AORTA

From Big Medical Encyclopedia

AORTA (grech, aorte) — the main arterial vessel beginning from a left ventricle of heart. Distinguish three passing each other department And.: the ascending A. (aorta ascendens), arch of A. (arcus aortae) and the descending A. (aorta descendens). Descending And. divide into chest (aorta thoracica) and belly (aorta abdominalis). Branches And. bear an arterial blood to all parts of a body (fig. 1).

Fig. 1. Aorta, its departments and branches (anterior aspect; front sidewalls of a chest and abdominal cavity are removed): 1 — and. carotis communis sin.; 2 — trachea; 3 — a. subclavia sin.; 4 — arcus aortae; 5 — aorta thoracica; 6 — aa. intercostales post.; 7 — truncus cel i acus; 8 — a. mesenterica sup.; 9 — a. renalis; 10 — a. mesenterica inf.; 11 — bifurcatio aortae; 12 — a. iliaca communis sin.; 13 — a. iliaca int.; 14 — a. iliaca ext.; 15 — a. sacralis mediana; 16 — a. phrenica inf. dext.; 17 — bulbus aortae; 18 — aorta ascendens; 19 — truncus brachiocephalicus; 20 — a. subclavia dext.; 21 — a. carotis communis dext.

The name «aorta» is given to the specified vessel by Aristotle. Galen described And. as the main artery departing up from a left ventricle of heart and near it divided into two branches: upper — to upper extremities, a neck and the head and lower — to other parts of a body. V A., according to Galen, air from a left ventricle and blood — from right arrives. Galen established existence of the aortal valve. Vezaly denied a possibility of inflow of blood in And. from a right ventricle and stay of air in it. In 1628 Mr. Garvey experimentally proved that on And. only blood circulates. M. Sheyn in notes to «The reduced anatomy» (1757) correctly described three departments And., branches of an arch And. also showed options of their otkhozhdeniye. N. I. Pirogov (1832) in detail studied a structure, topography and function belly And.

Embryology

Fig. 2. Development of an aorta in vertebrata (arterial arches are noted by the Roman figures): And — the general plan of an arrangement of primary aortas and branchiate arterial arches: 1 — aorta ventralis sin.; 2 — aorta dorsalis sin.; 3 — aorta dorsalis; 4 — truncus arteriosus; 5 — aa. branchiales; 6 — a. carotis ext.; 7 — a. carotis int. B — an early stage of transformation of branchiate arterial arches: 1 — and. carotis communis; 2 — arcus aortae; 3 — a. pulmonalis sin.; 4 — ductus arteriosus; 5 — aorta descendens; 6 — a. subclavia sin.; 7 — aa. segmentales; 8 — a. subclavia dext.; 9 — truncus arteriosus; 10 — a. pulmonalis dext.; 11 — truncus brachiocephalicus; 12 — a. carotis communis dext.; 13 — a. carotis ext.; 14 — a. carotis int. In — definitivny derivatives of aortic arches: 1 — a. carotis communis sin.; 2 — arcus aortae; 3 — ductus arteriosus; 4 — truncus pulmonalis; 5 — a. subclavia sin.: 6 — aorta descendens; 7 — a. subclavia dext.; 8 — a. vertebralis; 9 — truncus brachiocephalicus; 10 — a. carotis communis dext.

At vertebrate animals the arterial trunk (truncus arteriosus) which shares on two ventral departs from heart And., from which 6 couples of arterial branchiate arches passing on the dorsal party of a germ into the right and left dorsal aortas (fig. 2) depart. The right and left dorsal aortas go caudally and connect in one dorsal (back) A. U mammal two front couples of branchiate arterial arches disappear before back are created.

At the person A. and the branches departing from its arch develop from ventral and dorsal And., their general trunks, 3, 4 and 6 couple of branchiate arterial arches. Other arches are exposed to involution. In the course of a reduction of arches cranial parts of dorsal and ventral aortas go for creation of carotid arteries, a caudal part right dorsal And. — right subclavial artery, caudal part left dorsal And. and back And. — descending And. the 3rd couple of arterial arches turns into initial parts of internal carotid arteries. On the right the 3rd arch together with the 4th will be transformed in a shoulder a head trunk. the 4th arch at the left intensively grows and creates an arch And.

The arterial trunk at a stage of division of the general ventricle of heart is divided into two parts: ascending And. and pulmonary trunk. A bulb ascending And. and semi-lunar valves form from a rudiment of heart. At the same time the 6th couple of arterial arches connects to a pulmonary trunk and forms pulmonary arteries. The left 6th arch keeps connection with left dorsal And., creating an arterial channel (see). The left subclavial artery develops separately from a segmented chest branch left dorsal And.

