Can We Change a Look at Atherosclerotic Aortic Aneurism Treatment?

Abstract

In recent years, the increasing number of cardiologists and cardiac surgeons tend to think that surgical treatment of patients with atherosclerotic aneurisms does not fully comply with contemporary ideas of what the disease is. Some data show that early operations in the presence of this pathology are associated with an unreasonably high mortality. Additionally, the use of intra-aortic stents and grafts cannot principally affect the therapeutic efficacy. Therefore, more attention is paid to the development of conservative therapeutic approaches leaving surgery defeated without surgical treatment. Two groups of patients with similar descending thoracic aortic atherosclerotic aneurisms (DTAAA) and abdominal aortic aneurisms (AAA) were retro-and prospectively studied over a 2-year period. Control group (Comparison group), (63 patients) received common surgical treatment from 2009 to 2010 whereas Main group (121 subjects) received multifaceted medical treatment to remove inflammatory reactions, strengthen aortic wall and control its dilation from 2011 to 2012. Operative treatment was used only in case of potential aneurism rupture. The comparison of the two groups of subjects showed that 2-year all-cause mortality in control group was 20.6% while in the main group it amounted to 9.1% due to the similar incidence of aneurism ruptures and deaths associated with concomitant diseases. It suggests that the odds ratio (OR) of survival when using attenuated therapeutic approach to treating atherosclerotic aneurisms is 2.6fold higher compared to conventional surgical approach. One of the principal factors contributing to a higher mortality when using traditional surgical approach was the presence of polyorgan pathology that required constant medical correction irrespective of therapeutic option (surgical or medical) used. Another important factor is aortic aneurism wall frailty. The development of mechanisms that would allow its strengthening is considered a principal challenge of cutting-edge medicine that should be based on studies of triggers, molecular genetic bases of aortic wall immune-depending inflammatory formation, the production of pro-inflammatory cytokines, metalloproteinase activity that damages elastin and collagen fibers. V. P. Krylov et al.

The Role of Atherosclerosis and Inflammation in the Development of Descending Aortic Aneurysms: Special Aspects of Medical Correction

“…Thus, it seems evident that the underlying mechanisms of vascular aneurysm development involve connective tissue dysfunction. The wide range of forms, sites and clinical manifestations is largely dependent on the dysfunctional (dysplasia) severity of the connective tissue, patient's age, elasticity, endothelium, and arterial stiffness, which determine the features of hydro-and hemodynamics [55].…”

Atherosclerotic Descending Aortic Aneurysms. Pros and Cons of Surgery

“…The more evident are mortality rates. As [8] [9] we mentioned the comparison of mortality rate seen in Group 1 and Group 2 which was 20.6% for active surgical approach, and 9.92% for sparing management.…”

“…A total of 200 patients were analyzed using sparing treatment standardized, premodified and approved scheme in outpatient clinic settings in which surgery was used only when there was a threat of rupture [8] [9]. Among these, 121 patients had a 2-year follow-up (Group 2) and 99 patients had a 4-year follow-up (Group 3).…”

“…Recently, new data have been described about the efficacy of medical treatment and potential options to surgical treatments of AAAs [8] [9] [14] [15]. Therefore, at present we may surely declare that not every aneurysm may be operated but every aneurysm needs treatment.…”

Ways to Correct Indications for Surgical Treatment of Atherosclerotic Descending Aortic Aneurysms

“…All patients were on file at the consultation departments. They received a standardized, preliminarily modified and verified scheme of DAA management when surgery was embarked on only if there was a peril of rupture [9][10].…”