主动脉夹层经胸超声心动图漏诊及误诊原因分析

摘要：目的：探讨主动脉夹层超声表现及部分病例漏诊误诊原因。方法：收集经手术证实为主动脉夹层诊断的病例50例进行回顾分析。结果：手术证实升主动脉夹层36处,主动脉弓夹层29处,降主动脉夹层43处。超声心动图对降主动脉病变漏诊16处,对主动脉弓病变漏诊9处,对升主动脉处病变漏诊1处。漏诊导致对主动脉夹层Debakey分型错误,I型夹层误诊16例,II型夹层误诊0例,III型夹层误诊1例。结论：主动脉夹层漏诊数量由高至低依次为降主动脉、主动脉弓、升主动脉,漏诊及误诊与超声医师因素、超声图像及设备因素密切相关。     

Ischemic stroke with left hemiparesis or shock should be evaluated by computed tomography for aortic dissection

An 82-year-old woman with consciousness disturbance, left hemeparesis, and dysarthria was discovered at home by her family and was transported to a hospital. On arrival, she remained in a sleepy and disorientated and shock state. She complained of nausea but no chest or back pain. She obtained stable circulation after infusion. Her chest roentgen results showed widening of the mediastinum and the existence of a separation of the intimal calcification from the outer aortic soft tissue border, thus suggesting a Stanford A–type aortic dissection. Her head computed tomography depicted no signs of cerebral infarction. Because she did not complain of any pain, the possibility of acute phase aortic dissection was rejected. A permissive hypertensive therapy was initiated. Next day, she suddenly died. We diagnosed that she had died of a Stanford A–type aortic dissection based on the following facts: (1) patients presenting with stroke due to a Stanford A–type aortic dissection tend to have left hemiparesis because of malcirculation of the innominate artery and (2) a patient presenting with stroke by aortic dissection may have hypotension, which is unusual in standard stoke cases. Ischemic stroke induced by aortic dissection is not common among the patients with aortic dissection. However, given the high morbidity and mortality after misdiagnosis of aortic dissection, patients with ischemic stroke with left hemiparesis or shock should be evaluated by enhanced truncal computed tomography.     

超声心动图和多层螺旋CT在急诊主动脉夹层中的应用价值

目的探讨经胸超声心动图（TTE）和多层螺旋CT（MSCT）在急诊主动脉夹层诊断中的应用价值。方法选取2016年1月~2020年4月在我院治疗的疑似主动脉夹层患者141例,给予TTE和MSCT检查,分析两者诊断价值差异;分析主动脉夹层和非主动脉夹层MSCT征象差异,以及主动脉夹层不同分型MSCT征象差异。结果141例疑似主动脉夹层患者,经手术或CT血管成像确诊112例主动脉夹层患者,29例为非主动脉夹层患者;MSCT诊断主动脉夹层的敏感度、准确性和阴性预测值分别为95.54%、94.33%和83.87%,明显高于TTE诊断（P < 0.05）;MSCT和TTE诊断主动脉夹层的特异性和阳性预测值比较差异无统计学意义（P>0.05）;MSCT征象中,主动脉夹层中钙化内移、主动脉区高密度、线样征和主动脉增宽的比例高于非主动脉夹层（P < 0.05）;主动脉夹层和非主动脉夹层中心包积液、胸腔积液比例差异无统计学意义（P>0.05）;MSCT征象中,A型主动夹层中主动脉区高密度比例高于B型主动脉夹层（P < 0.05）;A型和B型主动脉夹层中钙化内移、线样征、心包积液、胸腔积液和主动脉增宽比例比较差异无统计学意义（P>0.05）。结论相较于TTE,MSCT在急诊主动脉夹层诊断中有较好的应用价值,值得临床使用。      

