Atherosclerosis of the aorta
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Atherosclerosis of the Aorta: Insights and Implications
Introduction to Aortic Atherosclerosis
Atherosclerosis of the aorta is a condition characterized by the buildup of plaques within the aortic walls, leading to various cardiovascular complications. This article synthesizes recent research findings on the predictors, diagnosis, management, and underlying mechanisms of aortic atherosclerosis.
Predictors of Neurologic Events and Mortality
Ascending Aorta Atherosclerosis as a Predictor
Atherosclerosis of the ascending aorta has been identified as an independent predictor of long-term neurologic events and mortality. A study involving 1,957 patients undergoing cardiac surgery found that the severity of atherosclerosis in the ascending aorta significantly increased the risk of neurologic events and mortality. Specifically, the incidence of these outcomes increased more than threefold as the severity of atherosclerosis progressed from mild to severe.
Topography and Stroke Risk
The topography of aortic atherosclerosis also plays a crucial role in predicting stroke. Research indicates that atherosclerosis in the distal part and lesser curvature of the ascending aorta is particularly associated with a higher risk of stroke. Patients with extensive atherosclerosis in these regions had significantly lower five-year stroke-free survival rates compared to those without aortic disease.
Diagnosis and Management During Cardiac Surgery
Challenges and Surgical Interventions
Severe atherosclerosis of the ascending aorta and arch poses significant challenges during cardiac surgery, often necessitating complex surgical maneuvers to prevent systemic embolism. A study assessing the safety and effectiveness of replacing the atherosclerotic ascending aorta found that despite significant perioperative morbidity, the procedure is beneficial in reducing expected death and stroke rates. The study reported a cumulative survival rate of 85.6% at three years post-surgery.
Mechanisms and Pathophysiology
Metabolic and Inflammatory Alterations
Metabolic profiling of atherosclerotic plaques in the aorta has revealed significant alterations in oxidative stress and inflammation pathways. Elevated levels of metabolites such as glucosylceramide, tryptophan, and kynurenine were observed in plaque-containing aortic tissue, indicating dysregulated oxidative stress and inflammation. Additionally, autoimmune reactions involving the exudation of proteoglycans, globulins, and interleukin-17, along with plasma cell infiltration, have been implicated in the pathogenesis of aortic atherosclerosis .
Genetic and Epigenetic Factors
Research on murine models has shown that genetic predispositions, such as LDL receptor deficiency and apolipoprotein E deficiency, lead to extensive atherosclerotic lesions throughout the aorta. These models demonstrate a significant correlation between lesion formation in the aortic origin and the entire aorta, suggesting that similar pathological factors drive lesion development under severe atherogenic conditions. Furthermore, alterations in DNA methylation at enhancer regions of aorta-associated genes have been linked to phenotypic changes in vascular smooth muscle cells, contributing to the progression of atherosclerosis.
Clinical Implications
Aortic Dilatation and Aneurysm Formation
The relationship between atherosclerosis and aortic dilatation has been explored, with findings suggesting that atherosclerosis plays a minor role in aortic dilatation. Factors such as age, gender, and body surface area are major determinants of thoracic aortic dimensions, while atherosclerosis risk factors and plaques have a weak association with distal aortic dilatation. Additionally, the clinical course of atherosclerosis in the infrarenal aorta can lead to distinct conditions such as aortoiliac occlusive disease and abdominal aortic aneurysm, with differences in collagen accumulation and degradation influencing the disease outcome.
Conclusion
Atherosclerosis of the aorta is a complex condition with significant implications for neurologic events, mortality, and surgical outcomes. Understanding the predictors, diagnostic challenges, and underlying mechanisms is crucial for effective management and treatment. Ongoing research continues to uncover the intricate metabolic, inflammatory, and genetic factors driving this disease, offering potential avenues for targeted interventions and improved patient outcomes.
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