Lou Xiaoying, Chen Edward P, Duwayri Yazan M, Veeraswamy Ravi K, Jordan William D, Zehner Carl A, Leshnower Bradley G
Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
Division of Vascular and Endovascular Therapy, Emory University School of Medicine, Atlanta, Georgia.
Ann Thorac Surg. 2018 Jan;105(1):31-38. doi: 10.1016/j.athoracsur.2017.06.016. Epub 2017 Aug 12.
Currently, optimal medical therapy is first-line therapy for uncomplicated acute type B aortic dissection (aTBAD) despite poor long-term outcomes. This study examines the impact of thoracic endovascular aortic repair (TEVAR) in the acute and chronic phases on short-term and long-term survival of patients presenting with aTBAD.
A review of the Emory aortic database from 2000 to 2016 identified 398 patients diagnosed with aTBAD. At index hospitalization, complicated patients underwent TEVAR (aTEVAR [thoracic endovascular aortic repair in the acute phase], n = 80) and uncomplicated patients received optimal medical therapy (n = 318). Uncomplicated patients were divided into subgroups based on final treatment: (1) TEVAR (cTEVAR [thoracic endovascular aortic repair in the chronic phase], n = 87); (2) open aortic replacement (n = 59); and (3) optimal medical therapy (n = 172). Kaplan-Meier curves assessed long-term mortality.
The mean age of patients was 57 ± 12 years. In the uncomplicated group, 146 patients (45.9%) patients failed optimal medical therapy and underwent open repair (n = 59) or endovascular repair (cTEVAR, n = 87) repair in the chronic phase. Inhospital mortality was 5% and equivalent between complicated and uncomplicated aTBAD groups at index hospitalization. For patients requiring intervention, mortality and renal failure were highest for open patients (16.9%, p < 0.01, and 10.2%, p = 0.05, respectively), and stroke was highest among aTEVAR patients (7.5%, p < 0.01). The incidence of paraparesis and paraplegia was low and equivalent among the three groups. Despite a higher mortality risk at presentation, there was a trend toward improved long-term survival among complicated aTBAD patients (complicated 84.1% versus uncomplicated 58.9%, p = 0.17). Intervention-free survival at 5 and 10 years for all uncomplicated patients was 50.4% and 32.9%, respectively.
The treatment of uncomplicated aTBAD with optimal medical therapy results in a high incidence of surgical intervention and poor long-term survival. At the index hospitalization, TEVAR may confer a survival advantage and serve as optimal therapy for complicated and uncomplicated aTBAD patients.
目前，尽管长期预后不佳，但最佳药物治疗仍是单纯性急性B型主动脉夹层（aTBAD）的一线治疗方法。本研究探讨胸主动脉腔内修复术（TEVAR）在急性期和慢性期对aTBAD患者短期和长期生存的影响。
回顾2000年至2016年埃默里主动脉数据库，确定398例诊断为aTBAD的患者。在首次住院时，病情复杂的患者接受了TEVAR（急性期胸主动脉腔内修复术[aTEVAR]，n = 80），病情不复杂的患者接受了最佳药物治疗（n = 318）。病情不复杂的患者根据最终治疗方法分为亚组：（1）TEVAR（慢性期胸主动脉腔内修复术[cTEVAR]，n = 87）；（2）开放性主动脉置换术（n = 59）；（3）最佳药物治疗（n = 172）。采用Kaplan-Meier曲线评估长期死亡率。
患者的平均年龄为57±12岁。在病情不复杂的组中，146例（45.9%）患者最佳药物治疗失败，在慢性期接受了开放性修复术（n = 59）或血管腔内修复术（cTEVAR，n = 87）。住院死亡率为5%，在首次住院时，病情复杂和不复杂的aTBAD组之间相当。对于需要干预的患者，开放性手术患者的死亡率和肾衰竭发生率最高（分别为16.9%，p < 0.01和10.2%，p = 0.05），aTEVAR患者的中风发生率最高（7.5%，p < 0.01）。三组中截瘫和偏瘫的发生率较低且相当。尽管就诊时死亡风险较高，但病情复杂的aTBAD患者有长期生存改善的趋势（病情复杂的患者为84.1%，病情不复杂的患者为58.9%，p = 0.17）。所有病情不复杂的患者在5年和10年时无干预生存率分别为50.4%和32.9%。
采用最佳药物治疗单纯性aTBAD会导致手术干预发生率高和长期生存率低。在首次住院时，TEVAR可能具有生存优势，可作为病情复杂和不复杂的aTBAD患者的最佳治疗方法。