应用Cabrol手术治疗急性A型主动脉夹层根部病变

目的 Cabrol手术由Cabrol C教授于1981年首创,但至今关于该术式用于治疗A型主动脉夹层的报道并不多。本研究对我中心近7年来应用Cabrol术式治疗急性A型主动脉根部病变的病例进行总结。 方法 2009年1月~2016年12月,共有47例急性A型主动脉夹层的患者在我中心接受Cabrol手术治疗。所有病例术前均经心脏彩超及主动脉增强CT检查确诊。对其根部病变应用Cabrol技术处理,弓部病变采用半弓置换或全弓置换。对所有病例的相关数据进行回顾性分析。 结果 总共纳入47例患者,其中6例为单纯Cabrol手术,13例为Cabrol+右半弓置换,28例为Cabrol+孙氏手术。总的30 d死亡率为10.6%（5/47）。住院期间急性肾功能衰竭发生率25.5%（12/47）,有12.8%（6/47）的病人需要接受连续肾脏替代治疗。中位住院时间为25.5 d（15~128 d）,随访时间6~36月。 结论 Cabrol手术用于急性A型主动脉夹层的病人根部处理安全有效,术中部分技术细节需要注意。       

Serum D-dimer is a sensitive test for the detection of acute aortic dissection: a pooled meta-analysis

Acute aortic dissection is a rare but devastating condition with high mortality. Unfortunately, there is no sensitive screening indicator of disease in common use. The objective of this study was to assess the sensitivity and utility of the serum D-dimer as a test for acute aortic dissection. A pooled analysis was performed of all original research studies testing the sensitivity of serum D-dimer for acute aortic dissection. A search of MEDLINE, EMBASE, and the Cochrane Register using the terms “aortic dissection” and “d-dimer” was made of all English language publications. All original reports of consecutively enrolled patients with acute aortic dissection and a measured serum D-dimer were included. Case reports were excluded. A value of 0.5 microgram per milliliter was defined as the threshold for a positive D-dimer. The primary outcome was the pooled sensitivity of the D-dimer test for acute aortic dissection. There were 21 original reports of patients with acute aortic dissection and D-dimer measurements. Eleven studies were included and a total of 349 acute aortic dissection patients were described. The sensitivity of the D-dimer test was 327/349, 94% (95% confidence interval 91–96), and the point estimate was essentially unchanged in a sensitivity analysis, 183/192, 95% (95% confidence interval 91–98). Specificity ranged from 40% to 100%. Serum D-dimer is sensitive for acute aortic dissection and potentially represents a useful test for patients who present with a low likelihood of this disease.     

Aortic valve commissural tear mimicking type A aortic dissection.

A 52-year-old man came to the local emergency department with symptoms of heart failure and transient chest pain. Transthoracic echocardiography showed severe aortic regurgitation and a dilated ascending aorta. Aortic dissection was suspected, and he was transferred to our institution. Transesophageal echocardiography appeared to confirm the presence of a type A dissection. A mobile, linear structure was present in the proximal ascending aorta, suggesting the presence of dissection flap. Aortic cusp prolapse and severe aortic regurgitation were seen. At surgery, no aortic dissection was present. Rather, the commissure between right and left aortic valve cusps was separated from the wall of the aorta. Motion of the torn commissure with the cardiac cycle apparently led to the transesophageal echocardiographic appearance described. The ascending aorta was dilated. Histopathologic examination of the aorta confirmed the visual appearance of cystic medial necrosis. Aortic valve commissural tear is a rare event, which may lead to severe aortic regurgitation. This entity may lead to the false-positive transesophageal echocardiographic diagnosis of type A dissection.     

Total endovascular repair of an intraoperative stent-graft deployed in the false lumen of Stanford type A aortic dissection: A case report

BACKGROUND A 46-year-old male underwent ascending aortic replacement,total arch replacement,and descending aortic stent implantation for Stanford type A aortic dissection in 2016.However,an intraoperative stent-graft was deployed in the false lumen inadvertently.This caused severe iatrogenic thoracic and abdominal aortic dissection,and the dissection involved many visceral arteries.CASE SUMMARY The patient had pain in the chest and back for 1 mo.A computed tomography scan showed that the patient had secondary thoracic and abdominal aortic dissection.The ascending aortic replacement,total arch replacement,and descending aortic stent implantation for Stanford type A aortic dissection were performed 2 years prior.An intraoperative stent-graft was deployed in the false lumen.Endovascular aneurysm repair was performed to address this intractable situation.An occluder was used to occlude the proximal end of the true lumen,and a covered stent was used to direct blood flow back to the true lumen.A three-dimensional printing technique was used in this operation to guide prefenestration.The computed tomography scan at the 1stmo after surgery showed that the thoracic and abdominal aortic dissection was repaired,with all visceral arteries remaining patent.The patient did not develop renal failure or neurological complications after surgery.CONCLUSION The total endovascular repair for false lumen stent-graft implantation was feasible and minimally invasive.Our procedures provided a new solution for stent-graft deployed in the false lumen,and other departments may be inspired by this case when they need to rescue a disastrous stent implantation.     

