从自发性冠状动脉夹层到动脉壁内血肿1例

自发性冠状动脉夹层(spontaneous coronary artery dissection,SCAD)常见于无冠状动脉粥样硬化危险因素的年轻女性,多表现为急性冠脉综合征(acute coronary syndrome,ACS),需要紧急行冠状动脉造影(coronary angiography,CAG)并结合血管内超声(intravascular ultrasound,IVUS)或光学相干断层扫描(optical coherence tomography,OCT)影像检查明确,给予药物治疗、经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)或外科治疗.本文以1例SCAD患者2次诊治经过为背景,讨论了SCAD的病因、发病机制、临床表现、诊断及治疗策略.     

Computed tomography of aortic intramural hematoma and thrombosed dissection

A retrospective study was undertaken to evaluate the appearance of the aortic wall on computed tomography for the purpose of developing criteria for differentiating acute aortic intramural hematoma from thrombosed false lumen seen in aortic dissection. Computed tomography angiography findings of the thoracoabdominal aorta in 23 patients with suspected intramural hematoma and 25 with thrombosed false lumen were reviewed. The more common features of an intramural hematoma were hyperattenuation of the aortic wall, wall thickness less than a quarter of the aortic diameter, intrinsic wall calcification, a lesion extending around the entire aortic circumference, and ulcer-like projections that may be precursors of intramural hematoma. Wall thickness less than a quarter of the aortic diameter, lesion extending around the entire aortic circumference, and ulcer-like projections were the most useful indicators for distinguishing intramural hematoma from the thrombosed false lumen in aortic dissection.     

Laparoscopic drainage of an intramural duodenal hematoma

A 21-year-old man was admitted with vomiting and abdominal pain 3 days after sustaining blunt abdominal trauma by being tackled in a game of American football. A diagnosis of intramural hematoma of the duodenum was made using computed tomography and upper gastrointestinal tract contrast radiography. The hematoma caused obstructive jaundice by compressing the common bile duct. The contents of the hematoma were laparoscopically drained. A small perforation was then found in the duodenal wall. The patient underwent laparotomy and repair of the injury. Laparoscopic surgery can be used as definitive therapy in this type of abdominal trauma. (Received Nov. 12, 1997; accepted Aug. 21, 1998)     

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文章论述主动脉夹层(AD)、主动脉壁间血肿(出血)、主动脉穿透性溃疡的影像学诊断的进展,并讨论三者的关系,提出影像学检查在诊断和鉴别诊断中具有重要的作用。     

Different clinical features of aortic intramural hematoma versus dissection involving the ascending aorta

OBJECTIVES: The goal of this study was to test the hypothesis that the absence of direct flow communication through intimal tear in aortic intramural hematoma (AIH) involving the ascending aorta has different clinical impact on clinical course compared with typical aortic dissection (AD). BACKGROUND: Although emergent surgical repair has been applied for patients with proximal AIH as if it was typical AD, the natural history of proximal AIH is not known clearly yet. METHODS: Direct comparison of the clinical data of 81 patients with proximal AD and 24 patients with AIH was performed retrospectively. RESULTS: Patients with AIH were older (67 +/- 10 vs. 50 +/- 13, p = 0.001), and female gender was more predominant in AIH (19/24 vs. 29/81, p = 0.001). The development of mediastinal hemorrhage and pericardial and pleural effusion was more frequent in patients with AIH than it was in patients with AD. Although medical treatment was more frequently selected in the AIH group (75% vs. 15%, p = 0.001) due to old age and other associated medical diseases, the mortality rate with medical treatment was much lower in patients with AIH than it was in patients with AD (6% vs. 58%, p = 0.003). In follow-up imaging studies of 13 patients who survived AIH without surgical repair, seven patients showed complete resolution. Typical AD developed in three patients, and the other three patients showed focal AD only in the descending aorta. The two-year survival rate did not show significant difference (84% +/- 6% in AIH vs. 76% +/- 17% in AD, p = 0.47). CONCLUSIONS: Absence of continuous flow communication can explain a more favorable clinical course of AIH than for AD, and medical treatment with frequent imaging follow-up and timed elective surgery in cases with complications can be a rational option for patients with proximal AIH.     

Different clinical features of aortic intramural hematoma versus dissection involving the descending thoracic aorta

OBJECTIVE: The objective of this study is to test the hypothesis that the absence of flow communication in aortic intramural hematoma (IMH) involving the descending aorta may have a different clinical course compared with aortic dissection (AD). METHODS: We prospectively evaluated clinical and echocardiographic data in AD (76 patients) and IMH (27 patients) of the descending thoracic aorta. RESULTS: Patients did not differ with regard to age, gender, or clinical presentation. IMH and AD had the same predictors of complications at follow-up: aortic diameter (>5 cm) at diagnosis and persistent back pain. Surgical treatment was more frequently selected in AD (39% vs. 22%, P < 0.01) and AD patients who underwent surgical treatment had higher mortality than those with IMH (36% vs. 17%, P < 0.01). There was no difference in mortality with medical treatment (14% in AD vs. 19% in IMH, P = 0.7). During follow-up, of 23 patients with IMH, 11 (47%) showed complete resolution or regression, 6 (26%) increased the diameter of the descending aorta, and typical AD developed in 3 patients (13%). No changes occurred in 14% of the group. Three-year survival rate did not show significant differences between both groups (82 +/- 6% in IMH vs. 75 +/- 7% in AD, P = 0.37). CONCLUSION: IMH of the descending thoracic aorta has a relatively frequent rate of complications at follow-up, including dissection and aneurysm formation. Medical treatment with very frequent imaging and timed elective surgery in cases with complications allows a better patient management.     

Migrating type a intramural hematoma after repair of an anomalous right coronary artery aortocoronary dissection with a covered stent

Iatrogenic aortocoronary dissection is a rare and potentially life‐threatening complication of percutaneous coronary intervention (PCI). Prompt coronary stenting can stop progression and avoid the need for surgical intervention. Herein, we describe a case of migrating aortic intramural hematoma (IMH) after repair of an anomalous right coronary artery aortocoronary dissection with a covered stent. © 2011 Wiley‐Liss, Inc.