AORTITIS (aortitis; grech, aorte an aorta + - itis) — an inflammation of walls of an aorta, a special case of arteritis with preferential or exclusive localization of process in an aorta.
Uniform classification And. it is not developed. Most of specialists distinguishes syphilitic And., designating other inflammatory damages of an aorta as nonspecific And. At the same time depending on the nature of a disease it is obviously possible to allocate two groups A.: 1) infectious and 2) allergic.
To infectious And. it is possible to carry syphilitic And., bacterial endaortit, bacterial trombaortit, atero-ulcer And., bacterial and embolic, And. at infectious diseases and developed owing to transition of inflammatory process from surrounding bodies.
Allergic And. it is observed most often at so-called system vasculites and collagenoses.
And. — frequent display of visceral syphilis. According to G. F. Lang and M. I. Hvilivitskaya's section data (1930), A. it is observed at 70 — 88% of patients with visceral syphilis.
Pathological anatomy and pathogeny
And. it is characterized by the inflammatory process covering separate layers (endaortit, a mesaortitis, a periaortitis) or all wall of an aorta (panaortitis).
Ways of penetration of activators to a wall of an aorta are various: initially, gematogenno from a gleam of an aorta, on vasa vasorum, limfogenno through an outside cover of an aorta or for the second time at distribution of an inflammation from the next bodies.
Depending on dominance of purulent, necrotic, productive, granulematozny processes allocate the corresponding forms A. The first two forms proceed sharply or subacutely, the others — chronically. Many of them are followed by a mural thrombosis.
Syphilitic A. (aortitis syphilitica) is shown by heavy injury of an aorta. The internal cover looks wrinkled with the cicatricial retractions, cartilaginoid folds having a radiant arrangement that gives it a type of pebble-leather or bark of a tree (tsvetn. fig. and). Changes occupy the site of an aorta in several centimeters or are located tsirkulyarno more often in ascending, is more rare in other departments, sharply breaking at the level of a diaphragm or mouths of renal arteries.
Mouths of coronal arteries are involved in process that leads to their narrowing, however arteries are not surprised. The inflammation passes to a wall of sine of an aorta, a zone of an attachment of semilunar valves of the valve to an aorta. The tension arising at the same time and a valikoobrazny thickening of edges of gates with a simultaneous ectasia of the mouth of an aorta at naturally developing aneurism of its ascending department lead to aortic incompetence. In the late period And. diffusion or sacculate aneurisms form, and the atherosclerosis joining, as a rule, considerably distorts changes, characteristic of a mesaortitis. The microscopy found hron, a productive inflammation, preferential average cover of an aorta from where there was a name — mesaortitis productiva syphilitica. In average and outside covers of an aorta on the course of vasa vasorum, is more rare in internal, infiltrates from lymphocytes, plasmocytes are located (tsvetn. fig.), sometimes with existence of colossal multinucleate and epithelial cells. Seldom infiltrates gain character of miliary or large gummas that allows to allocate a gummous form A. (aortitis gummosa). The internal cover is always sclerosed. Localization of infiltrates around vasa vasorum is followed by a thickening of an internal cover and narrowing of its gleam (obliterating endarteritis) that in total with scarring of infiltrates leads to the lysis of elastic fibers revealed by coloring on elastin (tsvetn. c), to death of muscle cells and education thereof aneurisms. Seldom in a wall of an aorta by method of silvering across Levaditi pale treponemas are found.
Purulent And. develops upon transition of an inflammation to a wall of an aorta from surrounding cellulose or the next bodies, is more rare — as metastatic on vasa vasorum or owing to mural septic thrombosis. Sometimes it has the nature of phlegmon or abscess and leads to fusion of a wall of an aorta, formation of aneurism and perforation.
The necrotic ulcer Ampere-second polypostural blood clots at sepsis lenta arises upon transition from the valve or at systemic lesion of an endocardium and vessels. Mycotic (septic) aneurisms develop. Perhaps isolated damage of an aorta. Inflammatory and necrotic, cicatricial processes give to an internal cover the wrinkled look reminding a syphilitic mesaortitis.
Tubercular And. arises upon transition of an inflammation from kazeozno changed limf, nodes of a mediastinum, retroperitoneal area, juxtaspinal congestive abscess at a spondylitis, from lungs, at a pericardis. Development of specific granulations with the centers of a caseous necrosis conducts to a thickening of a wall, an ulceration, aneurism and perforation. At hematogenous generalization on an internal cover miliary hillocks or their conglomerates in the form of the polypostural centers with the phenomena caseose can develop.
