Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria.
Department of Interventional and Cardiovascular Radiology, Medical University of Vienna, Vienna, Austria.
J Vasc Surg. 2019 Feb;69(2):318-326. doi: 10.1016/j.jvs.2018.05.234.
This study retrospectively assessed in-hospital mortality and long-term results of emergency thoracic endovascular aortic repair (TEVAR) for patients with life-threatening acute complicated type B aortic dissection (acTBD).
Between March 2001 and December 2016, there were 55 patients (40 male; median age, 52 ± 13 years) with an acTBD who were treated with TEVAR for malperfusion (58%), aortic rupture (18%), or persistent untreatable pain with true lumen reduction or rapid aortic diameter enlargement (24%) as a sign of disease progression. The patients were categorized according to clinical appearance into two groups: group A, malperfusion, pending rupture, or rupture; and group B, persistent ongoing pain, rapid enlargement of aortic diameter, or significant changes in the true to false lumen ratio. Four patients (7%) had undergone previous aortic surgery.
Technical success (coverage of the primary intimal tear) was achieved in 50 patients (91%). The overall in-hospital mortality rate was 9% (n = 5), and there was a statistically significant difference in early mortality between group A and group B (7% vs 2%; P < .02). Causes of in-hospital death were all aorta related, including a rupture during the procedure and on the first postinterventional day in two patients and redissection (ascending aorta, n = 2; descending aorta, n = 1) with a consequent aortic rupture after TEVAR in the remaining three. Permanent neurologic dysfunction occurred in five patients (stroke, n = 2; paraplegia, n = 3). Overall, 19 patients (34%) developed early endoleaks (type IA, n = 5; type IB, n = 11; type II, n = 2; type IB plus type II, n = 1). Therefore, 5 patients needed early (within 30 days) endovascular intervention because of a type IA (n = 2), type IB (n = 3), or type II endoleak (n = 1) and the rapid progression of aortic diameter, persistent signs of ischemia (n = 2), or rupture (n = 1), whereas the remaining 14 patients were treated conservatively and followed up by computed tomography angiography. Seven patients with early endoleaks needed an endovascular intervention (n = 3) or conventional surgery (n = 4) because of aortic progression in the follow-up period (mean interval after procedure, 92 ± 56 months). The actual survival rates were 87%, 85%, and 75% at 1 year, 2 years, and 5 years, respectively, and freedom from aorta-related death was 87%, 87%, and 77% at 1 year, 2 years, and 5 years, respectively. Freedom from reintervention for any cause using a Kaplan-Meier analysis was 70%, 68%, 68%, and 63% at 6 months, 1 year, 2 years, and 5 years, respectively.
TEVAR of acTBD has been proven to be an excellent treatment modality in this cohort of high-risk patients, with promising midterm and long-term results.
本研究回顾性评估了危及生命的急性复杂型 B 型主动脉夹层（acTBD）患者行急诊胸主动脉腔内修复术（TEVAR）的院内死亡率和长期结果。
2001 年 3 月至 2016 年 12 月，55 例 acTBD 患者因灌注不良（58%）、主动脉破裂（18%）或持续性无法治疗的疼痛伴真腔缩小或主动脉直径快速增大（24%）而进展为疾病，采用 TEVAR 治疗。根据临床表现将患者分为两组：A 组，灌注不良、即将破裂或破裂；B 组，持续性持续疼痛、主动脉直径快速增大或真腔至假腔比值明显变化。4 例（7%）患者曾行主动脉手术。
50 例患者（91%）技术成功（覆盖主要内膜撕裂）。总体院内死亡率为 9%（n=5），A 组和 B 组的早期死亡率有统计学差异（7% vs 2%；P<.02）。院内死亡的原因均与主动脉相关，包括 2 例患者术中及术后第 1 天发生破裂，另外 3 例患者因再次夹层（升主动脉，n=2；降主动脉，n=1）导致 TEVAR 后主动脉破裂。5 例患者发生永久性神经功能障碍（脑卒中，n=2；截瘫，n=3）。总体而言，19 例患者（34%）发生早期内漏（IA 型，n=5；IB 型，n=11；II 型，n=2；IB 型加 II 型，n=1）。因此，5 例患者因 IA 型（n=2）、IB 型（n=3）或 II 型内漏（n=1）和主动脉直径快速增大、持续性缺血征象（n=2）或破裂（n=1）需要早期（30 天内）血管内介入治疗，而其余 14 例患者接受保守治疗并通过计算机断层血管造影进行随访。7 例早期内漏患者因主动脉进展（术后平均随访时间为 92±56 个月）需要血管内干预（n=3）或常规手术（n=4）。1 年、2 年和 5 年的实际生存率分别为 87%、85%和 75%，1 年、2 年和 5 年的无主动脉相关死亡率分别为 87%、87%和 77%。Kaplan-Meier 分析显示，因任何原因需要再次干预的无复发生存率分别为 6 个月、1 年、2 年和 5 年时的 70%、68%、68%和 63%。
在这组高危患者中，TEVAR 治疗 acTBD 已被证明是一种极好的治疗方法，具有良好的中期和长期结果。