The anatomy

the Ascending aorta begins from an arterial cone of a left ventricle of heart and proceeds to the place of an otkhozhdeniye of a brachiocephalic trunk (truncus brachiocephalicus) where it without visible border passes into an aortic arch. This department And. call kardiaorty [Neymann (And. Neumann)]. In the initial part ascending And. there is an expansion — an aortic bulb (bulbus aortae) in which there are three protrusions — aortal sine (sinus aortae) — Valsalva's sine. To edges of sine semilunar valves (valvulae semilunares) creating the valve of an aorta (valva aortae) are fixed. Length ascending And. at adults fluctuates within 4 — 8 cm (more often than 5 — 5,5 cm), diameter at the level of the middle of its length reaches 1,5 — 3 cm (more often than 2 — 2,5 cm). Children have 7 — 12 years length of ascending. And. 2,5 — 4,6 cm, and diameter are 1 — 1,5 cm. At men ascending And. is longer and wider, than at women. The more length of heart, the A. Voskhodyashchaya A. more long ascending is in a front mediastinum and passes slantwise from below up, from left to right and behind beforehand. It is projected on a breast: valve A. there corresponds to the level III of an intercostal space at the left, and the place of transition to an arch — to the II right grudino-costal joint. Almost all ascending And. it is located intrapericardiacally, and the epicardium forms the general vystilka for ascending And. and pulmonary trunk. Between parietal and visceral leaves of a pericardium in front from ascending And. anterosuperior torsion of a pericardium forms. In front an initial part ascending And. crosses a pulmonary trunk, on the right and in front to it prilezhit the right ear of heart, on the right — an upper vena cava, behind — the right pulmonary artery and the right primary bronchus.

Fig. 3. Various provisions of aortal sine (cross-section of heart at the level of the aortal valve; the front surface of heart is turned up): and — one sine behind, two — in front; biv — one sine in front, two sine behind. 1 — a front aortal sine; 2 — valva aortae; 3 — atrium dext.; 4 — atrium sin.; 5 — truncus pulmonalis.

Aortal sine have height of 1,3 — 1,5 cm and width of 1,2 — 3,3 cm at adults, children have 7 — 12 years respectively 0,9 — 1 cm and 0,8 — 2 cm. Their arrangement in relation to the frontal plane of heart floatingly (fig. 3). More often (in 70%) one sine lies behind and two in front — at the left and on the right. Therefore them call back, left and right (sinus aortae posterior, dexter, sinister; BNA, PNA). In the right and left sine there are mouths according to the right and left coronal arteries supplying with blood heart. Less often (in 30%) one sine holds antelocation, and two — back. Uolmsli's classification is of interest (T. Walmsley) distinguishing sine depending on position of mouths of coronal arteries: right and left coronal and bezvenechny sine. Most often the right aortal sine is projected on a pulmonary trunk, the right arterial cone and a right ventricle; left — on a cavity of a pericardium, a pulmonary trunk, the left auricle; back — on the right and left auricles. Width of semilunar valves is 2 — 3 mm more than the corresponding sine, and height of sine 1 — 2 mm smaller than height. Position of mouths of coronal arteries in relation to the upper edges of gates is variable. The mouth of the right coronal artery can be located above edge of the gate (almost in half of observations), at the level of it (in 2/5 all cases) or below it (in 1/5 observations). The left coronal artery departs at the level of edge of the gate (about a half of observations), below it (in 1/3 observations) or above (in 1/4 observations).

Fig. 4. Options of an order of an otkhozhdeniye and provision of branches of an aortic arch: 1 — aorta ascendens; 2 — and. subclavia dext.; 3 — and. carotis communis dext.; 4 — a. carotis communis sin.; 5 — a. subclavia sin.; 6 — truncus brachiocephalicus; 7 — a. vertebralis sin.; 8 — a. vertebralis dext.; 9 — truncus pulmonalis; 10 — trachea; 11 — esophagus; 12 — ductus arteriosus.

