Umaña Juan P, Miller D Craig, Mitchell R Scott
Department of Cardiovascular and Thoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, California 94305-5247, USA.
Ann Thorac Surg. 2002 Nov;74(5):S1840-3; discussion S1857-63. doi: 10.1016/s0003-4975(02)04140-1.
Controversy continues regarding treatment for patients with acute type B aortic dissection.
One hundred eighty-nine patients with acute type B aortic dissection managed over a 36-year period were analyzed retrospectively for three outcome endpoints: survival; freedom from reoperation, and freedom from late aortic-related complications or late death. Risk factors for death were identified using a multivariable Cox proportional hazards model. Then to account for patient selection bias, heterogeneity of the population, and continuous evolution in techniques, propensity score analysis was used to identify risk-matched cohorts (quintiles I and II) in which the results of medical (n = 111) or surgical (n = 31) therapy were compared more comprehensively.
The two main determinants of death were shock (hazard ratio [HR] = 14.5, 95% confidence level [CL] 4.7, 44.5; p < 0.001) and visceral ischemia (HR = 10.9, 95% CL 3.9, 30.3; p < 0.001). Arch involvement, rupture, stroke, previous sternotomy, and coronary or lung disease roughly doubled the hazard. Female sex was also a significant but weaker independent predictor of death. Actuarial survival estimates for all patients were 71%, 60%, 35%, and 17% at 1, 5, 10, and 15 years, respectively, and were similar for the medical and surgical patients. The Marfan syndrome predicted reoperation and late aortic complications or late death. In a separate analysis of the 142 patients in quintiles I and II, survival, freedom from reoperation, as well as freedom from late aortic complications or death were almost identical in the medical and surgical subsets.
The poor long-term prognosis of patients with acute type B aortic dissection is determined primarily by dissection-related and patient-specific risk factors, which are not readily modifiable. Whether the outlook in the future will be improved using stent-grafts remains to be determined.
关于急性B型主动脉夹层患者的治疗仍存在争议。
回顾性分析189例在36年期间接受治疗的急性B型主动脉夹层患者的三个结局终点：生存；免于再次手术，以及免于晚期主动脉相关并发症或晚期死亡。使用多变量Cox比例风险模型确定死亡的危险因素。然后，为了考虑患者选择偏倚、人群异质性和技术的持续发展，采用倾向评分分析来确定风险匹配队列（第一和第二五分位数），在该队列中更全面地比较了药物治疗（n = 111）或手术治疗（n = 31）的结果。
死亡的两个主要决定因素是休克（风险比[HR] = 14.5，95%置信水平[CL] 4.7，44.5；p < 0.001）和内脏缺血（HR = 10.9，95% CL 3.9，30.3；p < 0.001）。主动脉弓受累、破裂、中风、既往胸骨切开术以及冠状动脉或肺部疾病使风险大致增加一倍。女性也是死亡的一个显著但较弱的独立预测因素。所有患者的精算生存估计在1年、5年、10年和15年分别为71%、60%、35%和17%，药物治疗和手术治疗的患者相似。马凡综合征可预测再次手术以及晚期主动脉并发症或晚期死亡。在对第一和第二五分位数的142例患者进行的单独分析中，药物治疗和手术治疗亚组的生存、免于再次手术以及免于晚期主动脉并发症或死亡情况几乎相同。
急性B型主动脉夹层患者长期预后较差主要由夹层相关和患者特异性危险因素决定，这些因素不易改变。使用覆膜支架未来是否能改善预后仍有待确定。
