主动脉夹层239例临床分析
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摘要
目的:探讨主动脉夹层(AD)患者的基本情况、临床特征、误诊及辅助检查对诊断的意义和治疗情况。方法:对我院239例确诊为AD的临床资料做回顾性分析。结果:高血压是导致AD发生的常见原因,AD患者临床表现多样,胸痛为常见首发表现,部分病例以并发症为首发,以心肌梗塞为首发表现的夹层破口多位于升主动脉,以肩背部为首发疼痛累及腰腹或下肢者,夹层破口多位于降主动脉.部分患者亦合并心包积液、胸腔积液、主动脉瓣关闭不全等。超声, CT和MRI三种辅助检查各有缺点,三者联合应用有利于快速诊断和定位,以减少病死率,其中超声检查因为其准确率较高,价格便宜,技术要求不高,故有疑诊病人,常规做超声。AD的治疗现在有内科保守治疗,外科手术治疗和新兴的血管内带膜支架治疗,其中后者显示了很好的前景。结论:高血压是AD的主要危险因素,其临床表现复杂多变,误诊率高,患者的症状与夹层破口有一定的关系。正确诊断和积极的内科治疗以及根据患者分型和病情采取外科手术、介入治疗可减少病死率和改善患者的预后。
Objetives: To explor the basiec charaeteristies,clinieal features,misdiagosis examination methords of aortia dissectiao(AD) and treatment of aortic dissection (AD). Methods: Retrospective analysis of clinical records of 239 patientes with AD. Results: Hypertension was the most important caust of AD,The symptoms and physical signs of the 239 AD patients were diverse,chest pain was a common initial symptoms but some pations initial symptoms were atypical. Some patients with AD had complications such as pericardial effusion,pleural effusion,aortic regurgitation and so on. The echocardiography CT and MRI had their characters. But the combinon of them may help to make rapid diagnosis.We find the echocardimgraohy was the best examination methods for its cheap prise and better accur .There are Surgery,interventional stenting or medial therapy for AD,in whidh the interventing had good applied perspective. Conclusion: Hypertension was the most important cause of AD. Symptoms of AD are complicated and variable, resulting in a high misdiagnosis rate .clinical symptom had some relationship with the origin of AD.surgery,interventional stenting or medical therapy for AD depends on accurate diagnosis, actiue medical therapy or the types of AD .
Objetives: To explor the basiec charaeteristies,clinieal features,misdiagosis examination methords of aortia dissectiao(AD) and treatment of aortic dissection (AD). Methods: Retrospective analysis of clinical records of 239 patientes with AD. Results: Hypertension was the most important caust of AD,The symptoms and physical signs of the 239 AD patients were diverse,chest pain was a common initial symptoms but some pations initial symptoms were atypical. Some patients with AD had complications such as pericardial effusion,pleural effusion,aortic regurgitation and so on. The echocardiography CT and MRI had their characters. But the combinon of them may help to make rapid diagnosis.We find the echocardimgraohy was the best examination methods for its cheap prise and better accur .There are Surgery,interventional stenting or medial therapy for AD,in whidh the interventing had good applied perspective. Conclusion: Hypertension was the most important cause of AD. Symptoms of AD are complicated and variable, resulting in a high misdiagnosis rate .clinical symptom had some relationship with the origin of AD.surgery,interventional stenting or medical therapy for AD depends on accurate diagnosis, actiue medical therapy or the types of AD .
引文
[1]陈濒珠,廖履坦,杨秉辉等实用内科学第12版,人民卫生出版社,1593-1597.
[2] Meszarosl, MoroezJ, SxlaviJ, etal.Epidemiology and clinicoPathology of aortic disseetion.Chest, 2000, l17(5): 1271-1278.
[3] Von kodolitsch Y, Aydin MA, Loose R, et al. predictors of aneurysm formation afrer sugery of aortic coarctation[J]. Amcollcardiol, 2002, 39(4): 617-624.
[4] Meszarosl, MoroezJ, SxlaviJ, etal.Epidemiology and cliniocpathology of aortic disseetion.Chest, 2000, 117: 1271-1278.
[5] NeriE, SassiC, MassettiM, etal.Nonoeelusive intestinal isehemia inpatie nts with acutic aortie disseetion.vaseSurg, 2002, 36(4):738-745.
[6] AnerJ, BerentR, EherB.Aortic disseetion:ineidenee, natural history and inpact of surgery. Clin Basic Cardial 2000, 3151-154.
[7] Crwaofrd ES, CoselliJS, SvenssonLG, etal.Diffuse naeurysmal disease and multiple aneurysm Ann Surg, 1990, 211:521-537.
[8]张宗军,卢光明.双源CT及其临床应用[J].医学研究生学报, 2007, 20(4): 16-418.
