Department of Interventional Cardiology, San Salvatore Hospital, Pesaro, Italy.
J Am Coll Cardiol. 2013 Apr 23;61(16):1661-78. doi: 10.1016/j.jacc.2012.11.072.
An expert multidisciplinary panel in the treatment of type B aortic dissection reviewed available literature to develop treatment algorithms using a consensus method. Data from 63 studies published from 2006 to 2012 were retrieved for a total of 1,548 patients treated medically, 1,706 patients who underwent open surgery, and 3,457 patients who underwent thoracic endovascular repair (TEVAR). For acute (first 2 weeks) type B aortic dissection, the pooled early mortality rate was 6.4% with medical treatment and increased to 10.2% with TEVAR and 17.5% with open surgery, mostly for complicated cases. Limited data for treatment of subacute (2 to 6 weeks after onset) type B aortic dissection showed an early mortality rate of 2.8% with TEVAR. In chronic (after 6 weeks) type B aortic dissection, 5-year survival of 60% to 80% was expected with medical therapy because complications were likely. If interventional treatment was applied, the pooled early mortality rate was 6.6% with TEVAR and 8.0% with open surgery. Medical treatment of uncomplicated acute, subacute, and chronic type B aortic dissection is managed with close image monitoring. Hemodynamic instability, organ malperfusion, increasing periaortic hematoma, and hemorrhagic pleural effusion on imaging identify patients with complicated acute type B aortic dissection requiring urgent aortic repair. Recurrence of symptoms, aortic aneurysmal dilation (>55 mm), or a yearly increase of >4 mm after the acute phase are predictors of adverse outcome and need for delayed aortic repair ("complicated chronic aortic dissections"). The expert panel is aware that this consensus document provides proposal for strategies based on nonrobust evidence for management of type B aortic dissection, and that literature results were largely heterogeneous and should be interpreted cautiously.
一个治疗 B 型主动脉夹层的多学科专家小组回顾了现有文献，采用共识方法制定了治疗算法。从 2006 年至 2012 年发表的 63 项研究中检索到数据，共有 1548 例患者接受内科治疗，1706 例患者接受开放手术，3457 例患者接受胸主动脉腔内修复术（TEVAR）。对于急性（发病后 2 周内）B 型主动脉夹层，内科治疗的早期死亡率为 6.4%，TEVAR 增加至 10.2%，开放手术增加至 17.5%，主要是复杂病例。亚急性（发病后 2 至 6 周）B 型主动脉夹层治疗的有限数据显示，TEVAR 的早期死亡率为 2.8%。对于慢性（发病 6 周后）B 型主动脉夹层，由于可能出现并发症，预计内科治疗 5 年生存率为 60%至 80%。如果进行介入治疗，TEVAR 的早期死亡率为 6.6%，开放手术为 8.0%。对于不复杂的急性、亚急性和慢性 B 型主动脉夹层，内科治疗采用密切的影像学监测。血流动力学不稳定、器官灌注不良、主动脉周围血肿增加以及影像学上出现血性胸腔积液可识别需要紧急主动脉修复的复杂急性 B 型主动脉夹层患者。症状复发、主动脉瘤扩张（>55mm）或急性发作后每年增加>4mm 是不良预后和需要延迟主动脉修复的预测因素（“复杂慢性主动脉夹层”）。专家组意识到，本共识文件提供了基于非稳健证据的 B 型主动脉夹层管理策略建议，文献结果存在很大异质性，应谨慎解读。
