AKUT AORT SENDROMLARI

AkutAortSendromlariKapak

RİSK FAKTÖRLERİ VE ETİYOLOJİ

Izatullah Jalalzai

Atatürk Üniversitesi, Tıp Fakültesi, Kalp Damar Cerrahisi AD, Erzurum, Türkiye

Jalalzai I. Risk Faktörleri ve Etiyoloji. Ünlü Y, editör. Akut Aort Sendromları. 1. Baskı. Ankara: Türkiye Klinikleri; 2025. p.37-49.

ÖZET

Akut aort sendromları (AAS)—aort diseksiyonu (AD), intramural hematom (İMH) ve penetran aterosklerotik ülser (PAÜ)—görüntüleme ve tedavideki ilerlemelere rağmen yüksek olgu ölüm oranı taşıyan zaman duyarlı tablolardır. Toplum insidansı 100.000 kişi-yılda yaklaşık 3–16’dır; olayların çoğu 6.-7. dekadda görülür ve olguların ≈%60’ı erkektir; modifiye edilebilir başlıca maruziyet sistemik hipertansiyondur. Genç hastalarda Marfan, Loeys–Dietz ve vasküler Ehlers-Danlos sendromları, Turner sendromu, biküspit aort kapağı (BAV) aortopatisi ve ailesel torasik aort anevrizma/diseksiyon (FTAAD) gibi kalıtsal etiyolojiler ön plandadır. Cinsiyete bağlı aort geometrisi farklılıkları—genç kadınlarda daha küçük çap, yaşla birlikte beden yüzey alanına göre daha hızlı genişleme—cinsiyete özgü eşik gereksinimini destekler. Tip A diseksiyonların önemli bir kısmının klasik 5,5 cm elektif onarım sınırının altında ortaya çıkması, yalnızca çap temelli kararların yetersizliğini gösterir ve geometrinin, biyomekaniğin ve biyolojinin birlikte değerlendirildiği modellerin gerekliliğini vurgular. Elastik lif fragmentasyonu, düz kas hücresi apoptozu ve matriks proteolizi (MMP/TIMP dengesizliği) ile karakterize medial dejenerasyon; nabız basıncı, olumsuz kurvatur ve BAV’daki eksantrik jetler gibi hemodinamik stresörlerle birleşerek fokal duvar gerilimini artırır ve kırılganlığı belirler. Güncel BT/ MR anjiyografi ve TÖE, lezyon sınıfını ve komplikasyonları tanımlar; hızlı çap artışı, İMH kalınlığı, PAÜ’de ülser derinliği/boğazı, perikardiyal efüzyon, dirençli ağrı veya hipertansiyon, malperfüzyon ve patent-basınçlı yalancı lümen yüksek risk göstergeleridir. Tanısal kateterizasyon veya kardiyak cerrahi sırasında iyatrojenik yaralanmalar, TEVAR sonrası retrograd tip A, isthmus düzeyinde künt toraks travması, sempatomimetik maruziyet (örn. kokain) ve özellikle üçüncü trimesterde gebelik yatkın bireylerde olayı tetikleyebilir. Yönetim, derhal anti-impuls tedavisi, analjezi ve hızlı görüntülemeyi takiben anatomi-yayılım temelli müdahaleyi içerir: tip A için acil açık cerrahi, komplike tip B için torasik endovasküler onarım; seçilmiş komplike olmayan tip B olgularında tıbbi tedavi ve yapılandırılmış izlem uygundur. Uzun dönem süreç genetik danışmanlık ve kademeli aile taramasını, cinsiyete/gebeliğe duyarlı eşikleri ve standart BT/MRG izlemlerini kapsar. Gelecekte genotip, klinik değişkenler, matriks hasarı biyobelirteçleri ve görüntü kaynaklı biyomekaniği (4D-flow MR, radyomik analiz ve hesaplamalı duvar gerilimi haritalaması) birleştiren çok değişkenli platformların, koruyucu cerrahi ölçütlerini ve izlem aralıklarını çap-ötesi yaklaşımla rafine etmesi beklenmektedir.

Anahtar Kelimeler: Aort sendromları; Aort diseksiyonu; İntramural hematom

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