主动脉夹层诊治分析

目的 探讨主动脉夹层的临床表现特点、早期诊断及治疗方案.方法 对我院收治的65例主动脉夹层患者的临床资料进行回顾性分析,研究其临床特点、影像学诊断、治疗方式及效果.结果 65例中经内科保守治疗19例,介入治疗12例,外科手术治疗34例,62例均好转出院,3例死亡.结论 主动脉夹层是发病急,病情进展迅速,临床表现多样、误诊率及死亡率极高的心血管疾病.然而,合理的早期诊断与积极的治疗可以进一步减少并发症,降低急性期死亡率,大大提高患者的生存率.     

血浆D-二聚体在急性主动脉夹层诊断中的价值

目的探讨血浆D-二聚体在急性主动脉夹层诊断中的价值。方法回顾分析2005年1月至2011年10月在我院确诊的69例急性主动脉夹层患者（简称主动脉夹层组）、同期70例急性肺栓塞患者（肺栓塞组）和70例因胸痛住院的其他患者（胸痛组）的血浆D-二聚体等临床资料,比较D-二聚体在不同类型患者中的水平差异,分析D-二聚体水平与急性主动脉夹层预后的关系。结果所有急性主动脉夹层患者D-二聚体均超过500μg／L,敏感性100％;死亡患者血浆D-二聚体浓度高于存活患者（P〈0．05）。血浆D-二聚体浓度主动脉夹层组、肺栓塞组和胸痛组分别为（3479．2±2200．0）μg／L、（1560．7±940．0）μg／L和（179．8±167．0）txg／L,三组比较P〈0．01,每两组比较P〈0．05。结论急性主动脉夹层患者血浆D-二聚体明显升高,其平均浓度超过急性肺栓塞患者。D-二聚体阴性有助于排除急性主动脉夹层的诊断;D二聚体升高对判断预后有-定的指导价值。     

急性主动脉夹层9例误诊分析

目的 探讨以腹痛为主要表现的急性主动脉夹层的特点,以减少误诊.方法 对9例以腹痛为主要表现的急性主动脉夹层误诊患者的症状、体征、辅助检查做回顾性分析.结果 本组9例均有不同程度的误诊,误诊时间2～96 h,分别误诊为胆石症、急性胃炎、急性肠炎、肾结石、雷诺病、心绞痛、感染性休克等.结论 以腹痛为主要表现的急性主动脉夹层极易误诊,当腹痛有沿主动脉伸展方向转移,并伴血白细胞明显升高时,应及时进行主动脉的CTA检查.     

Multiple carotid stenting for extended thoracic aorta dissection after initial aortic surgical repair

Acute aortic dissection is one of the most common catastrophes affecting the aorta. Aortic branch occlusion occurs in up to one third of patients with aortic dissection and is associated with increased risk for early death and serious complications. A 67-year-old man without history of cardiovascular disease was referred to our center for acute aortic type A dissection and was treated with a 28-mm Vasculteck prosthesis. During the early postoperative period, he felt left hemiparesis, and an angio-computed tomography showed a progression of the dissection to the right common carotid artery and left brachiocephalic trunk: the abdominal aorta with the celiac trunk. We felt that the patient should receive conservative management, except for the carotid involvement, for which an endovascular approach was planned. After carefully engaging the carotid ostia with a modified no-touch technique, a self-expandable stent and a balloon-expandable stent were deployed to seal the left common and internal carotid artery dissection, whereas two self-expandable stents were implanted within the right internal carotid artery. Angiographic control demonstrated complete sealing of the carotid dissections. The patient recovered quickly after the intervention and was discharged after 2 days without any neurologic or vascular complication. The patient did extremely well at two 3-month follow-ups, and coverage of the descending thoracic aorta dissection was scheduled to be performed in the next 2 months. This case suggests that endovascular techniques may offer a reliable and effective answer to extended dissections, helping decrease the risk for neurologic or visceral complications and reducing the operative risk for further complete surgical or endovascular aortic repair.     

