Aneurysma a disekce aorty

31.3.2012 , MUDr. Libor Dujka

aneurysma-a-disekce-aorty2.jpg - kopie
aneurysma-a-disekce-aorty2.jpg - kopie
Aneurysma je výduť cévní stěny. Může sice vzniknout na jakékoliv tepně, obzvláště závažná - život ohrožující - mohou být však aneurysmata aorty. Disekce potom znamená trhlinu v cévní stěně. Při disekci se jednotlivé vrstvy cévní stěny oddělí od sebe a krev tak vlastně protéká dvěma řečišti.

Aneurysma a disekce aorty

Aorta, česky srdečnice, je největší tepna v lidském těle. Vychází z levé srdeční komory a končí v dutině břišní. Zde se dělí na dvě velké větve zásobující dolní končetiny. Je hlavní tepnou, ze které vycházejí větve zásobující životně důležité orgány, jako jsou mozek, srdce a ledviny. Z levé komory srdeční vychází tepna jako vzestupná aorta, přechází v aortální oblouk a pokračuje jako sestupná aorta. Dále se její části nazývají podle toho, kudy procházejí. Rozlišujeme tedy hrudní a břišní aortu. Aneurysma se tvoří častěji v aortě břišní, zatímco disekce v oblasti hrudní, přesněji vzestupné části aorty.

Aneurysma aorty

Aneurysma, tedy výduť, je vyklenutí cévní stěny. Vznikne jakási dutá kapsa, kterou proudí krev. Aneurysma se tvoří v místě oslabení cévní stěny. Na vině může být zánět cévní stěny, který jí tím zeslabuje, ateroskleróza a vysoký krevní tlak.

Příznaky a následky aneurysmatu

Problematika aneuryzmatu spočívá v tom, že pokud aneurysma nepraskne, což se projeví silnou bolestí, může zůstat zcela bez povšimnutí. Velká aneurysmata mohou být hmatná v podobě pulsujících útvarů při vyšetření břicha. Mohou tlačit na okolní orgány a působit bolesti břicha či zad. Přítomnost aneurysmatu je vždy důvodem ke sledování. V případě, že dosahuje určité velikosti, udává se do 5 cm, je indikováno k operaci. V oblasti hrudní části aorty je aneurysma vzácné, častěji se tvoří v části břišní. Jeho nebezpečí spočívá v tom, že může prasknout a krev se tak vylije do okolí. Vzhledem k velikosti aorty a množství krve, které jí protéká a také velikosti břišní dutiny, hrozí rozsáhlé vnitřní krvácení s rozvratem krevního oběhu. Pacient tak může upadnout až do velmi závažného stavu, tzv. šoku.

Diagnostika aneurysmatu aorty

Aneurysma aorty není lehké diagnostikovat, jelikož jeho velikost může být různá a většinou nevyvolává žádné příznaky. V případě jeho větších rozměrů můžeme nahmatat při fyzikálním vyšetření pulzující rezistenci v oblasti středu břicha. Rovněž můžeme tento nález ověřit poslechem za pomocí stetoskopu, kdy slyšíme vířivé zvuky. Spolehlivou metodou jak potvrdit diagnózu je užití CT či ultrazvuk břicha. CT neboli počítačová tomografie je vyšetření využívající rentgenového záření k vytvoření 3D obrazu. Jeho nevýhodou je vysoká dávka záření, kterou tělo absorbuje. Ultrazvuk je naopak zcela bezpečnou metodou, jež využívá průniku zvuku a jeho různého vstřebávání v různých tkáních.

Léčba aneurysmatu aorty

Léčba aneurysmatu aorty spočívá v sanaci faktorů, které se na vzniku tohoto onemocnění podílejí. K tomu se využívá léků různých skupin. Je nutné tedy snižovat vysoký tlak, snižovat hladinu cholesterolu v krvi. Jedinou možností jak vyřešit problém aneurysmatu je chirurgický zákrok. Často se nejprve přistupuje k zavedení stentu, kovové výztuhy, do vnitřku aorty a tím se céva zpevní. Existují i další metody zpevnění stěny aorty v oblasti výdutě, které jsou však náročnější a provádějí je pouze specialisti na cévní chirurgii.

Disekce aorty

Disekce aorty představuje trhlinu v cévní stěně. Stěnu tepny tvoří 3 vrstvy. Pokud je první, vnitřní, vrstva poškozena, krev vniká mezi první a druhou vrstvu a vznikne disekce. Na rozdíl od aneurysmatu se častěji tvoří v hrudní části aorty. Příčinami vzniku disekce aorty jsou vysoký krevní tlak, onemocnění vaziva cévní stěny a vzácně i ateroskleróza.

Příznaky a následky disekce aorty

Disekce aorty tedy představuje trhlinu v její stěně, v oblasti vzestupné části aorty. Krev se hromadí v trhlině a tvoří kapsu podobnou aneurysmatu. Tato kapsa může omezit průtok krve cévou, popř. ji zcela uzavřít. Může se dále rozšiřovat a zasáhnout tepny, které z aorty vycházejí. Ty může rovněž zúžit nebo uzavřít. Disekce aorty se projevuje náhlou silnou bolestí za hrudní kostí, tento stav se může spontánně upravit. Vzhledem k tomu, že často vzniká v oblasti výstupu aorty ze srdce, kde vystupují i věnčité tepny, může být příčinou infarktu, popř. postižení aortální chlopně. Podobně mohou být postiženy tepny zásobující mozek, což se projeví jako cévní mozková příhoda, popř. ochrnutí některé části těla. Může postihnout i ledviny, čímž se sníží množství moči. V případě velké ztráty krve se rozvine šok.

Diagnostika disekce aorty

Diagnostika disekce aorty spočívá především v podrobné a pečlivé anamnéze s vyloučením akutního infarktu myokardu pomocí EKG. Dále můžeme provést rentgen hrudníku, či echokardiografii, tedy ultrazvukové vyšetření srdce. Zásadní metodou, která odhalí drtivou většinu disekcí aorty je tzv. transezofagealní echokardiografie. Jde o ultrazvukové vyšetření srdce, kdy je sonda zaváděna ústy do jícnu a žaludku a je tak možné přesněji zobrazit struktury srdce včetně aorty.

Léčba disekce aorty

Disekce je vždy považována za život ohrožující stav. Nicméně ne vždy musí být průběh dramatický. Dočasná i trvalá stabilizace stavu je možná. Závisí především na velikosti trhliny. Disekce v oblasti hrudní je vždy indikována k operaci. U břišní disekce, při dobrém stavu a bez rizika komplikací, není operace nutná.

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