B型主动脉夹层98例报告

摘要

目的 探讨B型主动脉夹层的治疗效果,急、慢性主动脉夹层的治疗措施. 方法 2001年7月～ 2011年6月98例B型主动脉夹层(胸主动脉夹层96例,腹主动脉夹层2例；急性主动脉夹层89例,慢性9例)行胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)83例,外科手术修复1例,保守治疗10例,术前夹层动脉瘤突然破裂死亡4例.采用直型带膜支架修复80例,分支带膜支架修复3例.杂交手术7例,先行右腋动脉-左腋动脉人工血管旁路移植5例,行左颈动脉-左锁骨下动脉人工血管旁路移植2例.保守治疗的10例中,4例经1周治疗痊愈.9例慢性主动脉夹层发现夹层不断扩大,采取腔内修复治疗. 结果 83例腔内修复手术围手术期死亡2例,病死率2.4％(2/83),死亡原因:1例术后1周因心包填塞(尸检结果),1例为不明原因于术后第2天死亡,考虑为其他位置再次破裂所致；余81例术后恢复良好,无脑卒中发生.腔内手术发生Ⅰ型内漏14例(16.9％)；81例出院时夹层内血栓形成69例,12例夹层中仍可见部分血流.保守治疗的10例,6例显示夹层内血栓形成,其余变化不大.84例随访2～121个月,平均36.5月,随访率91.3％ (84/92),其中TEVAR随访75例,保守治疗随访8例,外科手术随访1例:1例腔内修复术后3个月胸降主动脉再次破裂死亡,2例Ⅰ型内漏存在,夹层不断扩大,再次放置带膜支架后消失,其余病例情况良好. 结论 急性B型主动脉夹层的治疗要积极,TEVAR为首选,可以取得比较好的疗效；慢性B型主动脉夹层应注意随访,必要时采用TEVAR治疗.%Objective To explore the therapeutic regimen and outcomes of acute and chronic type B aortic dissection. Methods Data of 98 patients with type B aortic dissection, who were treated from July 2001 to June 2011, were retrospectively analyzed. Of these patients, thoracic aortic dissection was found in 96 cases, and abdominal aortic dissection in the other 2; acute aortic dissection was diagnosed in 89 of the patients and chronic aortic dissection in the other 9. Thoracic endovascular aortic repair (TEVAR) was done in 83 patients, surgical repair in one patient, and conservative treatment was carried out in the other 10 patients. Four patients died of ruptured aortic aneurysm before operation. In the rest of the patients, we used tubular membrane-covered stent in 80 patients, and branched membrane-covered stent in 3; hybrid operation was performed on 7 patients including axillo-axillary arterial bypass in 5 patients, and left carotid-subclavian arterial bypass in 2 before endovascular treatment. In the 10 patients who received conservative treatment, 4 recovered in one week. Nine patients with chronic aortic dissection underwent endovascular repair for progressively expanded false lumen. Results Perioperative death occurred in 2 patients who received TEVAR(2. 4% ) :one patient died of pericardial tamponade ( confirmed by autopsy) one week after the endovascular repair, and the other patient died on the second postoperative day with an unidentified cause which was supposed to be a new tear in the aortic wall. Other 81 patients who received TEVAR recovered uneventfully. Type I endoleak was found in 14 of the patients (16. 9% ) ; thrombosis in the false lumen was found in 69 patients on discharge, whereas partial blood flow was still present in the false lumen in 12 patients. Six out of the 10 cases of conservative treatment had thrombosis in the false lumen. Totally 84 patients,including 75 patients who underwent endovascular repair, 8 patients who received conserving treatments,and 1 patient who had surgical repair,were followed up (91. 3% ) for 2-121 months (mean, 36. 5 months). One patient died 3 months after the endovascular repair due to rupture of the descending thoracic aorta. Progressive aortic dissection was found in 2 patients during the follow-up, which was cured with a second operation with a membrane-covered stent. Conclusions Acute type B aortic dissection should be actively treated with TEVAR as the first choice. Patients with chronic type B aortic dissection must be attentively followed up, and TEVAR shall be carried out when necessary.