[9] NeriE, SassiC, MassettiM, etal.Nonoeelusiveintestinalisehemiain Patientswithae, eaortiedisseetion.vaseSurg, 2002, 36(4):738-745.
[10] AnerJ, Berent R, EherB.Aortic dinssection:incidence, natural history and impact of surgery.Clin Basic Cardial 2000, 3:151-154.
[11] Crawford ES, CoselliJS, Svensson LG, etal.Diffuse aneurismal disease and multiple aneurysm.Ann Surg, 1990, 211:521-537.
[12] Fann, JL, Sarris, GE, Mitehell, RS, etal Treatment of Patients with aortic disseetion presenting with peripheral vaseular comPlications.AnnSurg, 1992, 212-705.
[13] Lin AE, LippeB, Rosenfeld RG.Further delineation of aortic dilation, disseetion and rupture in patients with Turner syndrome.Pediatries, 1998, 102:e12
[14] AngourasD, Sokolis DP, DosiosT, etal Effeet of impaired vasavasorum flow on the stueture and meehanics of the thoraeic aorta:implieations for the Pathogenesis of aortie disseetion.EurJCardiethoraeSurg, 200, 17:468-473.
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[17] Meszarosl, MoroezJ, SxlaviJ, etal.Epidemiology and diniocpathology of aortic disseetion.Chest, 2000, 117:1271-1278.
[18] Reinhard DP.OnoRN.Notbohm, et al.Mutations in calcium-binding epidermal growth factor moduls render fibrillin-1 susceptible to proteolysis[J].J Biol Chem, 2000, 275(16):12339-12345.
[19] Dean JC.Management of Marfan syndrome.Heart, 2002.88:97-103.
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[21]布朗威,陈颧珠.心脏病学.北京:人民卫生出版社, 1999, 1408-1415.
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[34] Strauch JT, BohmeY, FrankeUF, etal. Selective cerebralperfusion via right axillary artery direct cannulation for aortic arch surgery[J]. Thorac Cardiovasc Surg, 2005,53(6): 334-340.
[35] DakeMD, NoriyukiK, MitchellS, etal. Endovascular stent-graft placement for the treatmentofacute aortic dissection[J]. NewEngl JMed, 1999, 340: 1546-1552.
[36] Fleck T, Hutschala D, Czemy M, et al . Comdined surgical and endovascular treatment of acute aortic dissection typy A; preliminary results[J] Ann Thorac Surg, 2002, 74(3);761-766
[37]许尚栋,郑斯宏,等.食管超声引导覆膜支架介入治疗胸主动脉夹层[J].中华内科杂志, 2004, 43(1):26-28.
[38]雅邵芳,卢占兴,等.带膜支架腔内修复治疗胸主动脉夹层动脉瘤[J].实用诊断与治疗杂志, 2006, 20(10):758-759.
[39] Shimono T, Kato N, Mitchell RS, et al. Endovascular stent-graft Placement for the treatments of acute onset and chronic aortic dissections[J]. Circulation, 2002, 22(6):891-897.
[40] Nienaber CA, Fattori R, Lund G, et al. Nonsurgical neconstruction of horacic aortic dissection by stent-grafPlacement[J]. N Engl J Med, 1999, 340(20):1539-1545.
[41] Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection[J].N Engl J Med, 1999, 340(20):1546-1552.
[42]常谦,孙立忠,朱俊明等。DBeakeyⅢ型主动脉夹层的外科治疗.中华外科杂志, 2002, 10:740-742.
[43] Sorokin VA, ChongCF, Lee CN, et al. Combined open and en-dovascular repair of acute typeA aortic dissection[J]. Ann ThoracSurg, 2007, 83(2): 666-668.
[44]孙立忠,刘志刚,常谦,等.主动脉弓替换加支架“象鼻”手术治疗Stanford A型主动脉夹层[J].中华外科杂志, 2004, 42(13): 812-816.
[45]孙立忠,常谦,胡晓鹏,等.一期次全或全主动脉替换术的临床应用[J].中华外科杂志, 2005, 43(22): 1425-1428.
[46] DakeMD, KatoN, MithehellRS, Etal Endovaseular stent graft Plaeement for the treatment of acute aortic disseetion.NEnglJMed, 1999, 340:1546-1552.
[47] NienaberCA, FattoriR, LundG, etal .Nonsurgieal reeonstruetion of thoracicaortiedisseeion by stent graft placement. N Engl J med, 1999. 340: 1539-1545
[48] SlonimSM, MillerDC, MitehellRS, etal.Pereutaneous balloon fenestration and stenting for life threatenning isehemic co1ieations in Patients with acute aortie disseetion.JThorae Cardiovase Surg, 1999, 117:1118.