The aortic arch stretches camber up from the place of the beginning of a brachiocephalic trunk to the level IV of a chest vertebra where it passes in descending And., forming insignificant narrowing — an isthmus (isthmus aortae). The concave surface of an arch and a pulmonary trunk are connected by an arterial sheaf (lig. arteriosum), which represents the obliterated arterial channel. Length of an arch at adults fluctuates within 4,5 — 7,5 cm (more often than 5 — 6 cm); diameter it in an initial piece 2 — 3,5sm willows final — 2 — 2,5 cm. Men have length of an arch and its diameter more, than at women. The arch in the slanting and sagittal plane is located, passing from a front mediastinum into back. The arch on the handle of a breast is projected: an initial part of an arch corresponds to the II right grudino-costal joint, and final — the left body surface of the IV chest vertebra. Children up to 12 years have an arch And. has bigger radius of curvature and lies above, than at adults. Back-right surface of an arch And. prilezhit to an upper vena cava, a gullet, nerves of a deep noncardiac texture. Near an arterial sheaf on this surface of an arch And. there passes the right recurrent guttural nerve. Dorsalno the specified surface is covered with the right mediastinal pleura. To the front-left surface of an arch And. prilezhit the left phrenic nerve, perikardo-phrenic vessels, the left vagus nerve and superficial noncardiac neuroplex. Under an arch the right pulmonary artery, the left primary bronchus, left upper tracheobronchial limf, nodes, bronchial arteries and the left recurrent guttural nerve lie. Upper surface of an arch And. the left brachiocephalic vein crosses. The provision of an arch depends on a shape of a thorax. At persons with a wide thorax the arch lies above, and the plane of its arrangement is more frontal, than at people with a narrow thorax. Large arterial trunks depart from a convex surface of an arch (from right to left): brachiocephalic trunk (truncus brachiocephalicus), left general carotid artery (and. carotis communis sin.) and left subclavial artery (and. subclavia sin.). The order of an otkhozhdeniye of trunks is very changeable (fig. 4).

The descending aorta — the longest department And.

Fig. 5. Topography of a chest aorta (anterior aspect). The pericardium is completely removed, except for its phrenic part, pulmonary arteries and veins are removed. Cellulose, lymph nodes, bronchial arteries and veins are excised: 1 and 7 — esophagus; 2 — n. vagus sin.; 3 — arcus aortae; 4 — a. pulmonalis sin.; 5 — n. laryngeus recurrens sin.; 6 — v. pulmonalis sin.; 8 — pars diaphragmatica pericardii; 9 — v. cava inf.; 10 — aorta thoracica; 11 — pleura mediastenalis; 12 — v. pulmonalis dext.; 13 — aorta ascendens; 14 — a. pulmonalis dext.; 15 — v. azygos; 16 — n. vagus dext.; 17 — truncus brachiocephalicus; 18 — trachea.

The chest aorta is located in a postmediastinum almost vertically; it is projected on a backbone from the left surface of IV to a front surface of the XII chest vertebra where it gets through an aortal opening of a diaphragm. Length chest And. depends on a shape of a thorax. Diameter descending And. from 2 to 3 cm fluctuate. To the front surface descending And. above prilezhit a root of the left lung, and it is lower than VII chest vertebras — the left vagus nerve, a gullet and a pericardium. The left surface descending And. it is covered with a mediastinal pleura (fig. 5). On the right to descending And. the chest lymphatic channel, an unpaired vein, the right mediastinal pleura prilezhit (below). Behind descending And. prilezhit to a backbone, it is crossed semi-unpaired and the left back intercostal veins. In an aortal opening of a diaphragm And. it is fixed to her right medial leg. From chest And. depart 2 — 6 bronchial (rr. bronchiales), 5 — 6 esophageal (rr. esophagei), 2 — 4 pericardiac (rr. pericardiaci) and 2 — 5 mediastinal branches (rr. mediastinales), 10 couples back intercostal (aa. intercostales posteriores) and upper phrenic arteries (aa. phrenicae superiores). The listed branches supply with blood the bodies of a mediastinum, easy, a chest wall, a diaphragm.

Fig. 6. Topography of a ventral aorta: 1 — glandula suprarenalis sin.; 2 — plexus celiacus; 3 — ren sin.; 4 — a. renalis sin.; 5 — aorta abdominalis; 6 — truncus sympathies sin.; 7 — ureter sin.; 8 — a. mesenterica inf.; 9 — a. iliaca communis sin.; 10 — v. iliaca communis sin.; 11 — plexus hypogastricus sup.; 12 — a. iliaca ext.; 13 — a. iliaca int.; 14 — v. cava inf.; 15 — ureter dext.; 16 — truncus sympathies; 17 — a. renalis dext.; 18 — a. mesenterica sup.; 19 — truncus celiacus; 20 — a. phrenica inf.

The ventral aorta goes from an aortal opening of a diaphragm usually to the IV lumbar vertebra where it is divided into the general ileal and median sacral arteries (fig. 6). Level of bifurcation depends on length A. Korotkaya belly And. shares at the level of III of a lumbar vertebra, and long — the V lumbar vertebra. With age there is a movement of level of bifurcation from top to bottom. It is located belly And. in retroperitoneal space, being projected on a backbone on the specified extent. On the right yut belly And. the lower vena cava, behind — a backbone, in front — a pancreas and vessels of a spleen, a root of a mesentery of a small bowel, the left renal vein, and also prevertebral vegetative textures lies (celiac, upper mesenteric, etc.). Belly And. gives pristenochny and visceral branches. Belong to pristenochny arteries: lower phrenic (aa. phrenicae inferiores), lumbar (aa. lumbales), the general ileal (aa. iliacae communes), median sacral (and. sacralis mediana). Treat visceral: averages adrenal (aa. suprarenales mediae), celiac trunk (truncus celiacus), top and bottom mesenteric (aa. mesentericae superior et inferior), renal (aa. renales) and yaichkovy or ovarian arteries (aa. testiculares, dd. ovaricae).