At rheumatism in all layers of an aorta find the centers of disorganization of fabric with consecutive development of mucoid hypostasis, fibrinoid swelling and transition to a granulomatosis and a sclerosis. Communication with rheumatism found sometimes in tunica media of the centers of accumulation of mucoid substances in the absence of elastic fibers and inflammatory reaction (medionecrosis idiopathica cystica) is discussed. At adult patients the proliferative component with existence of rheumatic granulomas in an average cover on the course of vasa vasorum prevails (rheumatic Meuse - a periaortitis). At an aggravation of process of the phenomenon of a sclerosis are combined with acute disorganization of fabric.
Further scarring with destruction of elastic fibers in an average cover, lymphocytic infiltrates in outside create the picture reminding a syphilitic mesaortitis. Changes are localized preferential in a ventral aorta, giving a hilly relief to an intima and promoting development of atherosclerosis [rheumatic «arteriosclerosis» according to F. Klinge]. Aneurism develops seldom.
A clinical picture
Clinical signs of damage of an aorta are usually combined with symptoms of a basic disease and in some cases are defined by it since localization, depth of defeat of walls and morphological features And., reflected in clinical manifestations, significantly depend on an etiology of process, ways of penetration of an infekt to walls of an aorta at infectious And. and from character of a basic disease at allergic And.
Syphilitic aortitis (synonym: a disease Business — Haler)
Symptoms of a disease depend on localization of process. Distinguish syphilitic And. the ascending aorta and syphilitic And. descending and belly And. At a syphilitic aortitis of the ascending aorta it is accepted to allocate three anatomo-clinical options. The first is characterized by dominance in a clinical picture of signs of coronary insufficiency and is connected with a stenozirovaniye of mouths of coronary arteries. Depending on rates of development of occlusion of coronal arteries, and also from perfection of an intercoronary anastomosis this option can proceed clinically differently. In one, rather rare, cases the picture of coronary insufficiency is characterized by anginous pains, the stopped receptions of nitrates, development small - and a macrofocal cardiosclerosis and heart failure. Such current completely corresponds to displays of coronary heart disease at atherosclerosis, cover the diagnosis usually mistakenly and it is put. The corresponding radiological signs of expansion of the ascending aorta, possible existence of clinical displays of visceral syphilis and serological researches can serve as the differential and diagnostic criteria allowing to distinguish coronary insufficiency of the syphilitic nature from coronary heart disease. The nature of a disease becomes clear with the advent of insufficiency of the aortal valve. Koronaroangiografiya reveals a true origin of a disease at the first signs of coronary insufficiency since syphilitic And. leads to narrowing of a gleam of coronal arteries in the place of their otkhozhdeniye from an aorta, leaving absolutely intact coronal arteries. However sharp narrowing of a gleam of the coronal arteries departing from an aorta does not allow to apply the most perfect method of a research — the selection koronaroangiografiya; it is necessary to carry out a chest aortografiya, edges allows to reveal not only narrowing of a gleam of mouths of coronal arteries, but also initial extent of syphilitic expansion of the ascending aorta long before emergence of clear clinical signs of insufficiency of the aortal valve.
Much more often coronary option syphilitic And. proceeds differently. At slow rates of narrowing of coronal arteries and good development of collateral blood supply of a myocardium stenocardia is absent; the only symptom of a disease is slowly progressing heart failure which sometimes is followed by frustration of a cordial rhythm. In a clinical picture an asthma prevails. Further there are attacks of cardiac asthma. Despite weight of a clinical picture, electrocardiographic changes can be absent or be insignificant and be caught only at a dynamic research. From frustration of a rhythm is more often than others atrial or ventricular premature ventricular contraction develops. A ciliary arrhythmia — rare manifestation of syphilitic A. Opisana of disorder of atrioventricular and intra ventricular conductivity up to development Morganyi-Adams-Stokes of a syndrome (see).
Second option syphilitic And. proceeds with dominance of symptoms of insufficiency of the aortal valve and occurs at a third or a half of patients. It is shown more often at the age of 40 — 50 years, combined with coronary insufficiency and rather quickly leads to heart failure. Existence, in addition to diastolic, and systolic noise is characteristic of this option. The last is caused not by a stenosis of the mouth of an aorta, and expansion of an initial part of the ascending aorta.
