急性A型主动脉壁内血肿中灌注不良综合征的管理
Management of malperfusion syndrome in acute type A aortic intramural hematoma.
作者信息
Norton Elizabeth L, Williams David M, Kim Karen M, Wu Xiaoting, Khaja Minhaj S, Patel Himanshu J, Deeb G Michael, Yang Bo
机构信息
Creighton University School of Medicine, Omaha, NE, USA.
Department of Radiologyy, Michigan Medicine, Ann Arbor, MI, USA.
出版信息
Ann Cardiothorac Surg. 2019 Sep;8(5):540-550. doi: 10.21037/acs.2019.07.03.
BACKGROUND
We report the outcomes of acute type A aortic intramural hematoma (ATAAIMH) with malperfusion treated with endovascular intervention and delayed open aortic repair.
METHODS
Between April 1998 and April 2018, 644 patients were treated at our institution with an acute type A aortic dissection (ATAAD) or ATAAIMH, 82 (13%) had intramural hematomas (IMHs) including 12 (15%) with malperfusion syndrome (MPS) and 70 (85%) without MPS (no MPS). Data was obtained through medical record review, the Society of Thoracic Surgeons data elements, and the National Death Index database.
RESULTS
Both MPS and No MPS groups had similar comorbidities including coronary artery disease, hypertension, diabetes, and peripheral vascular disease; however, those with MPS were sicker on admission with higher rates of acute renal failure (50% . 1%, P<0.0001) and acute paralysis (17% . 0%, P=0.02). Patients with MPS amenable to endovascular reperfusion (n=10) underwent endovascular fenestration/stenting and delayed aortic repair. Those with cerebral or coronary MPS (n=2) and those without MPS (n=70) underwent emergent open aortic repair. Of the ten patients undergoing fenestration/stenting, seven went on to aortic repair, one survived to discharge without aortic repair, one died from aortic rupture on hospital day 34, and one died from organ failure prior to aortic repair. Following endovascular fenestration/stenting or aortic repair, all patients with MPS had higher in-hospital mortality (17% . 0%), P=0.02. Following aortic repair, patients with MPS had more postoperative sepsis and longer postoperative length of stay (all P<0.05). However, both groups had a 0% operative mortality (including in-hospital and 30-day mortality following aortic repair). The 5-year survival of all ATAAIMH patients was 79%. The 2-year survival was significantly better in the No MPS group (94% . 62%, P=0.006).
CONCLUSIONS
ATAAIMH with MPS can be effectively managed with upfront endovascular fenestration/stenting followed by delayed aortic repair.
背景
我们报告了采用血管内介入治疗和延迟性主动脉开放修复术治疗的伴有灌注不良的急性A型主动脉壁内血肿（ATAAIMH）的治疗结果。
方法
1998年4月至2018年4月期间，我院对644例急性A型主动脉夹层（ATAAD）或ATAAIMH患者进行了治疗，其中82例（13%）患有壁内血肿（IMH），包括12例（15%）伴有灌注不良综合征（MPS）和70例（85%）不伴有MPS（无MPS）。数据通过病历审查、胸外科医师协会数据元素和国家死亡指数数据库获得。
结果
MPS组和无MPS组的合并症相似，包括冠状动脉疾病、高血压、糖尿病和外周血管疾病；然而，MPS组患者入院时病情更重，急性肾衰竭发生率更高（50%对1%，P<0.0001），急性瘫痪发生率更高（17%对0%，P=0.02）。适合血管内再灌注治疗的MPS患者（n=10）接受了血管内开窗/支架置入术和延迟性主动脉修复术。患有脑或冠状动脉MPS的患者（n=2）和无MPS的患者（n=70）接受了急诊主动脉开放修复术。在接受开窗/支架置入术的10例患者中，7例接受了主动脉修复术，1例未进行主动脉修复术存活至出院，1例在住院第34天死于主动脉破裂，1例在主动脉修复术前死于器官衰竭。在进行血管内开窗/支架置入术或主动脉修复术后，所有MPS患者的院内死亡率更高（17%对0%），P=0.02。主动脉修复术后，MPS患者术后脓毒症更多，术后住院时间更长（均P<0.05）。然而，两组的手术死亡率均为0%（包括主动脉修复术后的院内死亡率和30天死亡率）。所有ATAAIMH患者的5年生存率为79%。无MPS组的2年生存率明显更高（94%对62%，P=0.006）。
结论
伴有MPS的ATAAIMH可通过先行血管内开窗/支架置入术，随后进行延迟性主动脉修复术进行有效治疗。
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