大动脉炎并发主动脉夹层临床特点分析

目的:探讨大动脉炎并发主动脉夹层的临床特点,为临床诊治提供参考.方法:回顾分析阜外心血管病医院2002-10至2011-08收治的5例大动脉炎并发主动脉夹层患者的临床资料,对其临床特征、影像特点及治疗情况进行总结.结果:5例患者均为女性,年龄中位数为39岁(18 ～46岁).1例患者降主动脉内置人两枚支架,4例内科保守治疗.中位数随访时间2年(3个月～8.8年),所有患者夹层无进展,无肢体灌注不足及缺血性疼痛等临床症状.1例假腔减小,支架内血流通畅,无再发狭窄.1例因血压不能控制于2009年行腹主动脉人工血管置换术.2例假腔无明显变化.1例夹层愈合,假腔消失.结论:大动脉炎可并发主动脉夹层,病程隐匿,临床应予重视.     

以急腹症表现的血液透析患者并主动脉夹层2例分析

探讨以急腹症表现的维持性血液透析患者并发主动脉夹层的临床特点。对2例血液透析患者并发主动脉夹层临床资料进行分析。1例开始拟诊为急性心肌梗塞。而另1例开始则怀疑急性胰腺炎。血液透析患者易并发血管性疾病,且临床表现不典型,应引起我们的重视。     

急性主动脉夹层临床特征的分析

目的：了解当前国人急性主动脉夹层（AAD）的临床特征,以指导疾病诊断及治疗。方法收集2008年1月1日~2011年12月31日国内15家大型心脏中心经影像学检查确诊AAD患者1812例（其中Stanford A型726例,Stanford B型1086例）的临床资料。研究内容包括人口学特征、合并症、临床表现、诊断、治疗、预后及随访等情况,并比较Stanford A型与B型夹层患者之间临床特征的差别。结果患者平均年龄为（51.1±10.9）岁,男女比例约为3.44：1。Stanford B型AAD患者的平均年龄大于A型AAD患者[（53.3±10.1）vs.（47.5±11.2）,P＜0.001],Stanford A型AAD患者男性比例较B型更高（83.7%vs.73.3%,P＜0.001）。B型AAD患者中,86.8%患者合并高血压病,22.0%患者合并动脉粥样硬化,49.5%患者吸烟,均高于A型夹层患者（P＜0.05）。A型AAD患者中,32.5%患者合并马凡综合征,19.1%患者合并主动脉瓣二瓣化畸形,均明显高于B型AAD患者（P＜0.01）。A型AAD患者有疼痛表现占89.4%,其中前胸痛76.3%,迁移痛12.3%;B型AAD患者中背痛占73.8%,腹痛14.2%。76.3% AAD患者采用CT检查确定诊断。75.3% A型AAD患者实施了外科手术治疗,死亡率为15.9%;76.1%B型AAD患者实施了血管内介入治疗,术后发生内漏占7.8%,死亡率为0.6%。Cox住院死亡风险显示,合并高血压病发生AAD的风险度（HR）为2.80、合并马凡综合征HR为1.76。结论与Stanford B型AAD比较,A型AAD患者发病年龄较轻,且男性比例较高。B型AAD患者多合并高血压、动脉粥样硬化和吸烟,A型AAD患者多合并马凡综合征和主动脉瓣二瓣化畸形多见。疼痛是主要的临床表现,CT检查是最常用的确定诊断方法。     

Use of real-time three-dimensional transesophageal echocardiography in type A aortic dissections: Advantages of 3D TEE illustrated in three cases

