胸主动脉腔内修复术对亚急性期Standford B型主动脉重塑的影响
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摘要
为了探讨胸主动脉腔内修复术(thoracic endovascular aortic repair, TEVAR)治疗亚急性期Standford B型主动脉夹层术中远端破口特点对术后主动脉重塑的影响,本研究分析了本院2011年7月至2015年4月期间Stanford B型主动脉夹层TEVAR术中支架置入封闭近端破口后,所有支架都植入成功,远端破口仍有明显造影剂返流的43例,随访跟踪术后3~24月主动脉真、假腔面积变化及血栓化情况,同时分析破口血流方向及假腔造影剂充填所需心搏数对主动脉假腔血栓的影响。结果表明:不同假腔造影剂充填所需心搏(<2和≥2)、患者术前和术后的真假腔面积变化及假腔形成率方面存在统计学差异(p<0.05),同时单因素分析显示远端破口血流溢入假腔方向对TEVAR对术后主动脉重塑无影响,但术后血压控制不佳(≥140/90 mmHg),不利于术后主动脉重塑。本研究初步结论表明,TEVAR术中支架置入封闭近端破口远端仍有破口且流速较快的患者,术后需严格控制血压并密切随访。
In order to investigate the effect of distal tears on postoperative aortic remodeling after thoracic endovascular aortic repair(TEVAR) for the patients with subacute stage of Stanford type B aortic dissection, this study analyzed the successful implantation of stents in Stanford B type aortic dissection TEVAR from July 2011 to April 2015 in our hospital. It was found that in 43 patients with surgically placed stents and closed proximal ruptures, there was still significant contrast agent reflux in the distal rupture. The area of true aortic and aortic false lumen and thrombosis in3~24 months after operation were traced. At the same time, we analyzed the effect of the direction of the blood flow and number of heart beats required for filling the false lumen contrast agent on the false lumen of the aorta. The results show that, the number of heart beats required to fill the false cavity with contrast agent was <2 and ≥2. There were significant differences in the area of true and false lumen and the rate of false lumen formation between the two groups before and after operation(p<0.05). Univariate analysis showed that the direction of distal rupture of blood flow into the false lumen had no effect on postoperative aortic remodeling(p<0.05), but postoperative hypertension(≥140/90 mm Hg)slows down the formation of false lumen thrombosis. The preliminary conclusions of this study indicate that after stent placement in TEVAR, patients with distal rupture and fast flow rate need to strictly control blood pressure and closely follow up after operation.
In order to investigate the effect of distal tears on postoperative aortic remodeling after thoracic endovascular aortic repair(TEVAR) for the patients with subacute stage of Stanford type B aortic dissection, this study analyzed the successful implantation of stents in Stanford B type aortic dissection TEVAR from July 2011 to April 2015 in our hospital. It was found that in 43 patients with surgically placed stents and closed proximal ruptures, there was still significant contrast agent reflux in the distal rupture. The area of true aortic and aortic false lumen and thrombosis in3~24 months after operation were traced. At the same time, we analyzed the effect of the direction of the blood flow and number of heart beats required for filling the false lumen contrast agent on the false lumen of the aorta. The results show that, the number of heart beats required to fill the false cavity with contrast agent was <2 and ≥2. There were significant differences in the area of true and false lumen and the rate of false lumen formation between the two groups before and after operation(p<0.05). Univariate analysis showed that the direction of distal rupture of blood flow into the false lumen had no effect on postoperative aortic remodeling(p<0.05), but postoperative hypertension(≥140/90 mm Hg)slows down the formation of false lumen thrombosis. The preliminary conclusions of this study indicate that after stent placement in TEVAR, patients with distal rupture and fast flow rate need to strictly control blood pressure and closely follow up after operation.
