老年高血压伴主动脉夹层患者临床及病理分析

目的探讨老年高血压伴主动脉夹层临床表现与病理特点。方法选择15例老年高血压伴主动脉夹层患者为夹层组,同期选择高血压未伴主动脉夹层15例患者为对照组,取入选患者的尸体解剖病理切片,回顾性分析2组临床表现、病理特点及免疫组织化学检测状况。结果与对照组比较,夹层组患者临床表现复杂多样,病理特点为夹层壁内平滑肌细胞明显退行性变,弹力纤维减少或断裂,胶原纤维增生,夹层壁内血管第八因子相关抗原表达增强,平滑肌肌动蛋白表达降低。结论高血压伴主动脉夹层是严重威胁老年人生命的一种并发症。严格控制血压,是预防老年人主动脉夹层发生的重要手段。     

17例主动脉夹层动脉瘤临床病理分析

对１７例主动脉夹层动脉瘤的临床病理进行了分析。其中１１例合并高血压（高血压组）；６例合并马凡氏综合征（马凡氏组）。前者年龄较大，病起常有剧烈的心前区疼痛，夹层多属Ｉ或ＩＩＩ型，常合并严重的动脉粥样硬化。内破口常在升主动脉或胸主动脉；患者常因夹层破裂引起出血性休克而死亡。后者年龄较轻，病程时间较长，均有升主动脉夹层动脉瘤形成，破口常与夹层腔融合。主动脉无或仅有轻度动脉粥样硬化，病变常累及主动脉窦和主动脉瓣，患者常因顽固性心力衰竭而死亡。对主动脉夹层动脉瘤的形成和主要病理改变，结合文献进行了分析、讨论。     

主动脉夹层的误诊原因及防范措施探讨

主动脉夹层的特点是发病突然，病情进展迅速，急性期死亡率高，未经治疗者24小时内病死率达21％，且该类患者的临床表现差异较大，症状不典型者多见，临床极易误诊。所以进一步提高临床医师对该病的认识，降低误诊率至关重要。本文就主动脉夹层的误诊原因及防范措施探讨如下。     

3例主动脉瘤及主动脉夹层合并主动脉良性肿瘤及瘤样病变的临床病理学分析

目的:发生在主动脉的良性肿瘤并伴有主动脉疾病(主动脉瘤、主动脉夹层及马方综合征)是少见病例。本文总结分析伴有主动脉疾病的主动脉良性肿瘤及瘤样病变的临床病理特点,复习发生于主动脉良性肿瘤的文献,探讨其发生与主动脉疾病之间的关系。方法:回顾性分析我院病理科2006年至2012年,手术切除的胸主动脉瘤及胸主动脉夹层的标本129例,通过复习临床病历,观察HE染色切片,辅以弹力/VG及Masson等组织化学染色及SMA、CD31及CD34等免疫组织化学染色,对主动脉壁结构的改变进行分析。结果:所有病例主动脉壁均发生了结构的改变,主要是中膜弹力纤维、平滑肌及基质的变化,但有3例标本内膜增生明显,1例形成了平滑肌瘤,另2例发生了内膜下弹力纤维瘤样增生及平滑肌瘤样增生。结论:主动脉壁内不同组成成分的改变,使得主动脉壁重构,导致主动脉瘤及主动脉夹层的形成,而某一单一成分过度增生可形成主动脉腔内的肿瘤。     

36例主动脉夹层早期诊断及误诊分析

目的探讨主动脉夹层的临床表现、早期诊断及误诊情况。方法分析36例主动脉夹层临床表现，体检、实验室检查、心电图检查、X线片、超声心动图、CT、MPd等检查结果。结果36例主动脉夹层的临床表现各异，典型撕裂样疼痛22例（61．1％），部分患者以并发症为首发症状，影像学检查能确定诊断。主动脉夹层的临床表现复杂，初诊误诊率50％。结论主动脉夹层临床表现复杂，易误诊，应引起临床医师的高度重视。     

老年急性主动脉夹层36例

急性主动脉夹层(AAD)是极凶险、死亡率极高的疾病,临床表现复杂多样,剧烈胸痛并向腰背、腹部放散常为首发症状,但老年人由于多种疾病并存而使临床表现常不典型。本文主要分析老年人,尤其是高龄老年患者AAD的特点及治疗体会。     