At the third option more highly located part of the ascending aorta and its arch is involved in process. The disease proceeds, as a rule, asymptomatically. Only after careful inquiry of patients it is possible to reveal existence of a peculiar pain syndrome — an aortalgiya. Apparently, considerable morphological changes in an adventitia of an aorta with involvement in process of paraortalny neuroplexes are the cornerstone of this syndrome. It is difficult to differentiate Aortalgiya with stenocardia as the nature of pains, localization and their irradiation are rather similar. At the same time aortalgichesky pains are longer, are less accurately connected with an exercise stress, irradiate in the left hand less often, do not give in to effect of nitrates. Aortalgiya does not exhaust effects of syphilitic neuritis of cardioaortical textures. Them also such symptoms as attacks of a pertussoid and suffocation which cannot be explained with a condition of a cardiac muscle are a consequence. Carefully analyzing clinical symptomatology syphilitic And., some authors especially emphasize the constant asthma and tachycardia inherent to this patient which are not eliminated by a digitalis that is noted long before approach of symptoms of heart failure, the first manifestations a cut are caused in most of patients by already developed aortic aneurysm.
At syphilis of an aortic arch sharp narrowing of the mouth of one or several arteries departing from it can develop; there are symptoms of ischemia of a brain, a vision disorder, a syndrome of a hyperreactivity of a sinocarotid glome.
Early diagnosis syphilitic And. it is difficult therefore researches of patients shall be conducted carefully and repeatedly. In early stages And. the sizes of an aorta and heart are not changed therefore percussion and usual X-ray inspection do not help specification of the diagnosis. Exclusive value is gained in these conditions by auscultation, edges allows more than at a half of patients already at an early stage of a disease to catch the small systolic noise caused by its insignificant expansion over an aorta. The systolic noise caused by syphilitic damage of the ascending aorta is listened in the center of a breast and over a xiphoidal shoot quite often better. At some patients systolic noise can arise only at a raising of hands up (Sirotinin's symptom — Kukoverova). Over an aorta the accent of the II tone getting over time a metal timbre is listened. The phonocardiographic research of persons at whom suspect syphilitic is of great importance And.
Special attention should be paid to determination of diameter of the ascending aorta. The size of the ascending aorta is defined by a telex-ray analysis and a X-ray tomography, but the aortografiya gives the most exact data (see). Important, though late, radiological sign of syphilitic process is calcification of the ascending aorta. The modern x-ray equipment (electron-optical converters, X-ray cinematography) allows to increase considerably percent of identification of calcification of an aorta at syphilis. It is necessary to resort to an aortografiya for diagnosis of occlusal defeats of branches of an aorta, especially if medicinal therapy does not eliminate a stenosis and when in the gravity of a clinical picture inevitably surgical intervention. It is about a syndrome of ischemia of a brain at defeat of places of an otkhozhdeniye of a brachiocephalic trunk and left carotid artery.
The syphilitic aortitis of the descending, chest and ventral aorta is characterized by a difficult and peculiar symptom complex. Development back And. (a periaortitis — a mediastinitis) and involvement in inflammatory process of intercostal nerves cause emergence in some sick painful pains in a backbone and paravertebral area. At defeat of the bottom of a chest aorta pains in an anticardium — the epigastralgia simulating a gastralgichesky equivalent of stenocardia are quite often noted.
The clinical picture of defeat of a ventral aorta is characterized by attacks of a belly toad (see) and passing disorders of mezenterialny blood circulation up to development of Ilheus also went. - kish. bleedings. Stenozirovaniye of renal arteries is followed by development of an arterial hypertension.
Diagnosis of occlusal defeats of branches of a ventral aorta is possible only using a belly aortografiya.
Syphilis, especially in the first years of a current, is followed by the expressed rises in temperature. The temperature curve differs at syphilis in extreme inconstancy. To recognition of the syphilitic nature And. significantly serological tests help. However at active visceral syphilis they at a certain number of patients are negative.
Bacterial endaortit it is shown variously depending on its form.
Bacterial endaortit is a consequence of transition to an aorta of a bacterial endocarditis from the aortal valve. After surgical interventions on an aorta development of a bacterial endaortit on site of an aortotomy is possible.
At a subacute septic endocarditis a disease-producing factor most often is the green streptococcus, at a postoperative endaortit — staphylococcus.
The clinical picture corresponds to a subacute septic endocarditis (see); at a postoperative endaortit there are no signs of defeat of the valve device of heart. Complications — a thrombembolia, a bacterial embolism, a rupture of an aorta.
The diagnosis is based on clinical symptomatology of sepsis, positive crops of blood and effect of antibacterial therapy.