术中置入新型三分支主动脉弓覆膜支架治疗急性Stanford A型主动脉夹层临床研究

目的应用新型三分支型主动脉弓覆膜支架治疗急性Stanford A型主动脉夹层,总结其临床应用经验,并评价其安全性和疗效。方法 2009年12月至2011年1月7例急性Stanford A型主动脉夹层患者在我科接受新型三分支主动脉弓覆膜支架手术治疗。结果全组手术时间(259.2±53.6)分钟,体外循环时间(136.4±28.5)分钟,心肌血运阻断时间(85.3±11.7)分钟,深低温停循环选择性脑灌注时间(17.6±8.2)分钟。术中死亡1例,系术中主动脉开放后主动脉根部后壁大出血无法止血;其余6例患者术后及时清醒,循环稳定,无严重并发症发生。随访2～15个月,主动脉血管成像显示患者主动脉弓部及分支动脉内支架扩张贴壁满意,相应部位假腔消失,远端假腔内血栓填充;无与覆膜支架相关的并发症发生;患者心功能改善,生活质量良好。结论 采用新型三分支主动脉弓覆膜支架治疗急性Stanford A型主动脉夹层,可以简化主动脉弓部操作,降低手术风险,提高手术成功率,适合于大多数Stanford A型主动脉夹层患者的治疗。     

超声心动图诊断主动脉夹层的临床应用价值

目的探讨超声心动图诊断主动脉夹层动脉瘤的临床应用价值。方法对采用超声心动图检查诊断的15例主动脉夹层动脉瘤患者与CT、MRCT、DSA等检查方法进行比较,进行总结性分析。结果超声心动图诊断的Standford A型主动脉夹层动脉瘤与计算机断层扫描(CT)、磁共振成像(MRI)、数字减影血管造影(DSA)检查诊断符合率较高。结论超声心动图对诊断Standford A主动脉夹层动脉瘤有重要的临床价值,可作为主动脉夹层的筛查手段。     

Treatment of Stanford type A aortic dissection with triple pre-fenestration,reduced diameter,and three-dimensional-printing techniques: A case report

BACKGROUNDA 63-year-old female was diagnosed with acute Stanford type A aortic dissection. The patient had pain in the chest and back for 1 wk. The computed tomography angiography (CTA) showed Stanford type A aortic dissection (Myla type III aortic arch). The intimal tear was located at the top of the aortic arch and retrograded to the ascending aorta.CASE SUMMARYPreoperatively, a three-dimensional (3D)-printed model of the aortic arch was made according to CTA data. Then, under the guidance of the 3D-printed aortic model, a pre-fenestrated stent-graft was customized, and the diameter of the stent-graft was reduced intraoperatively by surgeons. 3D printing, triple pre-fenestration, and reduced diameter techniques were used during the surgery. The CTA examinations were performed at the 3^rd mo and 1st year after the surgery; the results showed that the aortic dissection was repaired without endoleak, and all three branches of the aortic arch remained unobstructed.CONCLUSIONApplying the triple pre-fenestration technique for aortic arch lesions was feasible and minimally invasive in our case. The technique provides a new avenue for thoracic endovascular aortic repair of Stanford type A aortic dissection.     

主动脉夹层的低场MRI诊断

目的评价低场磁共振成像(MRI)对主动脉夹层(AD)的诊断价值。方法分析14例AD的低场MRI表现,所有病例采用自旋回波(SE)序列轴位T1WI、T2WI和冠、矢状位T1WI扫描,部分病例加做梯度回波(GR)序列轴位扫描。结果14例主动脉夹层中,DeBakey A型2例,DeBakey B型12例。10例B型夹层,在轴位SE序列T1WI结合T2WI,可清晰显示真腔和假腔;2例B型夹层胸主动脉迂曲在冠状位和矢状位T1WI显示清晰。对于SE序列不能区别真假腔的2例A型夹层,轴位T1WI可显示剥离的内膜片。2例主动脉迂曲形成涡流的B型夹层,T1WI和T2WI不能区别真假腔,也不能显示内膜片,加行GR序列轴位扫描,可清晰显示等信号的内膜片。所有序列对内膜破口和再破口的显示效果不佳,对主动脉主要分支受累情况显示也不满意。结论低场MRI的SE序列可显示主动脉扩张和迂曲,也可准确识别主动脉夹层的真假腔和内膜片,但对内膜破口和再破口的显示不满意。     

