conservative and surgical treatment modalities (31.9% vs. 16.7%, respectively) might be explained by younger age and better somatic viability of operated subjects. The survival was as well influenced by this factor; within 6 years, it was 59.6% in conservative treatment group, and 66.7% in surgical treatment group.
Throughout the follow-up period, the group of conservative treatment annually includes 5 to 6 patients who die, and these subjects are typically older and more physically weak. Similar trend is observed among operated individuals. Survival rates are progressively reduced in both groups, with a slightly more prominent escalation among conservatively treated subjects.
Of 33 subjects with AD, 10 (10.3%) were operated, with four of them receiving ascending aortic replacement, two receiving open abdominal aortic repair, and 4 implanted with a stent-graft. The remaining 23 patients (69.7%) were treated conservatively.
During that period, six patients (18.1%) died. One patient was operated and received a stent-graft, but after four years, aneurysm rupture occurred at its distal edge. In the group of conservative treatment, five (15.2%) patients died; 2 due to aneurysm rupture (6%). Thus, as a percentage, mortality rate due to ruptured aneurysm in operated individuals turned out to be higher than in non-operated (10% vs. 8.7%, respectively).
The main cause of death in three (9.1%) patients includes comorbidity (stroke, short-term lower extremity gangrene during 8 months of follow-up). Survival throughout the group (operated and non-operated-27 patients) was 81.8%.
Major events in DAA and AD were reported at the beginning of the treatment when the threat of aneurysm rupture, technical feasibility of stent-graft implantation and the absence of contraindications for open aortic repair had been thoroughly assessed. A group of patients was selected in which the sole option was medical correction to strengthen aneurysm walls, treat inflammatory process and maintain BP within 132/78 mm・Hg. Generally, it was used in all the individuals, but the rest had an alternative-surgical treatment.
However, the proven procedure of DAA patient management is more often than not intervened by a crucial factor that can change patients’ fate at the very beginning. That is compliance! Lack of compliance brings doctors’ efforts to naught. Ruptured aneurysms are strongly related with carelessness of treatment and physical stresses in the first several years, as aneurysm wall has not fully restored. Therefore, the intensity of aortic ruptures tended to decline overtime. During the past 3 years, no cases of ruptured aneurysms were registered in operated patients, with only two cases reported in the sixth year of follow-up among non-operated subjects of older age. Similar was true for AD group.
However, the real problem afflicting patients suffering aneurysms, which uniformly boosted death rates with age was comorbidity. Thus, over 4, 5 and 6 years, 1, 2 and 4 patients (4.2%, 8.3%, and 16.7%, respectively) died. The similar trend was seen among non-operated, but was more prominent, i.e. 12, 18, and 23 (16%, 24.7%, 31.9%) subjects.
It might seem that the situation with conservative treatment of DAA is poorer than with operative (Table 2) treatment, but two operation-related fatal outcomes (8.3%) in the second and third follow-up year nullified the results. Therefore, among the survivors, there were no significant differences between those operated and non-operated. Given that the open aortic surgery is performed only to prevent rupture, it becomes clear that the aim is hard to achieve. In this regard, surgical approach to treat DAA shall not to be considered the best possible treatment modality.
In patients with AD, given their much younger age, no peculiar presentation of comorbidity was evident. Six patients died in this group, with three of them due to ruptured aneurysm (one following stent-graft implantation) and three due to concomitant conditions.
Our data suggest that DAA belongs to a nosology of comorbid disorders, which can abruptly terminate a person’s life. Cardiovascular diseases, diabetes mellitus, cancer, polyorgan insufficiency prevail, and aneurysm rupture is just a part of it. Operative treatment guarantees no safety from rupture or other cause of death. Data from multi-centered trials support these findings   . At least, the ruptured aneurysm is not a leading factor contributing to fatal outcomes, and the threat of rupture can be mostly managed medically. Such decision provides ground for an in-depth search for an underlying condition and change of basic approaches to treat aortic aneurysms     .
Aortic aneurysms must be treated with caution, as there is a wide variety of factors responsible for a fatal outcome. The acute and chronic patients require intensive medical therapy based on etiopathogenesis with a special focus on inflammatory process signs.
Groups of AD patients showed changes consistent with those registered in DAA group with some definable patterns characteristic for a younger age including fewer comorbidities. High CRP was another peculiar finding. Yet, some other factor seems to be mainly responsible for ruptured aneurysms, which is non-compliance. Non-compliance was responsible for ruptured aneurysms both in DAAs, and in ADs.
No doubt that the severe hypertension and aortic stiffness coupled with excessive static and emotional stress contribute to the development of AD and DAA. It is noteworthy that these conditions are common among most people, while dissected and ruptured aortas are still quite rare. Then there must be some other factors involved in the condition. One of them is evident―inflammatory process. Nevertheless, since some patients’ CRP remain very low, one can assume the presence of some defect in aortic wall, congenital or acquired, with structural changes of collagen and elastin (for example, flattened wave elastin fibers  ).
Our experience of treating patients who survived acute AD episode suggests that the dissection is not as dramatic as it might be depicted in literature   , with a 5-year survival amounting to 10% - 15% in the natural course of the disease. Our study shows general survival to be 81.9% provided a properly selected etiopathogenetic therapeutic strategy.
Acute period of dissecting aneurysm, timely diagnosis and awareness of the presence of severe pains remains a challenge when it comes to a decision-making, but using proper diagnosis and intensive treatment to control BP we can halt dissection which influenced by pathogenetically justified therapy, may later on lead patients into a chronic phase. Operations to treat thoracoabdominal lesions are challenging due to a practical impossibility of their complete repair, which is always potentially associated with fatal outcome.
Thus, when using DAA sparing treatment strategy, 2, 4 and 6-year survival rates were 90.1%, 76.8% and 59.4%, respectively, with uniform mortality increment mainly due to present comorbidity. Survival in AD group (81.8%) turned out to be more acceptable due to a younger age of individuals (Graph 1).
When assessing these results, it should be borne in mind, however, that there is a natural population decline. Based on statistical yearbook data, decline over the past 6 years for these age groups was more than 2% annually in Minsk. It is
Graph 1. Survival seen in patients with DAA and dissecting AA at 2, 4 and 6 years of follow-up.
more than 12% - 13% at 6 years. Therefore, the year-by-year dynamics of survival from DAA makes it feasible to use sparing treatment strategy with emphasis on gerontology, i.e. operations shall be performed only if there is a potential of aneurysm rupture and inefficiency of conservative treatment.
Complications of treatment, which resulted in death, were observed only in operated patients. Conservatively treated individuals demonstrated no complications. Still, it is noteworthy that early detection of comorbidity and efforts in symptomatic treatment thereof are of paramount importance for longer and productive life.