Histology

On a microscopic structure And. treats vessels of elastic type. Wall And. consists of three covers: internal (tunica intima), average (t. media) and outside (t. externa). The internal cover is covered from a gleam And. large endothelial cells. The Podendotelnalny layer is formed by the fine-fibered connecting fabric, bunches of elastic fibers and numerous star-shaped cells which are the rostkovy elements participating in regeneration of a wall And. An inner elastic membrane in And. no. Average cover And. develops of 40 — 50 elastic fenestrated membranes (membranae fenestratae) with the maintenance of the smooth muscle cells, fibroblasts and elastic fibers connecting fenestrated membranes. Outside cover And. it is created by friable connecting fabric. With age in a wall And. the amount of elastic fibers decreases, the maintenance of collagenic increases, there is a lipoid infiltration of layers.

The wall of various departments vascularizes And. branches of nearby arteries which form in it intramural arterial networks. Outflow of blood from venous networks of a wall And. occurs in the veins, of the same name with arteries. In a wall And. there are networks limf, capillaries and vessels from which lymph flows in located nearby limf. nodes. It is innervated And. branches of noncardiac neuroplexes (ascending And. and arch And.) and aortal neuroplex (descending And.). In a wall And. there are an intramural neuroplex, nerve terminations (effectors, the encapsulated lamellar little bodies, intersticial branched receptors), glomal little bodies and a paraganglion. The greatest concentration of receptors is noted in an arch And. (aortal reflexogenic zone).

Pathology

Anomalies of development

Anomalies of situation, form, structure And., an order of an otkhozhdeniye of its branches are caused by disturbances of development of primary aortas and branchiate arterial arches. It is possible to allocate the following five groups of anomalies of development And.

I. The anomalies caused by disturbances of separation process of the general arterial trunk of ventral aortas: 1) undivided general arterial trunk; 2) wide ascending And.; 3) an underdevelopment ascending And.; 4) full transposition A. and pulmonary trunk; 5) a nadklapanny stenosis ascending And.

II. The anomalies caused by disturbances of developments of the fourth couple of branchiate arterial arches: 1) double arch And.; 2) right-hand situation A.; 3) narrowing (coarctation) of an isthmus A.

III. The anomaly caused by disturbances of development of the sixth couple of branchiate arterial arches — an open arterial channel.

IV. The anomalies caused by disturbances of developments of the third and fourth couples of branchiate arterial arches — anomalies of branches of an arch And. (distinctions in number and the provision of branches, an otkhozhdeniye of the right subclavial artery from descending And., etc.).

V. The anomalies caused by disturbances of processes of growth and development primary left dorsal And.: 1) an underdevelopment descending And.; 2) narrowing chest and belly And.; 3) extended chest And. (with an excess or without it); 4) anomalies of an order of an otkhozhdeniye of branches chest and belly And. Not all anomalies are followed by pathological disturbances.

Malformations And., followed by pathological disturbances — see. Heart diseases inborn .

Diseases of an aorta — see. Aortic aneurysm , Aortitis , Arterialny Canal , Atherosclerosis , Coarctation of an aorta , Thrombosis , Embolism .


Kliniko-morfologichesky characteristic of the main anomalies of development, diseases of an aorta and their complications — see. table .


Injuries of an aorta

refer Injuries of an aorta to one of the heaviest types of injuries. Gaps And. arise at the closed injuries of a breast and stomach (automobile, plane crashes, falling from height, action of a blast wave, etc.) · Wounds And. can be caused by fire or cold weapon, and also be result of implementation of acute foreign bodys in a wall of a gullet or trachea. Casuistic tool gaps are known And. at endoscopic manipulations. Besides, there can be spontaneous gaps And., durabilities caused by change and elasticity of an aortal wall at atherosclerosis (see), Marfan's diseases (see. Marfana syndrome ), aortites (see. Aortitis ), at to an aortic aneurysm (see), and also at destruction of a wall And. malignant new growth.

Fire damages And. in surgical practice both in peace, and in wartime meet seldom, most of wounded at them dies on the spot incidents or in the battlefield.

