Endovascular stent-graft placement in aortic dissection: a meta-analysis.

AIMS: This article summarizes all available published data with respect to clinical success, complications, and outcomes of endovascular stent-graft placement among patients with descending aortic dissection (AD). METHODS AND RESULTS: We performed a meta-analysis of all published series on retrograde endovascular stent-graft placement encompassing >or=3 patients with AD. Thirty-nine studies, involving a total of 609 patients, were included. Procedural success was reported in 98.2+/-0.5% of patients. Major complications were reported in 11.1+/-1.4%, with the most dreaded neurologic complications in 2.9+/-0.7% patients. Periprocedural stroke was encountered more frequently than paraplegia (1.9+/-0.6% vs. 0.8+/-0.4%). Overall complications were significantly higher in patients undergoing stent-graft placement for acute AD than in patients with chronic AD (21.7+/-2.8% vs. 9.1+/-2.3%, P=0.005). The overall 30-day mortality was 5.3+/-0.9%, and was three-fold higher in patients with acute AD when compared with chronic AD (9.8+/-2.2% vs. 3.2+/-1.4%, P=0.015). In addition, 2.8+/-0.7% of patients died over a mean follow-up period of 19.5+/-7.1 months. Kaplan-Meier analysis yielded overall survival rates of 90.6+/-1.6% at 6 months, 89.9+/-1.7% at 1 year, and 88.8+/-1.9% at 2 years, respectively. CONCLUSION: Endovascular stent-graft placement in type B-AD is technically feasible with success rates of >95% in selected cohort. Although minimally invasive, major complications occurred in 14-18% of patients depending upon the acuity of presentation, with very low incidence of paraplegia. Both, acute and mid-term mortality of this novel treatment strategy appear to favourably compare with surgical treatment but further studies are necessary to compare stent-graft placement with medical treatment in uncomplicated AD.     

番茄红素对兔动脉粥样硬化形成和氧化损伤的影响

目的观察番茄红素对兔实验性动脉粥样硬化形成和氧化损伤的影响。方法采用高胆固醇喂饲模型;将21只新西兰家兔随机分为3组:对照组、高脂组和番茄红素组,分别给予普通饲料和高胆固醇饮食喂养,番茄红素组另加用番茄红素;于实验开始前1天和开始后第4、8、10周末取空腹血,测定血清超氧化物歧化酶活性、丙二醛含量。第10周末,测定血清一氧化氮合酶活性及一氧化氮含量。实验结束后,观察主动脉血管病理变化。结果与高脂组相比,番茄红素组主动脉脂质斑块面积减少;血超氧化物歧化酶活性明显增加;血清丙二醛含量减少,一氧化氮含量增加。结论研究结果提示,番茄红素具有较好的抗动脉粥样硬化作用,抗氧化损伤及保护血管内皮功能可能是番茄红素产生抗动脉粥样硬化作用的重要机制之一。     

Advanced atherosclerosis is associated with increased medial degeneration in sporadic ascending aortic aneurysms

Objective

The pathogenesis of non-familial, sporadic ascending aortic aneurysms (SAAA) is poorly understood, and the relationship between ascending aortic atherosclerosis and medial degeneration is unclear. We evaluated the prevalence and severity of aortic atherosclerosis and its association with medial degeneration in SAAA.

Methods and results

Atherosclerosis was characterized in ascending aortic tissues collected from 68 SAAA patients (mean age, 62.9 ± 12.0 years) and 15 controls (mean age, 56.6 ± 11.4 years [P = 0.07]) by using a modified American Heart Association classification system. Upon histologic examination, 97% of SAAA patients and 73% of controls showed atherosclerotic changes. Most SAAA samples had intermediate (types 2 and 3, 35%) or advanced atherosclerosis (types ≥ 4; 40%), whereas most control samples showed minimal atherosclerosis (none or type 1, 80%; P < 0.001 after adjusting for age). In a separate analysis, we examined the total incidence and grade distribution of medial degenerative changes among SAAA samples according to atherosclerosis grade. Advanced atherosclerosis was associated with higher grades of smooth muscle cell depletion (P < 0.001), elastic fiber depletion (P = 0.02), elastic fiber fragmentation (P < 0.001), and mucopolysaccharide accumulation (P = 0.04). Aortic diameter was larger in SAAA patients with advanced atherosclerosis than in patients with minimal (P = 0.04) or intermediate atherosclerosis (P = 0.04). Immunostaining showed marked CD3+ T-cell and CD68+ macrophage infiltration, MMP-2 and MMP-9 production, and cryopyrin expression in the medial layer adjacent to atherosclerotic plaque.

Conclusions

SAAA tissues exhibited advanced atherosclerosis that was associated with severe medial degeneration and increased aortic diameter. Our findings suggest a role for atherosclerosis in the progression of sporadic ascending aortic aneurysms.     

