Duebener Lennart F, Lorenzen Peter, Richardt Gert, Misfeld Martin, Nötzold Axel, Hartmann Franz, Sievers Hans-Hinrich, Geist Volker
Department of Cardiac Surgery, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.
Ann Thorac Surg. 2004 Oct;78(4):1261-6; discussion 1266-7. doi: 10.1016/j.athoracsur.2004.03.107.
There is still a considerable controversy regarding optimal treatment for patients with acute type B aortic dissection. Patients with complicated disease are particularly challenging for cardiovascular treatment. Early surgery for acute dissections of the descending aorta with life-threatening complications is known to carry a high mortality. Endovascular stent grafting is developing as an alternative treatment mainly for chronic stages of type B aortic dissection. It is not clear whether endovascular stent grafting is safe and effective in emergency treatment of acute type B aortic dissection.
In 10 patients (7 men, 3 women; mean age, 59.2 years; range, 46 to 65 years), endovascular stent grafting was performed within 11.0 +/- 5.9 hours (range, 4 to 24 hours) of diagnosis of complications. Indications for acute intervention included contained rupture, hematothorax, life-threatening malperfusion, and refractory pain. Using a retrograde endovascular route after surgical exposure of the femoral artery, self-expanding stent prostheses consisting of polyester-covered Nitinol (Talent, World Medical; mean diameter, 40 +/- 4 mm; length, 10 cm) were placed into the descending aorta distal to the subclavian artery. Before discharge and on follow-up visits, imaging of the aorta was performed using computed tomography.
In 9 of 10 patients (90%), the primary entry could be completely occluded with the endovascular stent. Early mortality was 20% (2 of 10): 1 patient died after disruption of the intimal layer distal to the stent, and 1 patient died in hemorrhagic shock after surgical fenestration of the abdominal aorta for persistent malperfusion. Three patients (30%) required consecutive surgical treatment: indications included acute development of retrograde type A aortic dissection, acute stent dislocation by fractured wires and secondary leakage, and late formation of an aneurysm of the descending aorta 6 months after endovascular stent grafting. There were no surgical or late deaths.
Our experience provides some evidence that early mortality of life-threatening acute type B aortic dissection may be reduced by emergency endovascular stent grafting and that this form of treatment is a promising therapeutic option. Refinements, especially in stent design and application, may further improve the prognosis of patients in the life-threatening situation of complicated acute type B aortic dissection.
对于急性B型主动脉夹层患者的最佳治疗方案仍存在相当大的争议。患有复杂疾病的患者在心血管治疗方面尤其具有挑战性。已知对伴有危及生命并发症的降主动脉急性夹层进行早期手术会带来高死亡率。血管内支架植入术正在发展成为主要用于B型主动脉夹层慢性期的替代治疗方法。目前尚不清楚血管内支架植入术在急性B型主动脉夹层的急诊治疗中是否安全有效。
对10例患者（7例男性，3例女性；平均年龄59.2岁；范围46至65岁）在诊断并发症后的11.0±5.9小时（范围4至24小时）内进行了血管内支架植入术。急性干预的指征包括局限性破裂、血胸、危及生命的灌注不良和顽固性疼痛。在手术暴露股动脉后采用逆行血管内途径，将由聚酯覆盖的镍钛诺制成的自膨胀支架假体（Talent，World Medical；平均直径40±4mm；长度10cm）置入锁骨下动脉远端的降主动脉。在出院前及随访时，使用计算机断层扫描对主动脉进行成像。
10例患者中有9例（90%）的原发破口能够被血管内支架完全封堵。早期死亡率为20%（10例中的2例）：1例患者在支架远端内膜层破裂后死亡，1例患者在因持续性灌注不良对腹主动脉进行手术开窗后死于失血性休克。3例患者（30%）需要连续进行手术治疗：指征包括逆行A型主动脉夹层的急性进展、钢丝断裂导致急性支架移位和继发性渗漏，以及血管内支架植入术后6个月降主动脉瘤的晚期形成。无手术死亡或晚期死亡病例。
我们的经验提供了一些证据，表明急诊血管内支架植入术可能降低危及生命的急性B型主动脉夹层的早期死亡率，且这种治疗形式是一种有前景的治疗选择。特别是在支架设计和应用方面的改进，可能会进一步改善处于复杂急性B型主动脉夹层危及生命状况患者的预后。