A型主动脉夹层术患者术后谵妄的影响因素分析

目的探讨A型主动脉夹层术患者术后谵妄影响因素及护理对策。方法选取2017年1月至2018年1月我院收治的A型主动脉夹层术患者82例为研究对象,通过问卷调查方式收集患者一般资料。记录术后谵妄发生情况,采用多因素logistic回归分析法分析A型主动脉夹层术患者术后谵妄的相关影响因素。结果82例患者中术后发生谵妄18例,占21.95%,其中发生短暂性谵妄11例,发生持续性谵妄7例。单因素分析显示,年龄、糖尿病史、脑梗死史、动脉夹层病史、冠心病、手术持续时间、术中最低动脉压、ICU持续时间、术后最低氧合指数及机械通气时间为A型主动脉夹层术患者术后谵妄的相关影响因素(P<0.05);多因素logistic回归分析结果显示,年龄、脑梗死史、ICU持续时间、术后最低氧合指数及机械通气时间均为A型主动脉夹层术患者术后谵妄的独立危险因素。结论通过对A型主动脉夹层术患者术后谵妄的相关影响因素进行早期识别和分析,临床可采取相应的护理措施,提升患者预后及康复进程,能降低术后谵妄的发生概率。     

急性Stanford A型主动脉夹层手术患者术中压力性损伤标准护理方案的构建

目的:构建急性Stanford A型主动脉夹层手术患者术中压力性损伤预防的标准护理方案。方法:2020年1—6月在文献检索、文献综述以及案例回顾总结急性主动脉夹层患者术中压力性损伤发生、发展的临床特征基础上,初步构建急性Stanford A型主动脉夹层手术患者术中压力性损伤患者预防的标准护理方案,采用德尔菲法对8名护理专家进行2轮咨询,对各项措施进行评分、修订并最终完成完整的干预方案。结果:2轮专家咨询问卷回收率均为100%;2轮函询专家权威系数分别为0.79、0.83。构建一套完整的急性Stanford A型主动脉夹层手术患者术中压力性损伤标准护理方案,包括3个维度、11项护理措施与26个条目。结论:本研究构建的急性Stanford A型主动脉夹层手术患者术中压力性损伤患者预防的标准护理方案的专家积极性和权威程度高,所形成的条目能很好地满足患者的护理需求,可以为此类手术患者术中压力性损的预防提供指导意见。     

Headache as the initial manifestation of acute aortic dissection type A

The most common initial symptom of aortic dissection is chest pain. Other initial symptoms include pain in the neck, throat, abdomen and lower back, syncope, paresis, and dyspnoea. Headache as the initial symptom of aortic dissection has not been described previously. A 61-year-old woman with a history of migraine and arterial hypertension developed continuous bifrontal headache. Two hours later, right-sided thoracic pain and a diastolic murmur were suggestive of aortic dissection that was confirmed by echocardiography and subsequent surgery. The dissection commenced in the ascending aorta and involved all cervical arteries until the base of the skull. Headache as the initial manifestation of aortic dissection was assumed due to either vessel distension or pericarotid plexus ischemia. Aortic dissection has to he considered as a rare differential diagnosis of frontal headache, especially in patients who develop aortic regurgitation or chest pain for the first time.     

Asymptomatic dissection of the ascending aorta: diagnosis by transesophageal echocardiography

A young man with marfanoid habitus underwent transesophageal echocardiography to evaluate an aortic root abnormality visualized on transthoracic echocardiography. Transesophageal echo demonstrated a type A aortic dissection traversing across the right sinus of Valsalva but not involving the aortic valve, right coronary artery, or pericardial sac. The aorta was not dilated. This is apparently the first reported case of an asymptomatic and uncomplicated aortic dissection localized to the sinus of Valsalva.     

