Nienaber C A, Fattori R, Lund G, Dieckmann C, Wolf W, von Kodolitsch Y, Nicolas V, Pierangeli A
Department of Cardiology, University Hospital Eppendorf, Hamburg, Germany.
N Engl J Med. 1999 May 20;340(20):1539-45. doi: 10.1056/NEJM199905203402003.
The treatment of thoracic aortic dissection is guided by prognostic and anatomical information. Proximal dissection requires surgery, but the appropriate treatment of distal thoracic aortic dissection has not been determined, because surgery has failed to improve the prognosis.
We prospectively evaluated the safety and efficacy of elective transluminal endovascular stent-graft insertion in 12 consecutive patients with descending (type B) aortic dissection and compared the results with surgery in 12 matched controls. In all 24 patients, aortic dissection was diagnosed by magnetic resonance angiography. In each group, the dissection involved the aortic arch in 3 patients and the descending thoracic aorta in all 12 patients. With the patient under general anesthesia, either surgical resection was undertaken or a custom-designed endovascular stent-graft was placed by unilateral arteriotomy.
Stent-graft placement resulted in no morbidity or mortality, whereas surgery for type B dissection was associated with four deaths (33 percent, P=0.09) and five serious adverse events (42 percent, P=0.04) within 12 months. Transluminal placement of the stent-graft prosthesis was successful in all patients, with no leakage; full expansion of the stents was ensured by balloon inflation at 2 to 3 atm. Sealing of the entry tear was monitored during the procedure by transesophageal ultrasonography and angiography, and thrombosis of the false lumen was confirmed in all 12 patients after a mean of three months by magnetic resonance imaging. There were no deaths or instances of paraplegia, stroke, embolization, side-branch occlusion, or infection in the stent-graft group; nine patients had postimplantation syndrome, with transient elevation of C-reactive protein levels and body temperature plus mild leukocytosis. All the patients who received stent-grafts recovered, as did seven patients who underwent surgery for type B dissection (58 percent) (P=0.04).
These preliminary observations suggest that elective, nonsurgical insertion of an endovascular stent-graft is safe and efficacious in selected patients who have thoracic aortic dissection and for whom surgery is indicated. Endoluminal repair may be useful for interventional reconstruction of thoracic aortic dissection.
胸主动脉夹层的治疗以预后和解剖学信息为指导。近端夹层需要手术治疗，但远端胸主动脉夹层的恰当治疗方法尚未确定，因为手术未能改善预后。
我们前瞻性评估了12例连续性降主动脉（B型）夹层患者择期经腔血管内支架移植物置入术的安全性和有效性，并将结果与12例匹配对照患者的手术结果进行比较。所有24例患者均通过磁共振血管造影诊断为主动脉夹层。每组中，3例患者夹层累及主动脉弓，所有12例患者夹层累及降主动脉。在全身麻醉下，对患者进行手术切除或通过单侧动脉切开置入定制的血管内支架移植物。
支架移植物置入未导致任何发病或死亡，而B型夹层手术在12个月内导致4例死亡（33%，P = 0.09）和5例严重不良事件（42%，P = 0.04）。支架移植物假体经腔置入在所有患者中均获成功，无渗漏；通过在2至3个大气压下球囊扩张确保支架充分展开。术中通过经食管超声心动图和血管造影监测入口撕裂的封闭情况，平均3个月后通过磁共振成像证实所有12例患者假腔均形成血栓。支架移植物组无死亡、截瘫、中风、栓塞、侧支闭塞或感染病例；9例患者出现植入后综合征，C反应蛋白水平和体温短暂升高，伴有轻度白细胞增多。所有接受支架移植物治疗的患者均康复，接受B型夹层手术的7例患者也康复（58%）（P = 0.04）。
这些初步观察结果表明，对于有胸主动脉夹层且适合手术治疗的特定患者，择期非手术置入血管内支架移植物是安全有效的。腔内修复术可能有助于胸主动脉夹层的介入重建。
