum is accompanied by thickening of the inner membrane and narrowing of its lumen (obliterating endarteritis), which, together with scarring of the infiltrates, leads to lysis of elastic fibers, revealed by staining for elastin (color Fig. c), death of muscle cells and the resulting formation of an aneurysm. Rarely, pale treponemas are detected in the aortic wall using the Levaditi silvering method.
Purulent aortitis develops when inflammation spreads to the aortic wall from the surrounding tissue or neighboring organs, less often as metastatic to the vasa vasorum or as a result of parietal septic thrombosis. Sometimes it has the character of phlegmon or abscess and leads to melting of the aortic wall, the formation of an aneurysm and perforation.
Necrotizing ulcerative aortitis with polypous thrombi with sepsis lenta occurs during the transition from the valve or when systemic damage endocardium and blood vessels. Mycotic (septic) aneurysms develop. Isolated damage to the aorta is possible. Inflammatory-necrotic, cicatricial processes give the inner membrane a wrinkled appearance, reminiscent of syphilitic mesaortitis.
Tuberculous aortitis occurs during the transition of inflammation from caseous changes lymph nodes mediastinum, retroperitoneal region, paravertebral leak abscess with spondylitis, from the lungs, with pericarditis. The development of specific granulations with foci of caseous necrosis leads to wall thickening, ulceration, aneurysm and perforation. With hematogenous generalization, miliary tubercles or their conglomerates in the form of polypous foci with caseous phenomena can develop on the inner membrane.
In rheumatism, foci of tissue disorganization are found in all layers of the aorta with the sequential development of mucoid edema, fibrinoid swelling and transition to granulomatosis and sclerosis. The connection with rheumatism of foci of accumulation of mucoid substances sometimes found in the tunica media in the absence of elastic fibers and inflammatory reaction(medionecrosis idiopathica cystica) is debated. In adult patients, the proliferative component predominates with the presence of rheumatic granulomas in the middle shell along the vasa vasorum (rheumatic mes-, peri-aortitis). When the process worsens, the phenomena of sclerosis are combined with acute tissue disorganization.
Further scarring with destruction of elastic fibers in the middle shell, lymphocytic infiltrates in the outer layer create a picture reminiscent of syphilitic mesaortitis. The changes are localized mainly in the abdominal aorta, giving a tuberous relief to the intima and promoting the development of atherosclerosis [rheumatic “arteriosclerosis” according to Klinge (F. Klinge)]. An aneurysm rarely develops.
Clinical picture
Clinical signs of aortic damage are usually combined with symptoms of the underlying disease and in some cases are determined by it, since the localization, depth of damage to the walls and morphological features aortitis, reflected in clinical manifestations, significantly depend on the etiology of the process, the ways of penetration of the infection into the walls of the aorta in infectious aortitis and on the nature of the underlying disease in allergic aortitis.
Syphilitic aortitis (synonym: Dele-Geller disease)
Symptoms of the disease depend on the location of the process. There are syphilitic aortitis of the ascending aorta and syphilitic aortitis of the descending and abdominal aortitis. In syphilitic aortitis of the ascending aorta, it is customary to distinguish three anatomical and clinical variants. The first is characterized by the predominance of signs of coronary insufficiency in the clinical picture and is associated with stenosis of the coronary artery ostia. Depending on the rate of development of occlusion of the coronary arteries, as well as on the perfection of intercoronary anastomoses, this option can clinically occur in different ways. In some relatively rare cases, the picture of coronary insufficiency is characterized by anginal pain, relieved by taking nitrates, the development of small- and large-focal cardiosclerosis and heart failure. This trend is fully consistent with the manifestations coronary disease heart with atherosclerosis, the diagnosis of which is usually erroneous. Differential diagnostic criteria for distinguishing coronary insufficiency of a syphilitic nature from coronary heart disease can include appropriate radiological signs of dilatation of the ascending aorta, the possible presence of clinical manifestations of visceral syphilis and serological studies. The nature of the disease becomes clear with the appearance of aortic valve insufficiency. Coronary angiography reveals the true origin of the disease at the first signs of coronary insufficiency, since syphilitic aortitis leads to a narrowing of the lumen of the coronary arteries at the point of their origin from the aorta, leaving the coronary arteries themselves completely intact. However, the sharp narrowing of the lumen of the coronary arteries extending from the aorta does not allow the use of the most advanced research method - selective coronary angiography; it is necessary to carry out thoracic aortography, which makes it possible to detect not only a narrowing of the lumen of the mouths of the coronary arteries, but also the initial degree of syphilitic expansion of the ascending aorta long before the appearance of clear clinical signs of aortic valve insufficiency.
