Estrera Anthony L, Miller Charles C, Goodrick Jennifer, Porat Eyal E, Achouh Paul E, Dhareshwar Jayesh, Meada Riad, Azizzadeh Ali, Safi Hazim J
Department of Cardiothoracic and Vascular Surgery, The University of Texas-Houston Medical School, Houston, Texas 77030, USA.
Ann Thorac Surg. 2007 Feb;83(2):S842-5; discussion S846-50. doi: 10.1016/j.athoracsur.2006.10.081.
The optimal treatment of acute type B aortic dissection remains controversial. This study reports early clinical outcomes of medical management for acute type B aortic dissection.
Between January 2001 and April 2006, data on 159 consecutive patients (55 women [35%]) with the confirmed diagnosis of acute type B aortic dissection were prospectively collected and analyzed. Mean age was 62 years (range, 29 to 94). On admission, all patients were initiated on an acute type B aortic dissection protocol with the intent to manage all patients medically. Indications for surgical intervention included rupture, aortic expansion, retrograde dissection, malperfusion (visceral, peripheral), and intractable pain. All patients were followed up after discharge with serial clinical and radiographic examinations.
Overall hospital mortality was 8.8% (14/159): 17% (4/23) with procedural intervention, and 7.4% (10/136) when medical management was maintained. Early intervention was required in 23 patients (14.5%), of which 21 (13.2%) were open vascular/aortic procedures, and two (1.3%) were percutaneous aortic interventions. Morbidity included rupture (5.0%), stroke (5.0%), paraplegia (8.2%), bowel ischemia (5.7%), acute renal failure (20.1%), dialysis requirement (13.8%), and peripheral ischemia (3.8%). Mortality associated with complicated dissection (74/159) was 17%, and mortality associated with uncomplicated dissection (85/159) was 1.2% (p < 0.0003). Late vascular related procedures were performed in 11 (7.6%) of 144 cases (9 aortic, 2 peripheral vascular). The only independent risk factors for hospital mortality by multiple logistic regression analysis was rupture (p < 0.0009). Independent risk factors for mid-term death were history of chronic obstructive pulmonary disease (p < 0.002) and glomerular filtration rate at admission (p < 0.0001).
Medical management, especially for uncomplicated acute type B aortic dissection, is associated acceptable outcomes. This study provides current data for initial medical management of acute type B aortic dissection. Alternative strategies for the treatment of acute Type B aortic dissection should be compared with these results.
急性B型主动脉夹层的最佳治疗方案仍存在争议。本研究报告了急性B型主动脉夹层内科治疗的早期临床结果。
在2001年1月至2006年4月期间，前瞻性收集并分析了159例连续确诊为急性B型主动脉夹层患者（55例女性[35%]）的数据。平均年龄为62岁（范围29至94岁）。入院时，所有患者均启动急性B型主动脉夹层治疗方案，旨在对所有患者进行内科治疗。手术干预的指征包括破裂、主动脉扩张、逆行夹层、灌注不良（内脏、外周）和顽固性疼痛。所有患者出院后均接受系列临床和影像学检查进行随访。
总体医院死亡率为8.8%（14/159）：手术干预患者为17%（4/23），维持内科治疗患者为7.4%（10/136）。23例患者（14.5%）需要早期干预，其中21例（13.2%）为开放性血管/主动脉手术，2例（1.3%）为经皮主动脉介入治疗。并发症包括破裂（5.0%）、中风（5.0%）、截瘫（8.2%）、肠缺血（5.7%）、急性肾衰竭（20.1%）、透析需求（13.8%）和外周缺血（3.8%）。复杂夹层患者（74/159）的死亡率为17%，非复杂夹层患者（85/159）的死亡率为1.2%（p<0.0003）。144例患者中有11例（7.6%）进行了晚期血管相关手术（9例主动脉，2例外周血管）。多因素logistic回归分析显示，医院死亡率的唯一独立危险因素是破裂（p<0.0009）。中期死亡的独立危险因素是慢性阻塞性肺疾病史（p<0.002）和入院时的肾小球滤过率（p<0.0001）。
内科治疗，尤其是对于非复杂的急性B型主动脉夹层，具有可接受的结果。本研究为急性B型主动脉夹层的初始内科治疗提供了当前数据。急性B型主动脉夹层的替代治疗策略应与这些结果进行比较。