Allocate the following types of damages And. 1. Gutter (tangential) wound without opening or with opening of a gleam of a vessel. 2. A nonperforating wound of Ampere-second implementation in a wall of a hurting subject (a bullet, a splinter, a knife). 3. A nonperforating wound with an intravascular arrangement of a hurting subject. 4. Through wound with existence of entrance and output openings. 5. Complete separation And.

Fig. 7. The mechanism of a rupture of an aorta as a result of an injury. The upper arrow specifies the typical point of fracture, lower — the direction of a deviation of an aorta at blow; the dotted line showed normal position of an aorta, by a solid line — the shift of an aorta. The ring-shaped line in the bottom of the drawing corresponds to an opening in a diaphragm.

Most often And. it is injured below an arterial sheaf less often — over the valve. Injury of an isthmus A. it is connected with a deviation of its more mobile sites and the subsequent their counterstroke about a backbone (fig. 7) since an arch and chest And. have various conditions of fixing. Kremer (K. Kremer, 1962) considers that an isthmus A. is the place of the smallest resistance since here often there are atheromatous changes.

The damage rate of an aortal wall can be various — from a small crack of an intima to a complete separation of all layers of A. V the same cases when it is broken off internal and average layers And., there is an intramural hematoma with stratification (see the Aneurism stratifying) or an anguish of aortal walls and formation of a traumatic aortic aneurysm (see).

Separation of the peripheral vessel departing from And., is complicated by bleeding, formation of a hematoma (false aneurism) and can come to the end with an independent stop of bleeding owing to reduction of an intima, its vvorachivaniye, a spasm and thrombosis of a vessel, and also closing of the damaged place with a hurting subject. Wound And. and a large vein can lead to formation of false traumatic arteriovenous aneurism or fistula.

Clinical picture of damages And. it is not always characteristic and consists of symptoms of internal bleeding in chest and belly cavities (see Bleeding, internal), shock (painful shock is caused by the nature of an injury) since damage And. it is usually combined with wound of adjacent internals.

At suspicion on damage And. it is necessary to consider localization of a wound, and at through wounds — the direction of the wound channel. Diagnostic value has a dullness in places of accumulation of blood in pleural and belly cavities and over a hematoma, and also identification of symptoms of the developing acute anemia: the excitement which is replaced by an unconscious state, pallor of integuments, the pointed features, a cold, clammy sweat, frequent pulse of very small tension, thirst, nausea, vomiting or a hiccups. Damage And., followed by stratification of its walls, it is characterized by a sharp pain syndrome. At the getting damages And. and adjacent hollow bodies (a stomach, intestines, a trachea) symptoms of internal bleeding appear. At wound of the intrapericardiac zone ascending And. bleeding in a cavity of a pericardium is shown by a clinical picture of an acute cardiac tamponade (see). X-ray inspection specifies the diagnosis of damage And.

Damage And., complicated by bleeding or stratification of an aortal wall, demands urgent surgical treatment (see below).

X-ray inspection

X-ray inspection And. it is known from first years of development of a radiology [Goltsknekht (G. Holzknecht, 1900)]. X-ray inspection And. — the most perfect way of intravital studying And. normal (radioanatomy) and at her various diseases. Research A. make by means of roentgenoscopy, a X-ray analysis, a tomography, a rentgenokimografiya, an elektrokimografiya, and also at administration of contrast medium in an aorta (see. Aortografiya ). Apply a straight line, slanting and side projections. Though the shadow of vessels is generally formed And., in a direct projection it is not possible to receive it the correct image because of projective imposing of parts A. at each other. Separate image of parts chest And. it is possible to receive in slanting provisions, hl. obr. in left front slanting, when And. takes place in the plane parallel to the plane of a film, and its shadow is exposed to the smallest distortion. However, if there is no emphysema, a shadow And. it is usually badly visible on roentgenograms. The tomography (by L. E. Kevesh's technique and L. D. Lindenbrata on, 1961) considerably facilitates studying of morphology And. Radiological signs of anomalies and diseases And. are its expansion (diffusion or limited), is much more rare — narrowing, lengthening, curvature and a razvernutost. X-ray diagnostic characters of anomalies are more detailed And. and her diseases — see the relevant articles ( Aortic aneurysm ; Aortitis ]; Arterialny Canal ; Atherosclerosis ; Coarctation of an aorta ; Heart diseases inborn ).

Fig. 8. The scheme of measurement of diameter of an aorta on the roentgenogram. The arrow specifies distance from the most convex part of an aortic arch to the left contour of a gullet.