引文
Akgul A.,Gursoy M.,and Bakuy V.,2013,Sopntaneous triple coronary artery dissection,Ann.Thorac.Surg.,95(4):1443-1445
Alfson D.B.,and Ham S.W.,2017,Type B aortic dissections current guidelines for treatment,Cardiol.Clin.,35(4):387-410
Booher A.M.,Isselbacher E.M.,Nienaber C.A.,Trimarchi S.,Evangelista A.,Montgomery B.G.,Froehlich J.B.,Ehrlich M.P.,Oh J.K.,Januzzi J.L.,O'Gara P.,Sundt T.M.,Harris K.M.,Bossone E.,Pyeritz R.E.,and Eagle K.A.,2013,The IRADclassification system for characterizing survival after aortic dissection,Am.J.Med.,126(8):730
Hagan P.G.,Nienaber C.A.,Isselbacher E.M.,Bruckman D.,Karavite D.J.,Pamela L.,Russman P.L.,Evangelista A.,Fattori R.,Suzuki T.,Oh J.K.,Moore A.G.,Malouf J.F.,Pape L.A.,Gaca C.,Sechtem U.,Lenferink S.,Deutsch H.J.,Diedrichs H.,Robles J.M.,Llovet A.,Gilon D.,Das S.K.,Armstrong W.F.,Deeb G.M.,and Eagle K.A.,2000,The international registry of acute aortic dissection(IRAD):new insights into an old disease,JAMA,283(7):897-903
Han S.M.,Kuo E.C.,Woo K.,Elsayed R.,Nguyen B.S.,Ham S.W.,Rowe V.L.,and Weaver F.A.,2016,Remodeling of abdominal aortic branch perfusion after thoracic endovascular aortic repair for aortic dissections,J.Vasc.Surg.,64(4):902-911
Hiratzka L.F.,Bakris G.L.,Beckman J.A.,Bersin R.M.,Carr V.F.,Casey Jr.D.E.,Eagle K.A.,Hermann L.K,Isselbacher E.M.,Kazerooni E.A.,Kouchoukos N.T.,Lytle B.W.,Milewicz D.M.,Reich D.L.,Sen S.,Shinn J.A.,Svensson L.G.,and Williams D.M.,2010,ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease,J.Am.Coll.Cardiol.,55(14):e27~e129
Li J.,Dou N.,Zhang Y.J.,Fang G.,Ma Y.M.,and Bai L.,2012,A comparative study of subacute and chronic Stanford type B aortic dissection intracavitary isolation,Ningxia Yixue Zazhi(Ningxia Medical Journal),24(9):869-871(李俊,窦宁,张玉京,方刚,马彦敏,白雷,2012,亚急性和慢性Stanford B型主动脉夹层腔内隔绝术的对比研究,宁夏医学杂志,24(9):869-871)
Lombardi J.V.,Cambria R.P.,Nienaber C.A.,Chiesa R.,Mossop P.,Haulon S.,Zhou Q.,and Jia F.,2014,Aortic remodeling after endovascular treatment ofcomplicated type B aortic dissection with the useof a composite device design,J.Vasc.Surg.,59(6):1544-1554
Melissano G.,Bertoglio L.,Rinaldi E.,Civilini E.,Tshomba Y.,Kahlberg A.,Agricola E.,and Chiesa R.,2012,Volume changes in aortic true and false lumen after“PETTICOAT”procedure for type B aortic dissection,J.Vasc.Surg.,55(3):641-651
Nauta F.J.,Trimarchi S.,Kamman A.V.,Moll F.L.,van Herwaarden J.A.,Patel H.J.,Figueroa C.A.,Eagle K.A.,and Froehlich J.B.,2016,Update in the management of type B aortic dissection,Vasc.Med.,21(3):251-263
Ren H.,Ci H.B.,Fang Q.B.,Guan S.,Sai L.M.,and Ge X.H.,2014,To investigate the distribution and clinical classification of Stanford B type distal aortic dissection,Guoji Waikexue Zazhi(International Journal of Surgery),41(12):824-826(任昊,慈红波,方青波,管圣,赛力木,戈小虎,2014,探讨Stanford B型主动脉夹层远端破口的分布特点及临床分型,国际外科学杂志,41(12):824-826)
Scali S.T.,Feezor R.J.,Chang C.K.,Stone D.H.,Hess P.J.,Martin T.D.,Huber T.S.,and Beck A.W.,2013,Efficacy of thoracic endovascular stent repair for chronic type B aortic dissection with aneurysmal degeneration,J.Vasc.Surg.,58(1):10-7.e1