主动脉夹层33例临床分析

目的：探讨主动脉夹层（AD）的临床诊断、及误诊情况。方法：通过33例主动脉夹层患者的临床表现、超声心动图、CT、MRI等辅助检查，分析主动脉夹层的诊断及误诊情况。结果：高血压为主动脉夹层的主要易患因素，突发剧烈的胸、腹痛为其首发及主要临床表现，超声心动图、CT、MRI对主动脉夹层的确诊有重要意义，多层螺旋CT血管成像（SCTA）的敏感性优于超声心动图及MRI。结论：因AD临床表现的多样性及非特异性，应借助于辅助检查早期诊断及治疗，避免漏诊及误诊，降低死亡率。     

常见大血管病变的外科治疗

需要外科治疗的升主动脉病变主要是指各种原因造成的升主动脉瘤、主动脉夹层分离和主动脉根部扩张.升主动脉瘤约占各种胸主动脉瘤的45%,病因以主动脉壁中层退行性变(如马凡氏综合征的主动脉中层囊性坏死)为多见,动脉粥样硬化次之,感染性动脉瘤及创伤性动脉瘤则较少见.高血压和动脉硬化则是主动脉夹层分离的重要病因.根据DeBakey分型升主动脉夹层分离可分为两型,Ⅰ型破口在升主动脉,但向远端剥离可达降主动脉的胸或腹段,Ⅱ型则夹层剥离范围仅限于升主动脉 .此两型均归类于Baily的A型. 升主动脉瘤很少产生症状,也不易压迫临近器官或组织,只有根部动脉瘤引起主动脉瓣环扩张造成主动脉瓣明显关闭不全时,出现劳累、心慌、胸闷等心功能不全和心前区疼痛等冠状动脉供血不足表现;升主动脉夹层分离患者可出现剧烈胸背痛,如血液大量渗入心包,患者会出现呼吸困难、血压下降等心包压塞等症状,严重者可因急性心包填塞而猝死.以往该病的诊断主要依靠主动脉根部造影,胸部CT和磁共振显像对该病诊断也有一定意义.目前多普勒超声心动图对升主动脉病变的诊断价值日益重要,通过二维显像和彩色多普勒可清楚显示动脉瘤的大小、范围和夹层分离的破口以及有无累及主动脉根部、主动脉瓣环的直径及主动脉瓣的返流程度.有人认为如结合经食管超声检查,其诊断符合率可达100%.     

无痛性急性主动脉夹层的临床分析

目的:分析无痛性急性主动脉夹层患者的临床特点,探讨如何提高无痛性急性主动脉夹层的诊断率及降低死亡率。方法:收集2004-2011年在武汉同济医院住院的急性主动脉夹层患者共625例,其中无痛性39例,对其临床特点进行回顾性研究。结果:无痛性夹层患者从发病到住院的时间、住院后到确认的时间均明显长于痛性主动脉夹层患者,死亡率也较痛性主动脉夹层患者高;常规心脏彩超对无痛性主动脉夹层的确诊率达到74.19%。结论:了解无痛性主动脉夹层的临床表现,有效结合彩色多普勒超声、CT等影像学检查,早期诊治是降低无痛性夹层患者死亡率的关键。     

大动脉炎症候群临床与病理改变的意义

对８例大动脉炎症候群的临床表现及病理改变进行了分析。结果显示，由于主动脉及其主要分支受累部位、程度不同，临床症状多种多样，可出现头晕、视力障碍、指端发凉、肾性高血压等。对该病病因、鉴别诊断及主动脉窦瘤的形成等进行了讨论。     

Clinical and anatomical characteristics of subtle-discrete dissection of the ascending aorta