[49] Dorros G, Dorros AM, Planton S, et al. Transseptal guidewire stabilization facilitatesstent–garft deplpyment for persistent proximal ascending aortic dissdection [J]. J Endovas Ther, 2000, 71(6); 506-512.
[50] Fleck T, Hutschala D, Czemy M, et al . Comdined surgical and endovascular treatment of acute aortic dissection typy A; preliminary results[J] Ann Thorac Surg, 2002, 74(3): 761-766
[51]常光其,李晓曦,李松奇,等.腔内修复联合旁路手术治疗DeBaKey I型生主动脉夹层[J].中国使用外科杂志, 2005.25(12): 741-742.
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[24] Fleck T, Hutschala D, Czemy M, et al. Comdined surgical and endovascular treatment of acute aortic dissection typy A, preliminary results[J]. Ann Thorac Surg, 2002, 74(3): 761-766
[25]常光其,李晓曦,李松奇,等.腔内修复联合旁路手术治疗DeBaKeyI型生主动脉夹层[J].中国使用外科杂志, 2005.25(12): 741-742, T0001
[2] Meszarosl, MoroezJ, SxlaviJ, etal.Epidemiology and clinicoPathology of aortic disseetion.Chest, 2000, l17(5): 1271-1278.
[3] Von kodolitsch Y, Aydin MA, Loose R, et al. predictors of aneurysm formation afrer sugery of aortic coarctation[J]. Amcollcardiol, 2002, 39(4): 617-624.
[4] Meszarosl, MoroezJ, SxlaviJ, etal.Epidemiology and cliniocpathology of aortic disseetion.Chest, 2000, 117: 1271-1278.
[5] NeriE, SassiC, MassettiM, etal.Nonoeelusive intestinal isehemia inpatie nts with acutic aortie disseetion.vaseSurg, 2002, 36(4):738-745.
[6] AnerJ, BerentR, EherB.Aortic disseetion:ineidenee, natural history and inpact of surgery. Clin Basic Cardial 2000, 3151-154.
[7] Crwaofrd ES, CoselliJS, SvenssonLG, etal.Diffuse naeurysmal disease and multiple aneurysm Ann Surg, 1990, 211:521-537.
[8]张宗军,卢光明.双源CT及其临床应用[J].医学研究生学报, 2007, 20(4): 16-418.
[9] NeriE, SassiC, MassettiM, etal.Nonoeelusiveintestinalisehemiain Patientswithae, eaortiedisseetion.vaseSurg, 2002, 36(4):738-745.
[10] AnerJ, Berent R, EherB.Aortic dinssection:incidence, natural history and impact of surgery.Clin Basic Cardial 2000, 3:151-154.
[11] Crawford ES, CoselliJS, Svensson LG, etal.Diffuse aneurismal disease and multiple aneurysm.Ann Surg, 1990, 211:521-537.
[12] Fann, JL, Sarris, GE, Mitehell, RS, etal Treatment of Patients with aortic disseetion presenting with peripheral vaseular comPlications.AnnSurg, 1992, 212-705.
[13] Lin AE, LippeB, Rosenfeld RG.Further delineation of aortic dilation, disseetion and rupture in patients with Turner syndrome.Pediatries, 1998, 102:e12
[14] AngourasD, Sokolis DP, DosiosT, etal Effeet of impaired vasavasorum flow on the stueture and meehanics of the thoraeic aorta:implieations for the Pathogenesis of aortie disseetion.EurJCardiethoraeSurg, 200, 17:468-473.
[15] MartinRB.APoPtosis in the cardiovascular system.Heart, 2002, 87:480-487.
[16] MullerBT, Modlieho, Prisaek HB, etal.Gene expression Profile in the aeutely disseeted human aorta.EurJVasc Endovasc Surg, 2002, 24:356-364.
[17] Meszarosl, MoroezJ, SxlaviJ, etal.Epidemiology and diniocpathology of aortic disseetion.Chest, 2000, 117:1271-1278.
[18] Reinhard DP.OnoRN.Notbohm, et al.Mutations in calcium-binding epidermal growth factor moduls render fibrillin-1 susceptible to proteolysis[J].J Biol Chem, 2000, 275(16):12339-12345.
[19] Dean JC.Management of Marfan syndrome.Heart, 2002.88:97-103.
[20] PerterR, vonDegessersLKAortiedisseetion[J.neet.1997, 349(93)1461.
[21]布朗威,陈颧珠.心脏病学.北京:人民卫生出版社, 1999, 1408-1415.
[22]段志泉实用血管外科学沈阳:辽宁科学技术出版社199, 9322.
[23]孙明,漆私.主动脉夹层动脉瘤的诊断与治疗进展[]l.中国医师杂志, 2001, 3(9):566.