Much more often coronary variant Syphilitic aortitis proceeds differently. With a slow rate of narrowing of the coronary arteries and good development collateral blood supply myocardial angina is absent; the only sign of the disease is slowly progressive heart failure, sometimes accompanied by disorders heart rate. The clinical picture is dominated by shortness of breath. Subsequently, attacks of cardiac asthma appear. Despite the severity of the clinical picture, electrocardiographic changes may be absent or insignificant and can only be detected during a dynamic study. The most common type of rhythm disorder is atrial or ventricular extrasystole. Atrial fibrillation is a rare manifestation of syphilitic aortitis. Disorders of atrioventricular and intraventricular conduction have been described, up to the development of Morgagni-Adams-Stokes syndrome (see).
The second variant of syphilitic aortitis occurs with a predominance of symptoms of aortic valve insufficiency and occurs in a third or half of patients. It appears more often at the age of 40-50 years, is combined with coronary insufficiency and relatively quickly leads to heart failure. This option is characterized by the presence, in addition to diastolic, and systolic noise. The latter is not caused by stenosis of the aortic mouth, but by the expansion of the initial part of the ascending aorta.
In the third option, the process involves the more highly located part of the ascending aorta and its arch. The disease is usually asymptomatic. Only after careful questioning of patients can the presence of a peculiar pain syndrome- aortalgia. This syndrome appears to be based on significant morphological changes in the adventitia of the aorta with the involvement of the paraortic nerve plexuses. Aortalgia is difficult to differentiate from angina pectoris, since the nature of the pain, localization and irradiation are quite similar. At the same time, aortalgic pain is longer lasting and less clearly associated with physical activity, less often radiate into left hand, are not affected by nitrates. Aortalgia does not exhaust the consequences of syphilitic neuritis of the cardio-aortic plexuses. They also result in symptoms such as attacks of whooping cough and suffocation, which cannot be explained by the condition of the heart muscle. Carefully analyzing the clinical symptoms of syphilitic aortitis, some authors especially emphasize the constant shortness of breath and tachycardia characteristic of these patients, which is not eliminated by digitalis, which is noted long before the onset of symptoms of heart failure, the first manifestations of which in most patients are caused by an already developed aortic aneurysm.
With syphilis of the aortic arch, a sharp narrowing of the mouth of one or more arteries extending from it may develop; signs of cerebral ischemia, visual impairment, and syndrome of increased reactivity of the sinocarotid glomus appear.
Early diagnosis of syphilitic aortitis is difficult, so examinations of patients must be carried out carefully and repeatedly. In the early stages of aortitis, the dimensions of the aorta and heart are not changed, so percussion and conventional x-ray examination do not help clarify the diagnosis. In these conditions, auscultation acquires exceptional importance, which allows more than half of the patients to detect a slight systolic murmur over the aorta at an early stage of the disease, caused by its slight expansion. Systolic murmur caused by syphilitic lesions of the ascending aorta is often better heard in the center of the sternum and above the xiphoid process. In some patients, systolic murmur may occur only when raising the arms up (Sirotinin-Kukoverov symptom). An accent of tone II is heard above the aorta, acquiring a metallic timbre over time. Great importance has a phonocardiographic study of persons in whom syphilitic aortitis is suspected.
Particular attention should be paid to determining the diameter of the ascending aorta. The size of the ascending aorta is determined by teleradiography and X-ray tomography, but the most accurate data is provided by aortography (see). Important, although late, radiological sign The syphilitic process is calcification of the ascending aorta. Modern X-ray equipment (electron-optical converters, X-ray cinematography) can significantly increase the percentage of detection of aortic calcification in syphilis. Aortography must be resorted to to diagnose occlusive lesions of the aortic branches, especially if drug therapy does not eliminate stenosis even when, due to the severity of the clinical picture, surgical intervention is inevitable. We are talking about cerebral ischemia syndrome with damage to the origin of the brachiocephalic trunk and the left carotid artery.
Syphilitic aortitis of the descending, thoracic and abdominal aorta is characterized by a complex and unique symptom complex. The development of posterior aortitis (periaortitis - mediastinitis) and the involvement of intercostal nerves in the inflammatory process cause excruciating pain in the spine and paravertebral region in some patients. When the lower part of the thoracic aorta is affected, pain in the epigastric region is often noted - epigastralgia, simulating the gastralgic equivalent of angina.
The clinical picture of damage to the abdominal aorta is characterized by attacks of abdominal angina (see) and transient disorders of mesenteric circulation up to the development of ileus and gastrointestinal bleeding. Stenosis of the renal arteries is accompanied by the development arterial hypertension.