Emergency repair of aortic dissection in a 37-week parturient: a case report

Aortic dissection is a life-threatening condition with a 50% mortality rate in the first 48 hours and a 3-month mortality rate of 90% in untreated patients. Aortic dissection is a rare complication of pregnancy, but there is significant morbidity and mortality for the mother and infant. A 43-year-old woman with a 37-week intrauterine pregnancy was admitted to the emergency department 6 hours after the onset of tightness in her throat and neck pain. She described the pain as similar to pain she experienced with a myocardial infarction 2 years previously. Other pertinent history included hypertension, gestational diabetes, coronary artery disease, and a family history of aortic dissection. The patient was initially misdiagnosed. Transthoracic echocardio-" gram and computed tomography scan revealed a type A thoracic aortic dissection extending into the abdominal aorta. An emergency aortic repair and cesarean section were successfully performed. Recognition of aortic dissection and an evidence-based, collaborative approach to optimize treatment and recovery are vital to the patient's survival. The purpose of this article is to highlight successful management of aortic dissection in a parturient and to broaden the body of literature on the topic.     

胸主动脉夹层26例的手术治疗

目的总结26例各型胸主动脉夹层的手术治疗经验。方法2008年8月至2012年6月手术治疗26例胸主动脉夹层患者,男22例,女4例,年龄36～69岁,平均（51．1±12．9）岁。Stanford分型：A型10例,B型16例。A型中行升主动脉及全弓置换加术中象鼻支架植入术6例,Bentall术1例,升主动脉置换术3例;B型中行降主动脉置换术2例,降主动脉覆膜支架腔内隔绝术（EVGE）14例（其中1例2d后再行腹主动脉置换术）。6例全弓置换脑保护采用深低温停循环（DHCA）加上腔静脉逆行灌注（RCP）,1例降主动脉置换下半身供血采用左心转流。术后定期复查CTA。结果10例StandfordA型患者死亡2例（20％）,1例术中死于鱼精蛋白反应后大出血,另1例术中出血多,术后第1天死于多脏器衰竭,余治愈出院。16例B型患者死亡1例（6．2％）,死于大出血,余均治愈出院。术后CTA显示人工血管血流通畅,支架系统位置良好,无内漏,主动脉真腔较术前明显扩大,未闭的假腔血栓形成。结论手术是挽救主动脉夹层患者的重要手段,手术方式应根据破口特点及主动脉及其瓣膜具体情况来选择。全弓置换采用DHCA＋RCP脑保护效果良好。采用EVGE治疗StandfordB型夹层手术时间短、创伤小、效果佳。     

主动脉夹层的临床病理特点及CT临床诊断

目的分析主动脉夹层的临床特征、病因及CT对主动脉夹层的临床诊断。方法对我院收治的57例主动脉夹层患者资料进行回顾性分析,总结主动脉夹层的临床病理特点,并对CT平扫和CT血管成像扫描检查主动脉夹层结果进行对比。结果主动脉夹层患者临床症状主要表现为突发性疼痛52例(91.2%)以及高血压48例(84.2%),57例患者中Stanford A型39例,Stanford B型18例,DebakeyⅠ、Ⅱ型27例,DebakeyⅢ型30例;CT血管成像的检出率显著高于CT平扫检出率(χ2=4.940,P0.05)。结论主动脉夹层是以一种高致死性疾病,高血压可能为其主要诱发因素,CT平扫及CT增强扫描有较高的敏感性和特异性,能够对主动脉夹层进行快速准确的诊断。     

54例主动脉夹层临床分析

目的：探讨主动脉夹层的易患因素、临床特点、诊断方法、治疗厦预后，提高对该病的认识。方法：回顾性分析54倒主动脉夹层分离患者的临床资料。结果：剧烈疼痛是最主要的首发症状（91％）、MRI成像检查诊断准确性最高（100％），药物治疗A型病死率（53％）高于B型（8％）。结论：快速、及时、有效的诊断和治疗是提高生存率的关键。     

Headache: an unusual presentation of aortic dissection.

The most common presenting symptom of aortic dissection is chest pain - headache as the initial manifestation is rare. We report a patient with a history of hypertension who presented with severe bifrontal headache, and was found to have an acute aortic dissection in the absence of carotid artery dissection. A discussion of the atypical presentation and possible pathophysiology follows.