Subtle or discrete (class 3 in the classification of the European Society of Cardiology) dissection is the most neglected variant of aortic dissection. This study was conducted to define the clinical manifestations, diagnostic findings, and outcomes of subtle or discrete dissection involving the ascending aorta. The clinical and surgical records, preoperative studies, and outcomes of 109 consecutive patients with ascending aortic dissection observed from 1995 to 2005 were reviewed. Eight patients (7.3%) had discrete dissection. Five patients presented with acute anterior chest pain, 2 with abdominal pain, and 4 with syncope. The mean diameter of the ascending aorta was 44 +/- 8.8 mm. The intimal tears were located in all patients on the posterior aspect of the ascending aorta 1 to 40 mm above the left coronary ostium; its length varied from 2.8 to 12.3 mm. Preoperative aortography, magnetic resonance imaging, and computed tomography could not identify the discrete intimal tears. Transesophageal echocardiography provided unique diagnostic information on (1) subtle intimal discontinuity, (2) circumscribed intramural hematoma, and (3) discrete pericardial fluid around the dissected aorta. Six patients underwent emergency surgery on the basis of echocardiographic findings, and they were all alive at follow-up. Compared with patients with classic aortic dissection, those with discrete dissection had lower operative mortality (0% vs 26%, p = 0.11), shorter hospital stay (7.2 +/- 2.8 vs 21 +/- 19 days, p = 0.01), and less frequent need for blood transfusions (0% vs 39%, p = 0.02). In conclusion, elevated clinical suspicion and detailed transesophageal echocardiographic examination are important for the early identification of discrete aortic dissection, leading to prompt surgery, shorter hospital stays, and better outcomes.     

Natural history of a dilated ascending aorta after aortic valve replacement.

BACKGROUND: Little information is available regarding the incidence of aortic dissection or rupture in patients with a dilated ascending aorta after aortic valve replacement (AVR). The present clinical study aimed to demonstrate the incidence of aortic complications after AVR in patients with a dilated ascending aorta and to clarify those risk factors associated with the progression of a dilated ascending aorta or late aortic events. METHODS AND RESULTS: A total of 35 patients with a dilated ascending aorta at the time of AVR were enrolled. A dilated ascending aorta was defined as 40 mm or greater in diameter by preoperative computed tomography or operative findings. The baseline ascending aorta diameter ranged from 40 to 55 mm with a mean of 44.8+/-4.4 mm. There was a high frequency of bicuspid valve disease in patients with a dilated ascending aorta (57%). The mean follow-up interval was 8.1+/-3.5 years (range: 2.3-13). Aortic events occurred in 5 patients (aortic dissection in 1, rupture in 2, reoperation in 2) during the follow-up. One aortic dissection developed at a baseline aortic size of 42 mm, whereas 2 aortic ruptures occurred at baseline aortic sizes of 47 mm and 50 mm. There was no statistically significant univariate association between any of the patient clinical characteristics and late aortic events or ascending aortic progression. CONCLUSION: Although the clinical course of patients with a dilated ascending aorta is unpredictable, aortic events may occur even in patients with a baseline aortic diameter of <50 mm. Therefore, preventive aortic surgery at the time of AVR should be considered to prevent aortic dissection or rupture in patients with an even slightly dilated ascending aorta with a diameter of 40 to 50 mm, unless the patient has a high operative risk or older age.     

A case report on asymptomatic ascending aortic dissection

Aortic dissection is a relatively rare but dreadful illness, often presenting with tearing chest pain and acute hemodynamic compromise. Early and accurate diagnosis and treatment are essential for survival. In the present review, a rare case of an asymptomatic ascending aortic dissection is reported. The general clinical manifestations, diagnosis and management of aortic dissection will also be reviewed.     

Diagnosis of aortic dissection: The value and limitations of transesophageal echocardiography

Aortic dissection requires prompt and reliable diagnosis. The purpose of this study was to assess the accuracy and limitations of transesophageal echocardiography (TEE) for the diagnosis of aortic dissection. Twenty seven patients with clinically suspected aortic dissection were investigated by means of TEE. TEE results were compared to intraoperative findings (n=18), necropsy (n=4), and magnetic resonance imaging (n=5). The DeBakey classification was used for differentiation of dissection type. Twenty-three patients (85%) were correctly identified as having aortic dissection. Four false-positive TEE findings (15%) were confined to the nondissecting aneurysm of the ascending aorta in elderly patients. Retrospectively we found that protruding atherosclerotic plaques were recognized as small intimal flaps. Type of dissection was correctly diagnosed in all 23 patients, the primary entry site was identified in 15 patients (65%), aortic regurgitation was found in 55.5% of patients, and pericardial effusion was detected in 33.3%. We conclude that TEE allows accurate diagnosis and classification of aortic dissection. However, some cases could be overdiagnosed in lesions of the ascending aorta, especially in nondissecting aneurysms. Another limitation of TEE is the inability to define the primary entry site in some cases. Still, overall results may favor TEE as the primary bedside diagnostic procedure to identify patients requiring urgent surgical intervention.Presented at the 35th World Congress, International College of Angiology, Copenhagen, Denmark, July 1993     