Diagnosis of occlusive lesions of the branches of the abdominal aorta is possible only with the use of abdominal aortography.
Syphilis, especially in the first years of its course, is accompanied by pronounced rises in temperature. The temperature curve in syphilis is extremely inconsistent. Recognizing the syphilitic nature of aortitis is greatly helped by serological reactions. However, with active visceral syphilis they turn out to be negative in a certain number of patients.
Bacterial endortitis
Bacterial endortitis manifests itself differently depending on its form.
Bacterial endocarditis is a consequence of the transfer of bacterial endocarditis to the aorta from the aortic valve. After surgical interventions In the aorta, bacterial endaortitis may develop at the site of aortotomy.
In subacute septic endocarditis, the causative agent of the disease is most often viridans streptococcus, in postoperative endaortitis - staphylococcus.
The clinical picture corresponds to subacute septic endocarditis (see); with postoperative endortitis there are no signs of damage to the valvular apparatus of the heart. Complications - thromboembolism, bacterial embolism, aortic rupture.
The diagnosis is based on the clinical symptoms of sepsis, positive blood cultures and the effect of antibacterial therapy.
Bacterial thrombus-aortitis
Bacterial thrombus-aortitis occurs due to infection of the blood clots in the aorta, usually by various cocci, Proteus and Salmonella. Blood clots serve as a breeding ground for bacteria and can become a breeding ground for them. Develops in the aorta purulent inflammation up to the formation of small abscesses in its wall. Since the development of most blood clots is associated with ulcerative atherosclerosis, bacterial thromboortitis develops, as a rule, in the abdominal aorta. Parietal thrombi of the ascending aorta affected by the rheumatic process can also become infected.
The clinical picture corresponds to acute or subacute sepsis (see). Complications - thromboembolism, bacterial embolism, aortic rupture.
The diagnosis is based on the clinical symptoms of sepsis, detection of pathogenic flora in the blood and the effect of antibacterial therapy.
Athero-ulcerative aortitis- a type of bacterial thrombus-aortitis; It is not the blood clots that become infected, but the atherosclerotic ulcers themselves.
The course and symptoms correspond to subacute sepsis (see).
Bacterial embolic aortitis occurs with bacteremia caused by the introduction of microorganisms (viridans streptococcus, gram-positive cocci, pneumococci, gonococci, bacilli typhoid fever, Mycobacterium tuberculosis) into the aortic wall along vasa vasorum.
Clinical manifestations of aortitis are associated with its complications - mycotic aneurysms, rupture and dissection of the aorta.
Aortitis in infectious diseases, like damage to other arteries, is observed more often in diseases that occur with bacteremia. Clinical diagnosis Such aortitis is complex, although autopsy may reveal morphological changes in all layers of the aortic wall.
Auscultatory changes noted during typhus are a systolic murmur in the middle of the sternum, a flapping second sound over the aorta and positive symptom Sirotinin - Kukoverov - are considered as clinical manifestations of aortitis.
Aortitis due to the transition of the inflammatory process from surrounding organs. Most often observed in tuberculosis thoracic spine, less often - with tuberculosis of the paraortic lymph nodes. Tuberculous spondylitis leads to aortic perforation and fatal bleeding into the mediastinum or pleural cavities; Sometimes bleeding is preceded by the formation of saccular and dissecting aortic aneurysms. Ruptures of the aorta due to the transition of the inflammatory process from the lungs to it during an abscess, as well as with mediastinitis of various origins, have been described.
Allergic aortitis
Most often observed in collagen diseases (see), as well as in thromboangiitis obliterans (Buerger's disease), giant cell arteritis and other systemic vasculitis. Aortitis has been described in rheumatism, ankylosing spondylitis (Bechterew's disease), rheumatoid arthritis.
The clinical picture of allergic aortitis has been studied in particular detail in rheumatism; it resembles initial stage syphilitic aortitis, in which the coronary arteries of the heart are not affected. It is characterized by a variety of pain sensations behind the sternum, which are usually interpreted as a manifestation of pericarditis, and clinical signs of damage to the aortic valve and dilatation of the aorta. A systolic murmur is heard over the aorta and an accent of tone II is less bright than with aortic syphilis.
In Buerger's disease (see Thrombangiitis obliterans), the abdominal aorta is rarely affected. The clinical picture depends on the degree of involvement of the origins of the renal arteries in the process and the severity of the resulting arterial hypertension. The diagnosis is made using aortography (due to frequent obliteration of the femoral and iliac arteries, the probe must be inserted through the brachial artery).