Bacterial blood clot aortitis
Bacterial blood clot aortitis arises owing to infection of the blood clots which are available in an aorta with usually various cocci, Proteus and salmonellas. Blood clots serve as a medium for bacteria and can become the place of their reproduction. In an aorta the purulent inflammation up to formation of small abscesses in its wall develops. As development of the majority of blood clots is connected with ulcer atherosclerosis, bacterial trombaortit develops, as a rule, in a ventral aorta. Also pristenochny blood clots of the ascending aorta affected with rheumatic process can be infected.
The clinical picture corresponds to acute or subacute sepsis (see). Complications — a thrombembolia, a bacterial embolism, a rupture of an aorta.
The diagnosis is based on clinical symptomatology of sepsis, detection of pathogenic flora in blood and effect of antibacterial therapy.
Atero-yazvenny aortitis — version bacterial blood clot aortitis; not blood clots, but atherosclerotic ulcers are exposed to infection.
The current and symptoms correspond to subacute sepsis (see).
Bacterial and embolic aortitis proceeds with the bacteremia caused by a drift of microorganisms (the green streptococcus, gram-positive cocci, pneumococci, gonokokk, sticks of a typhoid, a mycobacterium of tuberculosis) in a wall of an aorta on vasa vasorum.
Clinical manifestations And. are connected with its complications — mycotic aneurisms, a gap and stratification of an aorta.
The aortitis at infectious diseases, as well as damage of other arteries, is observed more often at the diseases proceeding with bacteremia. Clinical diagnosis of it And. it is difficult though during the opening morphological changes of all layers of a wall of an aorta can be found.
The auskultativny changes noted at a sapropyra — the systolic noise on the middle of a breast clapping the II tone over an aorta and a positive symptom of Sirotinin — Kukoverova — consider as clinical manifestations
of A. Aortit owing to transition of inflammatory process from surrounding bodies. It is most often observed at tuberculosis of chest department of a backbone, is more rare — at tuberculosis paraortalny limf, nodes. The tubercular spondylitis leads to perforation of an aorta and fatal bleeding in a mediastinum or pleural cavities; sometimes bleeding is preceded by formation of the sacculate and stratifying aortic aneurysms. Ruptures of an aorta owing to transition to it of inflammatory process from lungs at abscess are described, and also at mediastinites of various origin.
The allergic aortitis
is Most often observed at collagenic diseases (see), and also at an obliterating thromboangitis (Thrombangiitis obliterans), giant-cell arteritis and other system vasculites. It is described And. at rheumatism, an ankylosing spondylarthritis (Bekhterev's disease), a pseudorheumatism.
Clinical picture allergic And. it is studied at rheumatism especially in detail, she reminds an initial stage syphilitic And., at Krom coronal arteries of heart are not surprised. It is characterized by various pain behind a breast which is usually treated as manifestation of a pericardis, and clinical signs of defeat of the aortal valve and an aortectasia. Over an aorta systolic noise and less bright is listened, than at syphilis of an aorta, accent of the II tone.
At a Thrombangiitis obliterans (see. Thromboangitis obliterating ) occasionally the ventral aorta is surprised. The clinical picture depends on extent of involvement in process of places of an otkhozhdeniye of renal arteries and the weight arising thereof an arterial hypertension. The diagnosis is made by means of an aortografiya (the probe in connection with a frequent obliteration of femoral and ileal arteries should be entered through a humeral artery).
An aortitis at a thromboangitis of an aortic arch (see. Takayasu syndrome ) the hl is observed. obr. at young women. Inflammatory process is localized preferential in an aortic arch and branches departing from it, but can take place in any large arterial trunk, including all departments of an aorta, brain, coronal, renal, mezenterialny and ileal arteries. In an aorta there can be pristenochny blood clots leading to development of thromboembolisms.
The symptomatology at the first stages of a disease of a malospetsifichn also comes down to a number of the general symptoms (weakness, heartbeat, increased fatigue, subfebrile, sometimes the febrile temperature, acceleration of ROE). The course of a disease depends on preferential localization of process and rates of its progressing. As the aortic arch and the arteries departing from it most often are surprised, there is a clinical picture of rather quickly progressing aortic arch syndrome: disturbances of cerebral circulation and visual disturbance.
The symptomatology of defeat of a ventral aorta also depends on involvement in process of its branches. Narrowing of a gleam of renal arteries is followed by development of an arterial hypertension, defeat of a celiac trunk, top and bottom mesenteric arteries — symptomatology of mezenterialny insufficiency.
The diagnosis is made on the basis of symptoms of ischemia of bodies of the pool of an aortic arch. The major diagnostic method is the aortografiya.