胸主动脉夹层相关的危险因素认识现状

胸主动脉夹层是一种病情变化快的灾难性疾病,其特点是发病急、病情复杂、急诊诊断困难、进展迅速、误诊率高、病死率高、易引起医疗纠纷.即便如此,形成胸主动脉夹层详细的原因还不明确,许多危险因素与胸主动脉夹层的发生有关,包括高血压、性别(男性)、主动脉的正常老化、吸食毒品、动脉粥样硬化、遗传性疾病和炎性疾病等.     

胎儿超声心动图检查定量11~17周正常胎儿主动脉和肺动脉内径Z-评分的初步研究

目的探讨早孕期（11^＋0周~13^＋6周）和中孕早期（14^＋0周~17^＋6周）胎儿主动脉内径（AO）与肺动脉内径（PA）与胎儿生物学生长参数的相关性,初步建立早孕期和中孕早期胎儿AO与PA的正常参考值范围及Z-评分方程,并评价方程的有效性。 方法随机选取孕周（GA）为（11^＋0周~17^＋6周）正常单胎胎儿270例,将成功显示左、右心室流出道切面的245例胎儿纳入研究,获得胎儿顶臀径（CRL）、双顶径（BPD）、股骨长径（FL）、孕周（GA）等生物学生长参数。在胎儿左、右心室流出道切面测量收缩末期AO及PA,以GA、BPD和FL作为独立自变量,AO及PA作为因变量,建立AO、PA的正常参考值范围,并对每个参数的绝对残差（SD）进行加权回归,建立Z-评分方程。 结果采用简单的线性回归模型,可以很好地描述AO和PA与非心脏生物特征参数（BPD、FL、GA）的关系。AO、PA与GA、BPD、FL均呈显著线性相关（GA与AO：r=0.9276,GA与PA：r=0.9271,BPD与AO：r=0.9551,BPD与PA：r=0.9558,FL与AO：r=0.9462,FL与PA：r=0.9483,均<0.001）,其中与BPD的相关性最强。 结论正常早孕期及中孕早期胎儿的AO、PA随着孕周的增加而增长,本研究初步建立了正常胎儿早孕期及中孕早期AO、PA的参考范围及其Z-评分方程。为早孕期及中孕早期评估胎儿大血管生长提供精确的参考标准,在早期筛查或诊断胎儿先天性心脏畸形方面具有潜在的应用价值。     

口服L-精氨酸对腹主动脉缩窄后大鼠血压、心肌肥厚和血管舒张功能的影响

本文利用缩窄大鼠腹主动脉的方法制备高血压模型，观察了正常大鼠、未服和口服Ｌ－精氨酸两周的腹主动脉狭窄的大鼠的血压、心肌肥厚及血管舒张功能的改变，旨在了解Ｌ－精氨酸对腹主动脉缩窄性高血压大鼠的作用。研究发现腹主动脉狭窄后大鼠发生了严重的高血压及心肌肥厚。未服Ｌ－精氨酸的大鼠心肌肥厚，且血管环对１０－８～１０－５ｍｏｌ／Ｌ乙酰胆碱诱导的舒张反应明显减低；而Ｌ－精氨酸口服治疗两周能减轻其心肌肥厚，并部分改善乙酰胆碱诱导的血管舒张功能，但两组大鼠腹主动脉缩窄后的血压均升高，两者相比较差别无统计学意义（Ｐ＞０．０５）。结果提示：Ｌ－精氨酸（１０－５～１０－３ｍｏｌ／Ｌ）有直接舒张该大鼠血管环的作用，且呈剂量依赖关系，长期口服Ｌ－精氨酸可减轻腹主动脉缩窄性大鼠的心肌肥厚，改善其血管的舒张功能，而其血压的变化与上述作用无关。     

高血压病患者血清载脂蛋白与主动脉壁厚度和视网膜动脉硬化的关系

从住院的高血压病患者中选择高脂血症者７６例（高脂组），血脂正常者５２例（对照组）。同时进行血清载脂蛋白（ａｐｏ）、主动脉壁厚度（ＡＷＴ）及眼底检查。结果：与对照组比较，高脂组血清ａｐｏＢ、ＡＷＴ、视网膜动脉硬化（ＲＡＳ）程度及冠心病患病率均显著增加，ａｐｏＡＩ及ａｐｏＡＩ／ａｐｏＢ均显著降低。相关分析显示，ＡＷＴ与ＲＡＳ呈正相关；ＡＷＴ和ＲＡＳ各自与ａｐｏＢ呈正相关，与ａｐｏＡＩ、ａｐｏＡＩ／ａｐｏＢ呈负相关（均Ｐ＜０．０１）。经逐步回归，筛选对ＡＷＴ和ＲＡＳ有显著作用的血脂指标均为ａｐｏＡＩ／ａｐｏＢ。提示ａｐｏＡＩ／ａｐｏＢ是反映Ａｓ疾病较可靠的血脂指标。     