Assessment of diameter And. (if there are no sharply expressed its changes) at a research without introduction in And. a contrast agent presents great difficulties. In a direct projection apply Kreytsfuks's technique to this purpose. Measure distance from a point of the greatest camber of an arch And. (the first arch at the left) to the left contour of the gullet filled with barium, subtracting from the received size of 2 mm on wall thickness of a gullet (fig. 8). This method is not suitable only in case of sharp curvature And., when there is no contact between And. and gullet. Normal at X-ray inspection diameter And. at the level of its arch it is equal to 3 — 3,5 cm. Depending on gender and age diameter And. from 2 to 4 cm can fluctuate: at men it it is insignificant more, than at women, with age gradually increases. Diameter ascending And. measure in slanting provisions; it approximately corresponds to distance from a front contour of a shadow of vessels to a contour of a trachea over its bifurcation at once. Lengthening And. leads to increase in height of its shadow and shift of its upper pole up. The Razvernutost is characterized by expansion of a shadow of vessels in a direct projection owing to shift ascending And. to the right, descending to the left.

Studying of amplitude of pulsations is of great importance And. at roentgenoscopy and on rentgenokimogramma since it allows to receive the qualitative characteristic of a stroke output of heart. Form of curves of a pulsation And. also has diagnostic value, it is the is best of all it can be studied with the help elektrokimografiya (see). Elektrokimogramma A. normal has an appearance of a tooth with the abrupt ascending knee, on time corresponding to the period of exile of blood from a left ventricle, and more flat descending knee (according to a diastole of a ventricle), in an upper half to-rogo small deepening with the subsequent low dicrotic wave caused by blow of the return stream of blood in is visible And. at the time of closing of semi-lunar valves. At disturbances of a blood-groove in And. the elektrokimogramma undergoes it changes.

Belly And. is not defined against the background of a shadow of bodies of a stomach if there is no calcification of its walls. For a research belly And. apply techniques of artificial contrasting.

At damages of a wall And. occurs: a) expansion of its shadow on a big extent (with preservation of the correct contour) owing to filling with blood of an additional gleam at stratification of a wall; b) emergence merging with a shadow And. an additional shadow owing to formation of a hematoma of a mediastinum.

Aorta operations

Operations on And. make generally at its damages, an aortic aneurysm (see) and coarctations of an aorta (see). An operative measure on And. at its damages includes the choice of rational access, audit and mobilization And., actions for the termination of bleeding and compensation of blood loss, opening of a gleam And. (according to indications), an angiorrhaphy, use of various ways of the reconstruction damaged And. and recovery of an adequate blood-groove (B. V. Petrovsky et al., 1970).

Accesses to various departments of an aorta. The most convenient access to ascending And. longitudinal chrezgrudinny access (a median sternotomy) is. The section of skin is made on the centerline of a breast from jugular cutting to a xiphoidal shoot and below it on 5 — 6 cm then in the direction from below up cut a breast. At the same time there are available the front surface of a pericardium all an ascending aorta and an ekstraperikardialny part of an aortic arch [P. Firt and soavt., 1965].

Make a right-hand front thoracotomy for access to an aortic arch in II or in the III mezhreberye. In need of expansion of access it is necessary to cross a breast in transverse direction and to open the left pleural cavity in the same intercostal space, i.e. to create chrezdvukhplevralny access.

Access to a chest aorta is the left-side posterolateral thoracotomy in V or the VI mezhreberye in position of the patient on the right side. If necessary the wound can be expanded, crossing costal cartilages is higher and lower than a section. The lung is discharged by kpered. Open a mediastinal pleura longwise to a projection And.

For operation on a chest aorta and an upper part of a ventral aorta use left-side torako-abdominal access. The section at this access is done on the course of the VIII edge at the left, from the back axillary line and slantwise by kpered to the centerline of a stomach; if necessary access can be expanded with continuation of a section down the centerline. Then cross costal cartilages, open the left pleural cavity and an abdominal cavity, cut a diaphragm to an aortal opening. Open a mediastinal pleura and allocate chest And. After mobilization in the left subphrenic space of abdominal organs together with And. in the left retroperitoneal space on a big extent becomes available belly And.

Access to a ventral aorta is provided by wide midsection from a xiphoidal shoot to a pubis. After movement of loops of a small bowel to the right and discharges by their wet towel wipes lengthways And. cut a peritoneum together with Treytts's team. Become available distal department belly And. and its bifurcation.

