Lin J, Marrocco C, Galovich J, Kopchok G, Khoynezhad A, Walot I, Haji F, Jaber R, Donayre C, White R
Division of Vascular Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA.
J Cardiovasc Surg (Torino). 2013 Apr;54(2):161-72.
The current paradigm for the treatment of chronic type B aortic dissection involves primarily medical treatment. The patients are then followed for sequelae like progressive dissection or aneurysmal degeneration, selecting this subgroup for further intervention. The European Collaborator Registry, the Talent Thoracic Retrospective Registry, and several meta-analysis showed that the uncomplicated type B dissection patients who underwent thoracic endovascular aortic repair (TEVAR) outperformed their counterpart in the complicated group. The INSTEAD trial, the first randomized trial to examine whether TEVAR is better than medical management in the chronic stable dissection patients, showed no benefit early on although mid-term data might show some benefit. Clearly more randomized controlled trials are necessary to create a paradigm shift. In the United States, the FDA approved TEVAR devices are for the descending thoracic aortic aneurysm and transection only. The use of these devices for dissection is off-label or for investigation only. As future study might broaden the use of TEVAR for the chronic dissection patients, the use of TEVAR in hybrid surgery and in the ascending aorta is also broadening the indication for this technology. With two decades of innovation behind, TEVAR will continue to evolve and innovate in the years ahead.
目前，慢性B型主动脉夹层的治疗模式主要是药物治疗。随后对患者进行随访，观察是否出现如夹层进展或动脉瘤样退变等后遗症，从中挑选出需要进一步干预的亚组患者。欧洲协作登记研究、Talent胸主动脉回顾性登记研究以及多项荟萃分析均显示，接受胸主动脉腔内修复术（TEVAR）的非复杂性B型夹层患者的治疗效果优于复杂性夹层组的患者。INSTEAD试验是首个探讨在慢性稳定型夹层患者中TEVAR是否优于药物治疗的随机试验，该试验早期未显示出TEVAR的优势，不过中期数据可能显示出一定益处。显然，需要更多随机对照试验来实现治疗模式的转变。在美国，美国食品药品监督管理局（FDA）批准的TEVAR器械仅用于降主动脉瘤和主动脉横断伤。将这些器械用于夹层治疗属于超适应证使用或仅用于研究。随着未来研究可能会扩大TEVAR在慢性夹层患者中的应用范围，TEVAR在杂交手术以及升主动脉中的应用也在拓宽这项技术的适应证。经过二十年的创新发展，TEVAR在未来几年将继续发展和创新。