An aortitis at giant-cell arteritis — rather rare disease. The age of most of patients exceeds 55 — 60 years. Men and women get sick equally often.
Inflammatory process has generalized character, almost in all cases affecting an aorta, in half of cases — the general carotid, internal carotid, subclavial and ileal arteries, in a quarter of cases — superficial temporal and coronal arteries, a brachiocephalic trunk and femoral arteries; the celiac trunk, mesenteric and renal arteries is occasionally involved.
The disease begins with the general symptoms: increased fatigue, subfebrile temperature; some patients are disturbed by night sweats and mialgiya; then there are severe headaches; rise in arterial pressure is often observed. At damage of superficial temporal arteries they become painful to the touch (see Arteritis giant-cell). The blood analysis reveals a moderate leukocytosis and the accruing hypochromia anemia.
More than at a third of patients of the leader in a clinical picture the eye symptomatology connected with thrombosis of the central artery of a retina, a retinal apoplexy, neuritis is. As a result of about a quarter of all patients grows blind on one or both eyes. Very hard proceed at patients of frustration of cerebral circulation, caused by disturbance of a blood-groove on large arterial trunks.
At timely begun treatment the forecast syphilitic And. it is favorable; it considerably is defined by degree of insufficiency of the aortal valve and degree of the cardiosclerosis connected with narrowing of coronal arteries.
The most frequent and heavy complication syphilitic And. — an aortic aneurysm (see).
At various forms bacterial And. the disease can be complicated by a thrombembolia, a bacterial embolism, a rupture of an aorta.
The forecast atero-ulcer is especially adverse And., coming to an end, as a rule, with a rupture of an aorta. The rupture of an aorta is quite often observed also at bacterial and embolic And. and at And. owing to transition of inflammatory process from surrounding bodies and fabrics.
Forecast allergic And. depends on character of a basic disease and localization of an inflammation on length of an aorta. At rheumatic And. the forecast is favorable as the listed changes are exposed in process of recovery to involution, leaving behind in some cases sclerous changes of an aorta.
Damage of an aorta at an obliterating thromboangitis is observed usually at the heavy, not giving in to treatment option of a thromboangitis. At an aortic arch syndrome the forecast is adverse though cases 10 — the 20-year duration of a disease are described. The forecast is adverse And. and at giant-cell arteritis. Patients perish from disturbances of cerebral circulation or a myocardial infarction in 1 — 2 years after emergence of symptoms of a disease. The myocardial infarction is more often caused by the accompanying atherosclerosis of coronal arteries of heart.
For all forms A. the forecast improves at early use of effective treatment of a basic disease.
Treatment And. substantially is defined by its etiology. At syphilitic And. it is identical to the treatment which is carried out at any forms of visceral syphilis (see), but demands extra care as the beginning of therapy sometimes causes the activation of syphilitic process fraught for patients with an aortitis with an acute disorder of coronary circulation.
At all forms bacterial And. apply massive antibacterial therapy (high doses of antibiotics).
At allergic And. only therapy by glucocorticoid hormones which daily dose is various at different basic diseases (40 — 60 mg of Prednisolonum at rheumatism, to 100 mg and more — at separate forms of system vasculites) is effective.
At insufficient effect of glucocorticoids that quite often happens at an obliterating thromboangitis, in addition appoint non-hormonal immunodepressants. Symptomatic therapy includes purpose (if necessary) of vasodilators, anticoagulants.
Prevention And. matches prevention of the basic diseases which are followed by an inflammation of an aorta. It includes also early diagnosis and vigorous therapy of the infectious diseases proceeding with bacteremia, first of all a subacute septic endocarditis.
Prevention of a postoperative endaortit consists in observance of rules of an asepsis and performing preventive antibacterial therapy in the postoperative period.
Bibliography: A. B. O bugloss rheumatic damages of an aorta (aortites) at children, Pediatrics, No. 5, page 46, 1938; Kogan-Yasny V. M. Visceral syphilis, Kiev, 1939, bibliogr.; Kurshakov N. A. Allergic diseases of peripheral vessels, M., 1962; Lang G. F. and Hvilivits-k and I am M. I. A syphilitic aortitis, in book: Mistakes in diagn. and therapies, under the editorship of S. A. Brustein, page 157, M. — D., 1930; Smolensk V. S. Diseases of an aorta, M., 1964, bibliogr.; Hvilivitskaya M. I. Aortites, Mnogotomn. the management on vnutr. to diseases, under the editorship of A. L. Myasnikova, t. 1, page 623, M., 1962, bibliogr.
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V. S. Smolensky; G. A. Chekareva (stalemate. An.).