von Kodolitsch Y, Nienaber C A
Universitätskrankenhaus Eppendorf, Abteilung für Kardiologie, Hamburg.
Z Kardiol. 1998 Dec;87(12):917-27. doi: 10.1007/s003920050248.
Penetrating aortic ulcers (PAU) result from progressive erosion of atheromatose plaques perforating the internal elastic lamina. PAU is considered both a predisposing condition and differential diagnosis of classic aortic dissection; 93 cases of PAU are documented in the world literature, 60% of which are male over 60 years old. Systemic hypertension was prevalent in 85%, history of smoking in 72%, hyperlipoproteinemia in 35%, and diabetes mellitus in 31%. In 61%, PAU was associated with coronary artery disease, in 53% with abdominal or thoracic aortic aneurysm, in 31% with chronic renal insufficiency, in 17% with peripheral artery disease, and in 12% with a history of cerebrovascular accidents. In 73%, PAU was associated with formation of medial hematoma and in 16% with a thick, calcified intimal flap of less than 10 cm extent. Angiography, computed tomography, magnetic resonance imaging and transesophageal echocardiography were used in 66, 64, 23 and 14%, respectively, for diagnosing PAU; sensitivities for demonstrating PAU were 83, 65, 86 and 61%, respectively. Chest or back pain was found in 76% and an acute onset of symptoms in 68%. Signs of mediastinal widening were found in 59%, neurologic signs comprising hoarseness, syncope or coma in 8%, pulse differentials caused by embolism in 4%, aortic regurgitation in 7%, and mediastinal hematoma, pleural- or pericardial effusion in 42, 27 and 10%, respectively. PAU of the ascending aorta or aortic arch (type A) leads to dissection and rupture in 57%, compared to 12% and 5%, respectively, in the descending aorta (type B); 57% of medically managed type A PAU patients died within 30 d of hospital admission compared to only 14% of type B PAU with 20 cases of uncomplicated long-term outcome without surgery. Thus, similar to the Stanford classification for aortic dissection, type A PAU should primarily be considered for surgical management, whereas type B PAU without signs of instability may be managed medically.
穿透性主动脉溃疡（PAU）是由穿透内弹力层的动脉粥样硬化斑块进行性侵蚀所致。PAU被认为是经典主动脉夹层的一种易患疾病和鉴别诊断；世界文献中记录了93例PAU，其中60%为60岁以上男性。85%的患者有系统性高血压，72%有吸烟史，35%有高脂蛋白血症，31%有糖尿病。61%的PAU与冠状动脉疾病相关，53%与腹主动脉或胸主动脉瘤相关，31%与慢性肾功能不全相关，17%与外周动脉疾病相关，12%有脑血管意外病史。73%的PAU与中层血肿形成相关，16%与厚度小于10 cm的增厚、钙化内膜瓣相关。分别有66%、64%、23%和14%的患者使用血管造影、计算机断层扫描、磁共振成像和经食管超声心动图来诊断PAU；显示PAU的敏感性分别为83%、65%、86%和61%。76%的患者有胸痛或背痛，68%症状急性发作。59%的患者有纵隔增宽体征，8%有包括声音嘶哑、晕厥或昏迷在内的神经体征，4%有栓塞引起的脉搏差异，7%有主动脉瓣反流，42%、27%和10%的患者分别有纵隔血肿、胸腔或心包积液。升主动脉或主动脉弓部的PAU（A型）导致夹层和破裂的发生率为57%，而降主动脉（B型）分别为12%和5%；药物治疗的A型PAU患者中有57%在入院后30天内死亡，相比之下，B型PAU仅为14%，有20例未经手术的长期预后良好。因此，与主动脉夹层的斯坦福分类相似，A型PAU应主要考虑手术治疗，而无不稳定体征的B型PAU可进行药物治疗。
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