糖尿病大鼠糖基化终产物与主动脉细胞外基质成分的关系

为探讨糖基化终产物在糖尿病大鼠动脉粥样硬化发生中对主动脉细胞外基质成分生成增加所起的作用,本实验将糖尿病大鼠、糖尿病＋ 氨基胍治疗大鼠和正常大鼠分别喂养１、２、３ 和４ 个月后,测定其血红蛋白－ 糖基化终产物及主动脉壁Ⅲ型前胶原、Ⅳ型胶原、Ⅳ型胶原－ 糖基化终产物及层粘蛋白含量。结果发现,糖尿病组大鼠各时相点血红蛋白－ 糖基化终产物（１ ～４ 个月分别为６．８８±１ ．２３、１０ ．２６±０．６３、１５．３±１．４９ 和１８．５７ ±２．９０ ｋｕｇ, 与血糖水平相关）、Ⅲ型前胶原（１ ～４个月分别为１５．２０±３．０３ 、２１．４４ ±１．７９、２７．１９±３ ．２８ 和３３．９９±４ ．９６ μｇＬ, 与血红蛋白－ 糖基化终产物和Ⅳ型胶原－ 糖基化终产物相关） 、Ⅳ型胶原（１～４ 个月分别为２３．６７±１．４９、３０．３７ ±２ ．８６、３６．６５ ±１．９８ 和４５．４６±５．７７ μｇＬ, 与血红蛋白－ 糖基化终产物和Ⅳ型胶原－ 糖基化终产物相关）、Ⅳ型胶原－ 糖基化终产物（１～４ 个月分别为０．７９ ±０．１５、１．２５ ±０．２２ 、１．５４ ±０．０６ 和１．８０±０ ．１４ Ｍｕｇ, 与血红蛋白－ 糖基化终产物和Ⅳ型胶原相关）      

单中心覆膜支架主动脉腔内修复术226例临床分析

目的 探讨单中心 主动脉疾病腔内修复术的安全性和有效性。方法 回顾分析2003年-11月至2017年-06月行腔内修复术的226例主动脉疾病患者,分析其临床腔内修复术的病种、围术期特点、左锁骨下动脉的处理方式、及近、远期疗效和严重并发症。采用覆膜支架主动脉腔内隔绝术治疗226例主动脉疾病患者,其中男185例,女41例;年龄16～83(48．12&amp;amp;#177;11．73)岁。病种：Stanford B型主动脉夹层 170例,主动脉穿透性溃疡：32 例,主动脉B型壁间血肿 18例,创伤性主动脉峡部假性动脉瘤 6例。术后随访3～60(12．64&amp;amp;#177;10.32)个月,分析其临床特点及疗效。结果 226例患者均行腔内修复术,手术时间(2&amp;amp;#177;1．03)h,术中失血量(150&amp;amp;#177;30．13)ml,术后住院时间(11&amp;amp;#177;3．52)d;手术成功率：100%。共植入支架 232枚, 其中6例采用两段式技术置入双支架。平均近端支架直径（37.6&amp;amp;#177;3.1）mm,平均支架长度（149.7&amp;amp;#177;25.6）cm。完全封堵左锁骨下动脉 13例,部分封堵左锁骨下动脉26例,采取烟囱技术保留左锁骨下动脉24例。急诊腋动脉-腋动脉转流2例。支架释放后少许残余内漏17例。术后6—9个月复查内漏消失;合并严重的冠心病患者于腔内修复术后5-7天 行冠状动脉支架置入术（PCI）5例。住院患者死亡2例。1例死于高血压脑出血,1例死于冠心病急性心肌梗死。在院期间无截瘫、脑卒中等并发症。中位随访48月,平均随访率84.3%。随访期间出现：慢性肾功能衰竭2例,因再发夹层或支架远端破裂再次行腔内修复术2例。支架近端逆斯至Stanford A型主动脉夹层3例,因经济情况保守治疗2例,1例死亡。其余病例恢复良好。结论 覆膜支架腔内修复术是治疗Stanford B型主动脉夹层及相关疾病的有效方法,具有微创,失血量小,严重并发症少,住院时间短,术后恢复快等优点,随访远期效果良好。     

成人先天性主动脉缩窄临床特征分析

目的总结成人先天性主动脉缩窄患者的临床特征。资料与方法回顾分析2009年1月至2012年11月在阜外心血管病医院住院治疗的85例年龄大于14岁的先天性主动脉缩窄患者的临床特征。结果平均年龄(25.9±9.9)岁,其中74.1%患者既往有高血压病史,最高血压达到(191.0±26.8/101.7±22.4)mmHg(1mmHg=0.133kPa),合并其他先天性心血管疾病的占69.4%,39.5%的患者接受了外科手术治疗。37.2%的患者接受了介入治疗。结论成人主动脉缩窄患者多因不明原因的高血压而发现,易造成多种高血压并发症,且多合并其他先天性心血管异常,详细的体格检查,测量四肢血压有助于尽早诊断,自然预后差,一旦发现,应尽早进行介入或外科治疗。