Luebke Thomas, Brunkwall Jan
Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany.
Aorta (Stamford). 2014 Dec 1;2(6):265-78. doi: 10.12945/j.aorta.2014.14-040. eCollection 2014 Dec.
According to international guidelines, stable patients with uncomplicated Type B aortic dissection (TBAD) should receive optimal medical treatment. Despite adequate antihypertensive therapy, the long-term prognosis of these patients is characterized by a significant aortic aneurysm formation in 25-30% within four years, and survival rates from 50 to 80% at five years and 30 to 60% at 10 years. In a prospective randomized trial, preemptive thoracic endovascular aortic repair (TEVAR) in patients with chronic uncomplicated TBAD was associated with an excess early mortality (due to periprocedural hazards), but the procedure showed its benefit in prevention of aortic-specific mortality at five years of follow-up. However, preemptive TEVAR may not be the treatment of choice in all patients with uncomplicated TBAD because of the inherent periprocedural complications like stroke, paraparesis, and death, as well as stent graft-induced complications (i.e., retrograde dissection or endoleaks). Thus, the TEVAR-related deaths and complications (especially paraplegia and stroke) raise concerns that moderate the better survival with TEVAR at five years. By timely identification of those patients prone for developing complications, early intervention, preferably in the subacute or early chronic phase, may improve the overall long-term outcome for these patients. Therefore, early detectable and reliable prognostic factors for adverse events are essential to stratify patients who can be treated medically and those who will benefit from rigorous follow-up and, in the long-term, from timely, or even prophylactic, TEVAR. Several studies have identified prognostic factors in TBAD such as aortic diameter, partial false lumen thrombosis, false lumen thickness, and location of the primary entry tear. Combining these clinical and radiological predictors may be essential to implement a patient-specific approach designed to intervene only in those patients who are at high risk of developing complications to improve the long-term outcomes of patients with uncomplicated Type B aortic dissection.
根据国际指南，病情稳定的单纯B型主动脉夹层（TBAD）患者应接受最佳药物治疗。尽管进行了充分的降压治疗，但这些患者的长期预后特点是，四年内25% - 30%的患者会形成明显的主动脉瘤，五年生存率为50%至80%，十年生存率为30%至60%。在一项前瞻性随机试验中，慢性单纯TBAD患者的预防性胸段血管腔内主动脉修复术（TEVAR）与早期死亡率过高（由于围手术期风险）相关，但该手术在五年随访中显示出预防主动脉特异性死亡的益处。然而，由于存在诸如中风、截瘫和死亡等固有的围手术期并发症以及支架移植物引起的并发症（即逆行夹层或内漏），预防性TEVAR可能并非所有单纯TBAD患者的首选治疗方法。因此，TEVAR相关的死亡和并发症（尤其是截瘫和中风）引发了人们的担忧，这削弱了TEVAR在五年时更好的生存率优势。通过及时识别那些容易发生并发症的患者，早期干预，最好是在亚急性期或慢性早期进行干预，可能会改善这些患者的总体长期预后。因此，早期可检测且可靠的不良事件预后因素对于区分可接受药物治疗的患者以及那些将从严格随访中获益、并从长期来看从及时甚至预防性TEVAR中获益的患者至关重要。多项研究已经确定了TBAD的预后因素，如主动脉直径、部分假腔血栓形成、假腔厚度和原发入口撕裂的位置。结合这些临床和放射学预测因素对于实施针对患者个体的方法可能至关重要，该方法旨在仅对那些发生并发症风险高的患者进行干预，以改善单纯B型主动脉夹层患者的长期预后。