Stanford type A aortic dissections often present to the hospital requiring emergent surgical intervention. Initial diagnosis is usually made by computed tomography; however transesophageal echocardiography (TEE) can further characterize aortic dissections with specific advantages: It may be performed on an unstable patient, it can be used intra-operatively, and it has the ability to provide continuous real-time information. Three-dimensional (3D) TEE has become more accessible over recent years allowing it to serve as an additional tool in the operating room. We present a case series of three patients presenting with type A aortic dissections and the advantages of intra-operative 3D TEE to diagnose the extent of dissection in each case. Prior case reports have demonstrated the use of 3D TEE in type A aortic dissections to characterize the extent of dissection and involvement of neighboring structures. In our three cases described, 3D TEE provided additional understanding of spatial relationships between the dissection flap and neighboring structures such as the aortic valve and coronary orifices that were not fully appreciated with two-dimensional TEE, which affected surgical decisions in the operating room. This case series demonstrates the utility and benefit of real-time 3D TEE during intra-operative management of a type A aortic dissection.     

Successful endovascular treatment of iatrogenic coronary artery dissection extending into the entire ascending aorta

Iatrogenic acute dissection of the ascending aorta during percutaneous coronary intervention occurs rarely. Localized aortic dissections may be treated by sealing the entry with a coronary stent. However, extensive dissections may require a surgical intervention. A case of iatrogenic coronary dissection with extensive propagation into the ascending aorta during angioplasty of the right coronary artery is presented. The aortic dissection was successfully treated by stenting at the right coronary artery ostium. Follow-up computed tomography and coronary angiography showed complete resolution of aortic dissection.     

血管腔内覆膜支架治疗胸主动脉夹层68例

目的探讨直筒型和分支型覆膜支架治疗急、慢性Stanford B型胸主动脉夹层的方法及效果。方法对天津胸科医院治疗68例Stanford B型胸主动脉夹层的临床资料作回顾性分析。结果使用直筒型覆膜支架52只,分支型覆膜支架22只,在不影响左上肢血流的前提下完全封堵动脉内膜破口,真腔血流恢复正常,近期疗效满意。结论使用覆膜支架腔内隔离术治疗Stanford B型胸主动脉夹层,符合其病理解剖特点,能很好的封闭内膜破口,具有创伤小、适应证宽、治疗效果确切、康复迅速等优点,为高龄高危患者提供了治疗机会。     

Multi-vessel percutaneous coronary intervention in a patient with a type B aortic dissection-transradial or transfemoral?

Patients with chronic aortic dissections are at high risk of catheter-induced complications. We report a 41-year-old patient with a type B aortic dissection (Stanford) who underwent successful three-vessel percutaneous coronary intervention via the right radial artery approach following a non-ST elevation myocardial infarction. The patient remained asymptomatic at 6 mo follow-up. Trans-radial approach for coronary interventions can be used safely in patients with Stanford type B aortic dissection without increasing the risk of procedure-related complications in this high-risk group of patients.     

Endovascular stent-grafts for acute and chronic type B aortic dissection: comparison of clinical outcomes

Within the recent months, endovascular repair of aor- tic aneurysms has become a rather interesting alternative to patients considering open surgery. In the past, the proce- dure was typically and more solely reserved to a selected group of elderly patients with several co-morbidities. Currently, there are a number of ongoing trials that are com-     

血管腔内覆膜支架治疗胸降主动脉瘤

目的探讨覆膜支架治疗急、慢性胸降主动脉瘤的方法及效果。方法对36例胸降主动脉瘤的临床资料作回顾性分析。结果使用覆膜支架36枚,完全封堵动脉内膜破口,真腔血流恢复正常,近期疗效满意。结论使用覆膜支架腔内隔离术治疗胸降主动脉瘤,符合其病理解剖特点,能很好地封闭内膜破口．具有创伤小、适应证宽、治疗效果确切、康复迅速等优点。     