[24] Prete R, V Segesser lk Aortic dissection lancet , 1997, 349:1461-1464.
[25] Crwaford ES.The diagnosis andmanagement of aortie disseetion.JAMA, 1990, 264:2537-2541.
[26] Suzki T, Mehta RH, Ine H, et al.Clinical profiles and outcomes ofacute type B aortic dissection in the current era:lessons from theinternational registry of aortic arch dissection(IRAD).Circulation, 2003, 18:464-470
[27]冯金华,杨茂萍,曹世平.主动脉夹层与高血压.高血压杂志, 2003, 3:251-253
[28] SPittell PC, SPittell JA, Joyee JW, etal.Clinical features and dieffrential diagnosis of aortic disseetion:experience with236 cases.MayoClin Proe, 1993, 68:642-651.
[29] astaner E, Andreu M, Gallardo X, et al. CT innontraumatic aortic disease: typical and atypical features and complications[J]. Radiographics, 2003, 23(Suppl 1):93-110.
[30] Ninaber CA, Vonkodolitsch Y, Nicolas V, et al.The diagnosisof thoracic dissection by noninvasive imaging procedures.N Engl JMed, 1993, 328:1-9.
[31] Iarussi D, Caruso A, Galderisi M, et al.Association of left ventricular hypertrophy and aortic dilation in patients with acutethoracic aortic dissection[J].Angiology, 2001, 52(7):447-455.
[32] Fikar CR, Koch S.Etiologic factors of acute aortic dissection in children and young adults[J].Clin Pediatr(Phila), 2000, 39(2):71-78.
[33] Coselli JS, Bozinovski J, LeMaire SA. Open surgical repair of 2286 thoracoabdominal aortic aneurysms[J]. Ann Thorac Surg, 2007, 83(2): 862-864.
[34] Strauch JT, BohmeY, FrankeUF, etal. Selective cerebralperfusion via right axillary artery direct cannulation for aortic arch surgery[J]. Thorac Cardiovasc Surg, 2005,53(6): 334-340.
[35] DakeMD, NoriyukiK, MitchellS, etal. Endovascular stent-graft placement for the treatmentofacute aortic dissection[J]. NewEngl JMed, 1999, 340: 1546-1552.
[36] Fleck T, Hutschala D, Czemy M, et al . Comdined surgical and endovascular treatment of acute aortic dissection typy A; preliminary results[J] Ann Thorac Surg, 2002, 74(3);761-766
[37]许尚栋,郑斯宏,等.食管超声引导覆膜支架介入治疗胸主动脉夹层[J].中华内科杂志, 2004, 43(1):26-28.
[38]雅邵芳,卢占兴,等.带膜支架腔内修复治疗胸主动脉夹层动脉瘤[J].实用诊断与治疗杂志, 2006, 20(10):758-759.
[39] Shimono T, Kato N, Mitchell RS, et al. Endovascular stent-graft Placement for the treatments of acute onset and chronic aortic dissections[J]. Circulation, 2002, 22(6):891-897.
[40] Nienaber CA, Fattori R, Lund G, et al. Nonsurgical neconstruction of horacic aortic dissection by stent-grafPlacement[J]. N Engl J Med, 1999, 340(20):1539-1545.
[41] Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection[J].N Engl J Med, 1999, 340(20):1546-1552.
[42]常谦,孙立忠,朱俊明等。DBeakeyⅢ型主动脉夹层的外科治疗.中华外科杂志, 2002, 10:740-742.
[43] Sorokin VA, ChongCF, Lee CN, et al. Combined open and en-dovascular repair of acute typeA aortic dissection[J]. Ann ThoracSurg, 2007, 83(2): 666-668.
[44]孙立忠,刘志刚,常谦,等.主动脉弓替换加支架“象鼻”手术治疗Stanford A型主动脉夹层[J].中华外科杂志, 2004, 42(13): 812-816.
[45]孙立忠,常谦,胡晓鹏,等.一期次全或全主动脉替换术的临床应用[J].中华外科杂志, 2005, 43(22): 1425-1428.
[46] DakeMD, KatoN, MithehellRS, Etal Endovaseular stent graft Plaeement for the treatment of acute aortic disseetion.NEnglJMed, 1999, 340:1546-1552.
[47] NienaberCA, FattoriR, LundG, etal .Nonsurgieal reeonstruetion of thoracicaortiedisseeion by stent graft placement. N Engl J med, 1999. 340: 1539-1545
[48] SlonimSM, MillerDC, MitehellRS, etal.Pereutaneous balloon fenestration and stenting for life threatenning isehemic co1ieations in Patients with acute aortie disseetion.JThorae Cardiovase Surg, 1999, 117:1118.
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