Aortitis with thromboangiitis of the aortic arch (see Takayasu syndrome) is observed mainly in young women. The inflammatory process is localized primarily in the aortic arch and its branches, but can occur in any large arterial trunk, including all parts of the aorta, cerebral, coronary, renal, mesenteric and iliac arteries. Parietal thrombi may occur in the aorta, leading to the development of thromboembolism.
Symptoms in the first stages of the disease are unspecific and boil down to a number of common symptoms(weakness, palpitations, increased fatigue, low-grade fever, sometimes febrile temperature, ROE acceleration). The course of the disease depends on the preferential localization of the process and the rate of its progression. Since the aortic arch and the arteries branching from it are most often affected, a clinical picture arises of a relatively rapidly progressing aortic arch syndrome: cerebrovascular accidents and visual disturbances.
The symptoms of damage to the abdominal aorta also depend on the involvement of its branches in the process. Narrowing of the lumen of the renal arteries is accompanied by the development of arterial hypertension, damage to the celiac trunk, superior and inferior mesenteric arteries - symptoms of mesenteric insufficiency.
The diagnosis is made based on signs of ischemia of the organs of the aortic arch. The most important method diagnosis is aortography.
Aortitis with giant cell arteritis - relatively rare disease. The age of most patients exceeds 55-60 years. Men and women get sick equally often.
The inflammatory process is generalized, affecting the aorta in almost all cases, in half of the cases - the common carotid, internal carotid, subclavian and iliac arteries, in a quarter of cases - the superficial temporal and coronary arteries, the brachiocephalic trunk and femoral arteries; occasionally the celiac trunk, mesenteric and renal arteries are involved.
The disease begins with general symptoms: increased fatigue, low-grade fever; some patients are bothered by night sweats and myalgia; then severe headaches appear; A rise in blood pressure is often observed. In case of damage to the superficial temporal arteries they become painful to the touch (see Giant cell arteritis). A blood test reveals moderate leukocytosis and increasing hypochromic anemia.
In more than a third of patients, the leading clinical picture is ocular symptoms associated with thrombosis of the central retinal artery, retinal hemorrhage, and neuritis. As a result, about a quarter of all patients become blind in one or both eyes. Cerebral circulatory disorders caused by impaired blood flow through large arterial trunks are very difficult in patients.
Forecast
With timely treatment, the prognosis for syphilitic aortitis is favorable; it is largely determined by the degree of aortic valve insufficiency and the degree of cardiosclerosis associated with narrowing of the coronary arteries.
The most common and severe complication syphilitic aortitis - aortic aneurysm (see).
In various forms of bacterial aortitis, the disease can be complicated by thromboembolism, bacterial embolism, or aortic rupture.
The prognosis of athero-ulcerative aortitis is especially unfavorable, ending, as a rule, with aortic rupture. Aortic rupture is also often observed in bacterial embolic aortitis and in aortitis due to the transition of the inflammatory process from surrounding organs and tissues.
The prognosis of allergic aortitis depends on the nature of the underlying disease and the localization of inflammation along the length of the aorta. In rheumatic aortitis, the prognosis is favorable, since the listed changes undergo reverse development as recovery progresses, leaving behind in some cases sclerotic changes in the aorta.
Damage to the aorta in thromboangiitis obliterans is usually observed in severe, non-treatable variants of thromboangiitis. With Takayasu syndrome, the prognosis is unfavorable, although cases of 10-20-year duration of the disease are described. The prognosis of aortitis is also unfavorable with giant cell arteritis. Patients die from cerebrovascular accidents or myocardial infarction 1-2 years after the onset of symptoms of the disease. Myocardial infarction is often caused by concomitant atherosclerosis of the coronary arteries of the heart.
For all forms of aortitis, the prognosis improves with early, effective treatment of the underlying disease.
Treatment
Treatment of aortitis is largely determined by its etiology. For syphilitic aortitis, it is identical to the treatment carried out for any form of visceral syphilis (see), but requires special caution, since the beginning of therapy sometimes causes activation of the syphilitic process, which is fraught for patients with aortitis with an acute violation of the coronary circulation.
For all forms of bacterial aortitis, massive antibacterial therapy (large doses of antibiotics) is used.
For allergic aortitis, only therapy with glucocorticoid hormones is effective, the daily dose of which varies for different underlying diseases (40-60 mg of prednisolone for rheumatism, up to 100 mg or more for separate forms systemic vasculitis).
If the effect of glucocorticoids is insufficient, which often happens with thromboangiitis obliterans, non-hormonal immunosuppressants are additionally prescribed. Symptomatic therapy includes the appointment (if necessary) of vasodilators and anticoagulants.