Hybrid技术应用于Stanford B型主动脉夹层的近期疗效

目的探讨腔内隔绝术联合血管旁路移植术（Hybird技术）治疗破口位于弓部的StanfordB型主动脉夹层（AD）近期疗效。方法选择武汉亚洲心脏病医院2008年8月至2012年6月收治的StanfordB型AD37例,均采取腔内隔绝术,并在其术前行血管旁路移植术。其中男33例,女4例,年龄36-71（51．84±9．21）岁。主动脉夹层第一破口距左颈总动脉或左锁骨下动脉开口处均小于15mm。27例行右颈总动脉-左颈总动脉旁路移植术,2例行右颈总动脉一右锁骨下动脉旁路移植术,6例行左颈总动脉-左锁骨下动脉移植术,2例行左颈总动脉-左腋动脉移植术（左锁骨下动脉开口及近端均被夹层血肿挤压）。术后立即转人介入导管室行腔内隔绝术。共置入带膜支架42枚（双支架5例,其中4例应用带膜支架加裸金属支架）。结果（1）37例行血管旁路移植术及腔内隔绝术均顺利。术后8—24（17．97±3．88）d出院。其中1例院内死亡,近期死亡1例（随访证实出院后当日死亡,等同于近期）。其余病例均无内漏、截瘫、内脏器官缺血、脑部缺血和左上肢缺血症状,随访30d,均恢复良好。（2）术后11例出现发热,排除感染因素,考虑为腔内隔绝术后综合征,经对症处理后恢复。2例因人工血管吻合口出血再次行吻合术。2例新出现肾功能不全,分析为对比剂肾病,经治疗后恢复。术后有5例仍有胸背痛症状,复查主动脉增强CT无内漏出血,治疗后均好转出院。结论腔内隔绝术联合血管旁路移植术治疗累及主动脉弓的StanfordB型主动脉夹层是一种创伤小、疗效好的治疗方法。     

支架型人工血管介入治疗主动脉夹层动脉瘤及主动脉穿透溃疡30例报告

目的探讨支架型人工血管介入治疗主动脉夹层动脉瘤和主动脉穿透溃疡的可行性及疗效。方法2001年6月至2004年3月,行支架型人工血管治疗主动脉夹层动脉瘤及主动脉穿透溃疡30例。男性24例,女性6例。平均年龄(523±119)岁。25例主动脉夹层动脉瘤中,慢性TypeB23例,急性TypeB1例,TypeA1例。主动脉穿透溃疡5例。术后随诊1～32个月。结果30例支架型人工血管均成功植入。5例有近端内漏,1例术中发生升主动脉夹层,2例分别在术后1d、7d发生升主动脉夹层。术后30d内死亡2例。术后30d内死亡率为67%。1例术后20个月因近端内漏接受第2次支架型人工血管植入术。术后随诊1～32个月,无死亡,亦无支架移位、狭窄等并发症。结论支架型人工血管是治疗主动脉夹层动脉瘤和主动脉穿透溃疡的有效方法,中远期效果还有待进一步观察。     

覆膜支架治疗胸降主动脉夹层

目的探讨覆膜支架治疗胸降主动脉夹层的方法和疗效。方法对11例胸降主动脉夹层患者行覆膜支架治疗。术前强化CT检查明确诊断，根据病变血管近侧正常血管直径加上其直径的15％～20％选择支架型号。术中先行主动脉造影，确定内膜破口位置，分辨真假腔，选择恰当的手术入路及合适的支架。腹股沟处切开，游离出股动脉并切开，插入支架输送器，降血压，于破口位置缓慢释放覆膜支架，封闭主动脉内膜破口。重新造影，观察支架的位置，检查是否有内漏。结果11例均成功植入支架，患者疼痛症状消失，升主动脉造影示真腔扩大，9例假腔血流消失，2例有内漏。所有病例随访3～30个月，无死亡。术后1、3、6个月和满1年分别行强化CT检查。2例内漏患者中，1例3个月后自行封闭，1例因破口大，靠近左锁骨下动脉口，术后3个月仍有内漏。2例肾动脉受影响者血流明显改善。5例胸膜后血肿患者术后3个月完全吸收。无截瘫、左上肢缺血等并发症。结论覆膜支架治疗胸降主动脉夹层创伤小，操作简单，手术死亡率低，并发症少，近期效果良好。     