Mobilization and A. Obnaruzhit's audit a wound is made And. removal of the streamed blood helps (the victim needs to collect and pour it). Bleeding from a wound And. it can be stopped by pressing of a finger and imposing of a pristenochny aortal clip. On a wound And. it is necessary to put a stitch, blood loss shall be compensated. At extensive or through wounds it is necessary to block completely a blood stream in this zone. Mobilization And. make both in distal, and in proximal the directions from a wound. And. and the vessels departing from it press unit artery forceps or tourniquets with complete cessation of a blood-groove on And. for no more than 15 — 20 min. since in the bodies deprived of blood supply during bigger term there can be irreversible changes. Therefore operation is interrupted if necessary and temporarily recover a blood stream. Time of switching off of a blood-groove increases during the performance of an operative measure in the conditions of a hypothermia (see the Hypothermia artificial) or during the use of artificial circulation (see). Intercostal branches And. in a zone of an operative measure temporarily block. For this purpose a desektor bypass the mouth of a vessel, without allocating it completely from surrounding fabrics, and lead round a tourniquet.

Allocation struck And. from the hematoma surrounding it, and also from bodies of a mediastinum and retroperitoneal space is the heaviest and long stage of operation. Danger of repeated bleeding owing to wound of the wall changed And. or a gap it at careless traction it is very big. Therefore in technically difficult cases site A., the wall a cut is intimately soldered to surrounding fabrics, will not mobilize, and leave fixed on a backbone, venas cava or make a regional resection soldered with And. body (lung).

Opening of a gleam And. — the aortotomy is made in lengthwise or transverse direction depending on purpose of operation. For audit of a gleam And., sewing up of a perforating wound, removal of the struck intima or blood clot, at stratification of walls And. opening is made in lengthwise direction. And. open in cross or slanting (at children) the direction when there is a danger to narrow its diameter seams.

And. take in the one-row blanket turning-out suture, supplementing with noose P-shaped sutures. The first row blanket, the second — P-shaped or on the contrary. The seam can be continuous, in two — three semi-circles. As a suture material use thick silk or synthetic threads with an atraumatic needle, the fine end cuts a wall And.

Use of a mechanical strochechny seam at sharply expressed degenerative changes And. it is dangerous since metal (tantalic) brackets easily cut the wall struck And.

As independent operation stitching on And. it is applied at its wounds. The side seam is shown at chipped or cut wounds And., and also in certain cases bullet wound, especially small-caliber weapon. At an imbibition of edges of a wound or the fragmentary nature of a wound of edge it is necessary to refresh then to start sewing up. The site of Ampere-second the put stitch in a similar case is strengthened an enveloping synthetic fabric.

Anesthesia at aorta operations

Operations on And. are carried out under an endotracheal anesthesia in the conditions of a full muscular relaxation and artificial ventilation of the lungs. Features of anesthesia are defined by hl. obr. weight of defeat of cardiovascular system, danger of bleeding and need of the termination of blood circulation at this or that level A., what causes hypertensia higher than the level of crossclamping And. and ischemia is lower than this level. It is important to consider also character, localization and expressiveness of pathological process, extent of its compensation, age of the patient etc.

Premedications shall prevent the negative emotional reactions especially undesirable at patients with initial hypertensia (at coarctation And.), since they can lead to a bigger increase in arterial pressure and a decompensation of blood circulation, a hematencephalon etc. For premedication tranquilizers, antihistamines, narcotic analgetics, and also m cholinolytics can be used. The introduction anesthesia can be carried out by barbiturates of short action, drugs for a neyroleptanalgeziya (see), Ftorotanum (see). At the same time at patients with coarctation And. intravenous administration of drugs shall be slow in order to avoid the overdose connected with their delay in an upper half of a body because of narrowing And.

Maintenance of an anesthesia is carried more often out by Ftorotanum with nitrous oxide or drugs for a neyroleptanalgeziya. Reduction of danger of bleeding and the prevention of an acute decompensation of cordial activity requires a lowering of arterial pressure for what, in addition to an anesthesia Ftorotanum, artificial hypotonia (is reasonable see. Hypotonia artificial ) arfonady or gigroniy. For protection against ischemia during the crossclamping And. (depending on duration of this period and expressiveness of collaterals) apply an artificial hypothermia (see. Hypothermia artificial ), perfusion of the lower half of a body oxygenic blood (at coarctation And.), artificial circulation (see), perfusion of coronary or carotid arteries (at aneurism chest And.) [C. A. Hufnagel, 1970].

A release of clamps with And. after the end of manipulations usually causes hypotension. For its prevention and therapy it is necessary to stop administration of ganglioblokiruyushchy substances, completely (or there is even a lot of) to fill blood losses), to remove clips gradually, to apply vazopressor [Kyyun (K. Keown, 1963), Haymovich (H. Haimovici, 1970)]. It is also necessary to korrigirovat a metabolic acidosis (to a release of clamps). For prevention of a renal failure introduction of Mannitolum is reasonable.

