急性Stanford B型主动脉夹层腔内修复术的指征和治疗时机选择

目的 探讨急性Stanford B型主动脉夹层腔内修复术的指征和治疗时机的选择.方法 对2004年2月至2008年6月收治的Stanford B型主动脉夹层464例进行分析.男性391例,女性73例;年龄26～88岁,平均56.6岁.分析导致急性主动脉夹层破裂的危险因素并评价急性组(n=298)和慢性组(n=166)的腔内治疗效果.结果 夹层破裂组中反复或持续性胸背痛和胸腔渗出的发生率(83.3%和94.4%)高于非破裂组(10.4%和14.1%,P＜0.01).破裂组降主动脉平均最大径(49.4 mm)大于非破裂组(35.1 mm,P＜0.01).合并内脏和下肢动脉缺血的病例在腔内修复术后症状体征和相关指标都得剑明显改善.急性组近端假腔消失率51.7%高于慢性组的19.5%,而远端假腔开放率59.2%低于慢性组的79.3%(P＜0.01).24例壁间血肿或假腔完全血栓形成病例中有4例出现夹层复发.结论 近端假腔持续开放的急性夹层应行腔内修复术,而壁间血肿或假腔完全血栓化的急性病例可暂予密切随访.对于有反复或持续性胸背痛、胸腔渗出和降主动脉直径＞4.5 cm等破裂先兆的病例或短时间内无法好转的主动脉分支血管缺血者,应立即行腔内修复术.

The indication and time of treatment of thoracic endovnscular aortic repair in acute Stanford B dissection

Objective To study the indication of thoracic endovascular aortic repair (TEVAR) in acute Stanford B dissection.Methods From February 2004 to June 2008,464 cases of Stanford B dissection (391 males and 73 females,age from 26 to 88 with a mean of 56.6 years) underwent TEVAR.Patients were divided into group A (acute,n=298) and group B (chronic,n=166). Risk factors of rupture were evaluated and results were compared between the two groups.Results The incidence of persistent or recurrent pain and hemothorax in ruptured patients was 83.3% and 94.4%,greater than 10.4% and 14.1% in the non-ruptured patients (P＜0.01).The mean maximal diameter of the descending thoracic aorta in the rupture group was 49.4 mm, greater than 35.1 mm in the non-rupture group (P＜0.01).Aortic branch vessel ischemia was greatly alleviated after TEVAR.Resolution of the proximal false lumen was 51.7% in group A,19.5% in group B,and the rate of patent distal false lumen was 59.2% in group A,79.3% in group B (P＜0.01). Four out of 24 cases of intramural hemotoma had recurrent dissection.Conclusions Acute dissection with a patent proximal false lumen is an indication for TEVAR. Intramural hemotoma could be given medical treatment under close follow-up. Persistent or recurrent pain,hemothorax,descending thoracic aorta greater than 4.5 cm,or aortic branch vessels ischemia warrant prompt TEVAR.