急性主动脉综合症100例临床特征分析

目的探讨急性主动脉综合症的临床特征。方法回顾性分析我院收治的100例急性主动脉综合症患者的临床资料,并分析其临床特征。结果:100例患者中,穿透性主动脉溃疡8例,主动脉夹层患者83例,胸主动脉瘤破裂3例,主动脉壁内血肿5例;磁共振成像显示阳性90.9%;行外科手术75例,存活率为62%;保守治疗25例,病死率为12%。结论急性主动脉综合症主要表现为主动脉夹层,另外还包括穿透性主动脉溃疡、主动脉壁内血肿以及胸主动脉瘤破裂,在临床特征上,后三者与主动脉夹层类似,磁共振成像对急性主动脉综合症的诊断特异性与敏感性均较强,要根据不同的病变部位采取不同的治疗措施。     

主动脉夹层神经系统并发症的研究进展

主动脉夹层的神经系统并发症较为常见,甚至以其为首要临床表现者亦不少见,临床上必须警惕以避免误诊。主动脉夹层围手术期神经系统并发症与多种因素相关,其确切机制尚未完全明确,预防措施有限,对预后的影响也存在争议,因此有待进一步深入研究。     

急性和慢性B型主动脉夹层介入疗效的对比研究

目的 比较急慢性期主动脉夹层行腔内隔绝术的临床疗效.方法 分析B型主动脉夹层住院患者的临床和影像资料,经股动脉置入覆膜支架封堵胸主动脉破裂口的临床特点、近期及远期疗效.结果 与慢性主动脉夹层组(慢性组)40例相比,急性主动脉夹层组(急性组)42例胸腔积液(16.7%比0,P=0.01),肢体或内脏缺血(23.8%比2.5%,P=0.01)发生率较高.与慢性组相比,急性组近期并发症发生率较高(38.1%比15.0%,P=0.02),出院后对患者进行了(18.7±17.3)个月随访,急性组远期并发症较慢性组发生率较高(21.4%比5.0%,P=0.03).Kaplan-Meier曲线提示两组长期生存率差异无统计学意义(P=0.38),急性组和慢性组5年生存率分别为90.0%、92.5%.慢性组长期无事件生存率显著高于急性组(P=0.04).结论 腔内隔绝术治疗B型主动脉夹层安全有效,但急性组较慢性组并发症增多.     

D-dimer in ruling out acute aortic dissection: a systematic review and prospective cohort study.

AIMS: Blood D-dimer testing has been proposed as diagnostic marker with high sensitivity for exclusion of acute aortic dissection (AAD). We performed a systematic review and validated the findings in a prospective patient cohort. METHODS AND RESULTS: We searched MEDLINE, EMBASE, CINAHL, and BIOSIS from inception until January 2007 using a combination of search terms for aortic dissection and D-dimer. Study type, type of assay used, predefined cut-off level, result of D-dimer testing, sensitivity, and specificity were abstracted. In 16 identified studies (437 patients), the reported cut-off values ranged from 0.1 to 0.9 microg/mL. D-dimer testing provided high sensitivity (0.97 95% CI 0.94-0.98) and negative likelihood ratio (0.06 95% CI 0.02-0.13). In our cohort of 65 patients (36 male, 55%; median age 59 years, IQR 49-67) with proven AAD, D-dimer levels scattered from 0.24 to 137.88 microg/mL (median 3.47; IQR 1.55-14.49). Mean NPV for the different cut-off levels ranged from 92 % for a cut-off level of 0.9 microg/mL to 100% for a cut-off level of 0.1 microg/mL in our study population. CONCLUSION: Current evidence supports a routine measurement of D-dimer in excluding AAD. A D-dimer <0.1 microg/mL will exclude AAD in all cases.