老年主动脉夹层的外科治疗

目的:探讨老年主动脉夹层的外科治疗策略、疗效及预后。方法:回顾性分析本院外科治疗35例老年主动脉夹层患者的临床资料。患者年龄60～77岁,平均(64.9±4.6)岁;男性28例,女性7例;按Debakey分型,Ⅰ型14例,Ⅱ型1例,Ⅲ型20例。结果:全组死亡3例,死亡率8.6%。行降主动脉腔内修复手术18例,杂交手术(即先行主动脉头臂血管转流术,同期行主动脉夹层腔内覆膜支架置入术)3例,均无死亡。开胸手术14例,包括升主动脉置换术2例(同期行主动脉瓣置换1例),升主动脉+半弓置换5例(同期行主动脉瓣置换2例,冠状动脉旁路移植手术1例),升主动脉置换+支架象鼻术2例,升主动脉+全弓置换+支架象鼻术3例,降主动脉置换术2例,共死亡3例,死亡原因为急性肾功能衰竭、多脏器功能不全、心跳骤停及纵隔感染。结论:老年主动脉夹层病情凶险,外科开胸手术治疗死亡率较高,采取杂交手术及微创腔内修复治疗,效果满意。     

Spontaneous rupture of the ascending aorta: case report and review.

Spontaneous nontraumatic rupture of the ascending aorta occurred in a hypertensive patient. The clinical findings suggested acute aortic dissection, and echocardiography showed a large pericardial effusion. Computed tomography scanning did not indicate aortic dissection, but aortography in 3 projections revealed an area of intimal disruption similar to the niche of an ulcer. The patient underwent replacement of the ascending aorta and proximal aortic arch, and the postoperative course was uneventful.     

Acute type A aortic dissection in the elderly: clinical characteristics,management, and outcomes in the current era

OBJECTIVES: We sought to evaluate the clinical characteristics, management, and outcomes of elderly patients with acute type A aortic dissection. BACKGROUND: Few data exist on the clinical manifestations and outcomes of acute type A aortic dissection in an elderly patient cohort. METHODS: We categorized 550 patients with type A aortic dissection enrolled in the International Registry of Acute Aortic Dissection into two age strata (<70 and >or=70 years) and compared their clinical features, management, and in-hospital events. RESULTS: Thirty-two percent of patients with type A dissection were aged >or=70 years. Marfan syndrome was exclusively associated with dissection in the young, whereas hypertension, atherosclerosis and iatrogenic dissection predominated in older patients. Typical symptoms (abrupt onset of chest or back pain) and signs (aortic regurgitation murmur or pulse deficits) of dissection were less common among the elderly. Fewer elderly patients were managed surgically than younger patients (64% vs. 86%, p < 0.0001). Hypotension occurred more frequently (46% vs. 32%, p = 0.002) and focal neurologic deficits less frequently (18% vs. 26%, p = 0.04) among the elderly. In-hospital mortality was higher among older patients (43% vs. 28%, p = 0.0006). Logistic regression analysis identified age >or=70 years as an independent predictor of hospital death for acute type A aortic dissection (odds ratio 1.7, 95% confidence interval 1.1-2.8; p = 0.03). CONCLUSIONS: Our study shows significant differences between older (age >or=70 years) and younger (age <70 years) patients with acute type A aortic dissection in their clinical characteristics, management, and hospital outcomes. Future research should evaluate strategies to improve outcomes in this high-risk elderly cohort.     

A case of delayed postoperative cardiac tamponade with unusual echocardiographic findings

Postoperative cardiac tamponade due to localized compression of the atria occurred in a 64-year-old man after aortic valve replacement and repair of an ascending aortic dissection. The clinical findings were subtle and the echocardiographic findings were unusual. Color Doppler flow imaging assisted in making the diagnosis of localized atrial compression.     

A giant post-dissection aneurysm of the ascending aorta in an octogenarian

Aneurysm formation is a well-known complication of untreated long-standing dissection of the aorta. Despite numerous advances in cardiac surgery, intrinsic diseases of the ascending aorta and aortic arch requiring surgical therapy, remain a technical challenge. However, surgery is the only option for effective treatment of ascending aorta aneurysm but carries an increased risk of severe morbidity and mortality, particularly in the elderly. We report on the successful repair of a giant ascending aorta aneurysm due to chronic dissection in an elderly woman with dyspnoea as main symptom.