Alfson D.B.,and Ham S.W.,2017,Type B aortic dissections current guidelines for treatment,Cardiol.Clin.,35(4):387-410
Booher A.M.,Isselbacher E.M.,Nienaber C.A.,Trimarchi S.,Evangelista A.,Montgomery B.G.,Froehlich J.B.,Ehrlich M.P.,Oh J.K.,Januzzi J.L.,O'Gara P.,Sundt T.M.,Harris K.M.,Bossone E.,Pyeritz R.E.,and Eagle K.A.,2013,The IRADclassification system for characterizing survival after aortic dissection,Am.J.Med.,126(8):730
Hagan P.G.,Nienaber C.A.,Isselbacher E.M.,Bruckman D.,Karavite D.J.,Pamela L.,Russman P.L.,Evangelista A.,Fattori R.,Suzuki T.,Oh J.K.,Moore A.G.,Malouf J.F.,Pape L.A.,Gaca C.,Sechtem U.,Lenferink S.,Deutsch H.J.,Diedrichs H.,Robles J.M.,Llovet A.,Gilon D.,Das S.K.,Armstrong W.F.,Deeb G.M.,and Eagle K.A.,2000,The international registry of acute aortic dissection(IRAD):new insights into an old disease,JAMA,283(7):897-903
Han S.M.,Kuo E.C.,Woo K.,Elsayed R.,Nguyen B.S.,Ham S.W.,Rowe V.L.,and Weaver F.A.,2016,Remodeling of abdominal aortic branch perfusion after thoracic endovascular aortic repair for aortic dissections,J.Vasc.Surg.,64(4):902-911
Hiratzka L.F.,Bakris G.L.,Beckman J.A.,Bersin R.M.,Carr V.F.,Casey Jr.D.E.,Eagle K.A.,Hermann L.K,Isselbacher E.M.,Kazerooni E.A.,Kouchoukos N.T.,Lytle B.W.,Milewicz D.M.,Reich D.L.,Sen S.,Shinn J.A.,Svensson L.G.,and Williams D.M.,2010,ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease,J.Am.Coll.Cardiol.,55(14):e27~e129
Li J.,Dou N.,Zhang Y.J.,Fang G.,Ma Y.M.,and Bai L.,2012,A comparative study of subacute and chronic Stanford type B aortic dissection intracavitary isolation,Ningxia Yixue Zazhi(Ningxia Medical Journal),24(9):869-871(李俊,窦宁,张玉京,方刚,马彦敏,白雷,2012,亚急性和慢性Stanford B型主动脉夹层腔内隔绝术的对比研究,宁夏医学杂志,24(9):869-871)
Lombardi J.V.,Cambria R.P.,Nienaber C.A.,Chiesa R.,Mossop P.,Haulon S.,Zhou Q.,and Jia F.,2014,Aortic remodeling after endovascular treatment ofcomplicated type B aortic dissection with the useof a composite device design,J.Vasc.Surg.,59(6):1544-1554
Melissano G.,Bertoglio L.,Rinaldi E.,Civilini E.,Tshomba Y.,Kahlberg A.,Agricola E.,and Chiesa R.,2012,Volume changes in aortic true and false lumen after“PETTICOAT”procedure for type B aortic dissection,J.Vasc.Surg.,55(3):641-651
Nauta F.J.,Trimarchi S.,Kamman A.V.,Moll F.L.,van Herwaarden J.A.,Patel H.J.,Figueroa C.A.,Eagle K.A.,and Froehlich J.B.,2016,Update in the management of type B aortic dissection,Vasc.Med.,21(3):251-263
Ren H.,Ci H.B.,Fang Q.B.,Guan S.,Sai L.M.,and Ge X.H.,2014,To investigate the distribution and clinical classification of Stanford B type distal aortic dissection,Guoji Waikexue Zazhi(International Journal of Surgery),41(12):824-826(任昊,慈红波,方青波,管圣,赛力木,戈小虎,2014,探讨Stanford B型主动脉夹层远端破口的分布特点及临床分型,国际外科学杂志,41(12):824-826)
Scali S.T.,Feezor R.J.,Chang C.K.,Stone D.H.,Hess P.J.,Martin T.D.,Huber T.S.,and Beck A.W.,2013,Efficacy of thoracic endovascular stent repair for chronic type B aortic dissection with aneurysmal degeneration,J.Vasc.Surg.,58(1):10-7.e1