Prevention
Prevention of aortitis coincides with the prevention of major diseases accompanied by inflammation of the aorta. It also includes early diagnosis and vigorous treatment of infectious diseases that occur with bacteremia, primarily subacute septic endocarditis.
Prevention of postoperative endaortitis consists of following the rules of asepsis and carrying out preventive antibiotic therapy in the postoperative period.
Bibliography: Volovik A. B. About rheumatic lesions of the aorta (aortitis) in children, Pediatrics, No. 5, p. 46, 1938; Kogan-Yasny V. M. Visceral syphilis, Kyiv, 1939, bibliogr.; Kurshakov N. A. Allergic diseases peripheral vessels, M., 1962; Lang G.F. and Khvilivitska M.I. Syphilitic aortitis, in the book: Errors in diagnosis. and therapy, ed. S. A. Brushteina, p. 157, M.-D., 1930; Smolensky V. S. Diseases of the aorta, M., 1964, bibliogr.; Khvilivitskaya M.I. Aortitis, Multivolume. internal manual diseases, ed. A. L. Myasnikova, vol. 1, p. 623, M., 1962, bibliogr.
Pathological anatomy A.- Abrikosov A.I. Particular pathological anatomy, c. 2, p. 414, M.-D., 1947; L I MΗ e in V. T. Features of the morphology of atherosclerosis of the aorta in syphilitic aortitis, Arch. pathol., t. 26, no. 4, p. 53, 1964, bibliogr.; Mitin K. S. Histochemistry of connective tissue of blood vessels in rheumatism, M., 1966; Talalaev V. T. Acute rheumatism, p. 137, M.-L., 1929; Handbuch der speziellen pathologischen Anatomie und Histologie, hrsg. v. F. Henke u. O. Lubarsch, Bd 2, S. 647, B., 1924; Kaufmann E. Lehrbuch der speziellen pathologischen Anatomie, Bd 1, Hft 1, S. 259, B., 1955; Klinge F.u. V a u-b e 1 E. Das Gewebsbild des fieberhaften Rheumatismus, Virchows Arch. path. Anat., Bd 281, S. 701, 1931; Lehrbuch der speziellen Pathologie, hrsg. v. L.-H. Kettler, S. 91, Jena, 1970; Leonard J. C. a. G a 1 e a E. G. A guide to cardiology, Baltimore, 1966.
V. S. Smolensky; G. A. Chekareva (pat. an.).
Aortitis is a pathology expressed by inflammation of the walls of the main vessel, most often of an infectious nature. This concept also includes reactive changes in the artery, which are immunoallergic in nature.
Types of aortitis
Depending on the size of the area of damage to the vessel, the disease is divided into three types:
- Diffuse.
- Rising.
- Descending.
Based on the area of localization of the pathology, the following types of pathology are distinguished:
- endaortitis;
- mesaortitis;
- periaortitis;
- panortitis.
In most cases, inflammation of the aortic walls spreads simultaneously to several areas, and isolated damage is extremely rare.
Reasons for development
- Syphilis.
- Streptococcal infection.
- Allergic processes.
- Rheumatism.
- Systemic collagenoses.
- Sepsis.
- Tuberculosis.
- Systemic thrombangitis.
Symptoms of inflammation
In acute infectious inflammation, resulting from infection with syphilis, streptococci, malaria and gonorrhea, the artery becomes swollen and its elasticity is significantly reduced. The microscopic membranes of the vessel are infiltrated with leukocytes.
With chronic infectious inflammation, which appears against the background of rheumatism, tuberculosis and syphilis, the walls of the aorta become denser, but the calcification process makes them vulnerable. Also characteristic are multiple foci of tissue death (necrosis), ruptures of elastic fibers and extensive areas of sclerosis.
Immunoallergic aortitis occurs predominantly in young people, especially women. The causes of inflammation of the aortic walls are unclear, and the diagnosis is made based on the signs inherent in this pathology. IN in this case the ascending thoracic aorta is affected. The inner membranes are diffusely thickened and not elastic. There is uneven development of connective tissues located under the endothelium. Swelling occurs in the walls of the artery and necrosis appears (like microinfarctions).
Immunallergic aortitis also includes giant cell aortitis. This disease causes not only inflammation of the walls of the aorta, but also aneurysmal expansion and tissue ruptures. The disease develops similarly to rheumatic aortitis, but in the focus of infiltration there are admixtures of giant cells that surround areas of necrosis. As a result, the disease leads to fibrosis of all the membranes of the large artery and provokes the development of secondary atherosclerosis.