Kliniko-morfologichesky characteristic of the main anomalies of development, diseases of an aorta and their complications

the Kliniko-morfologichesky characteristic of the main anomalies of development, diseases of an aorta and their complications - see the table

Bibliography

K. K Balakishisv to a question of options of branches of an aortic arch, Zhurn. teor. prakt. medical, t. 3, No. 3-4, page 27?, 1928 — 1929, bibliogr.; Zhedenov V. N. Final morphogenesis of initial sites of an aorta and pulmonary artery at the highest mammals and the person, Dokl. Academy of Sciences of the USSR, t. 58, No. 2, page 339, 1947; Mikhaylov S. S. and Moura of A. M. Topografoanatomicheskiye's h of a ratio of aortal sine (Valsal-vy) with surrounding anatomic educations, Arkh. annate., gistol, and embriol., t. 57, No. 7, page 65, 1969; M Ur and p A. M. Individual and age distinctions of the sizes of the ascending aorta and the aortal valve, Vestn. hir., t. 105, No. 10, page 20, 1970, bibliogr.; Nadj D. Surgical anatomy, the Thorax, the lane with Wenger., Budapest, 1959, bibliogr.; Pies N. Whether I. Yavlyaetsya bandaging of a ventral aorta at aneurism of inguinal area easily feasible and safe intervention? M, 1951; Petten B. M. Embryology of the person, the lane with English, M., 1959, bibliogr.; Yu. I molds. A sensitive innervation of an aortic arch of the person, in book: Vopr. morfol, receptors vnutren. bodies and cardiovascular system, under the editorship of N. G. Kolosov, page 126, M. — L., 1953, bibliogr.; Tikhomirov M. A. Options of arteries and veins of a human body, Kiev, 1900; Surgical anatomy of a breast, under the editorship of A. N. Maksimenkov, page 403, L., 1955, bibliogr.; Edwards J. E. Anomalies of the derivatives of the aortic arch system, Med. Clin. N. Amer., Mayo Clin., v. 32, No. 4, p. 925, 1948, bibliogr.; Pease D. C. Electron microscopy of the aorta, Anat. Rec., v. 121, p. 350, 1955; Wa lms ley T. The heart, L., 1929.

Damages of A., operations

Anichkov M. N. and Lev I. D. Kliniko-ana-tomichesky atlas of pathology of an aorta, L., 1967; Ballyuzekf. Century idyvyden-to about V. A. Diagnosis and surgical treatment of injuries of an aorta at the closed injury of a thorax, Voyen. - medical zhurn., No. 6, page 34, 1968; Dzhanelidze Yu. Yu. Collected works, t. 2, page 18, M., 1953; Kachorovsky B. V. Raneniye of an aorta foreign body of a gullet, Zhurn. ushn., nose. and throats, Bol., No. 1, page 104, 1967; P e t-rovsky B. V. Surgical treatment of wounds of vessels, M., 1949; Smolensk V. S. Diseases of an aorta. M, 1964; The Specialty surgery of a heart trouble and vessels, under the editorship of V. I. Burakovsky and S. A. Kolesnikov, M., 1967; Yarushe-v and p A. D. Wounds of large blood vessels of a breast, Experience of owls. medical in Great Otechestv, war of 1941 — 1945, t. 9, page 489, M., 1950; M a s s about w-S with h m i t t E. Der Mechanismus der traumatischen Aortenruptur und ihre Ausheilung, Diss., Hamburg, 1965, Bibliogr.; Verhandlungen der Deutschen Gesellschaft für Unfallheilkunde Versicherungs, Tag. 28, S. 9 u. a., B. u. a., 1965.

X-ray inspection of A.

Zodiyev V. V. Radiodiagnosis of heart diseases and vessels, page 93, M., 1957; Kevesh L. E and Lindenbraten L. D. Layer-by-layer X-ray inspection of heart and large vessels of a chest cavity, Vestn. rentgenol, and radio-gramophones., No. 3, page 19, 1961.

Anesthesia at operations on And.

Berezov Yu. E., Melnik I. 3. and Pokrovsk A. V. Koarktaiiya of an aorta, page 154, Chisinau, 1967; B at N I am t I A. A N. Anesthesia at heart operations and the main vessels, Much tomn. the management on hir., under the editorship of B. V. Petrovsky, t. 6, book 1, page 108, M., 1965; Porfiryev V. E. Anesthesia at aorta operations and its branches, M., 1972, bibliogr.; To e about w η K. K. of Anesthesia for surgery of the heart, Springfield, 1963; The surgical management of vascular diseases, ed. by H. Haimovici, Philadelphia, 1970.

A. A. Bunyatyan (anesteziol.), M. A. Ivanitskaya (rents), B. D. Komarov (hir.), C. S. Mikhaylov (annate.); authors of the table S. M. Kamenksr, A. M. Hilkin.

Яндекс.Метрика