German Aortic Center, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich, Germany.
J Endovasc Ther. 2020 Feb;27(1):145-152. doi: 10.1177/1526602819888672. Epub 2019 Dec 4.
To report a single-center experience with thoracic endovascular aortic repair (TEVAR) for complicated acute type B aortic dissection (cATBAD) comparing patients with vs without end-organ ischemia. Between November 2010 and December 2017, 64 patients (mean age 64.8±12.5 years; 49 men) underwent TEVAR for cATBAD. Patients were grouped into 2 cohorts: nonischemic (39, 61%) patients with unrelenting pain, early progressive aortic dilatation, uncontrolled hypertension, or rupture, and ischemic (25, 39%) patients with visceral, renal, lower extremity, or spinal cord hypoperfusion. Mean time from diagnosis to treatment was 7.5 days (range 1-32) in the nonischemic group vs 2.3 days (range 1-14) days in the ischemic group (p=0.007). Fourteen (56%) of 25 ischemic cATBAD patients had stents implanted in the renovascular branch vessels, while 4 (16%) patients had stents implanted in the iliac arteries. When branch vessel cannulation failed, fenestrations were made in the intimal flap to improve perfusion of the involved branch (n=5). In the nonischemic group, 3 arteries were stented owing to atherosclerotic stenosis. Technical success was achieved in 62 (97%) of 64 patients; despite stenting, 2 patients had low renal artery perfusion on final angiography. There were no statistically significant differences in early or late outcomes between the nonischemic vs ischemic cATBAD patients. Six (9%) patients died within 30 days: 2 (5%) in the nonischemic group vs 4 (16%) in the ischemic group. Major complications (1 stroke, 2 cases of paraplegia, 1 retrograde type A dissection, and 1 case of bowel ischemia) occurred only in the nonischemic group. The mean follow-up was 28 months. Late endoleaks were observed in 3 (8%) nonischemic patients and 1 (4%) ischemic patient. Reinterventions were required in 7 (18%) nonischemic patients and 4 (16%) ischemic patients. TEVAR is an effective and safe method of treating cATBAD. Early intervention in ischemic cATBAD may have played a significant role in the lack of significant difference between ischemic and nonischemic cATBAD outcomes. Direct visceral reperfusion through branch vessel stenting during TEVAR may be crucial in achieving good outcomes in ischemic cATBAD.
报告一项比较合并终末器官缺血与未合并终末器官缺血的急性 B 型主动脉夹层（a BAD）患者行胸主动脉腔内修复术（TEVAR）的单中心经验。2010 年 11 月至 2017 年 12 月，64 例（平均年龄 64.8±12.5 岁；49 例男性）因 a BAD 而行 TEVAR。患者分为两组：非缺血（39 例，61%）患者为持续性疼痛、早期进行性主动脉扩张、无法控制的高血压或破裂；缺血（25 例，39%）患者为内脏、肾脏、下肢或脊髓灌注不足。非缺血组从诊断到治疗的平均时间为 7.5 天（范围 1-32），而缺血组为 2.3 天（范围 1-14）（p=0.007）。25 例缺血性 a BAD 患者中有 14 例（56%）在肾动脉分支血管中植入支架，4 例（16%）在髂动脉中植入支架。当分支血管不能插管时，在内膜瓣上制作窗孔以改善受累分支的灌注（n=5）。在非缺血组，3 支动脉因粥样硬化性狭窄而植入支架。64 例患者中，62 例（97%）技术成功；尽管植入支架，但 2 例最终血管造影显示肾动脉灌注低。非缺血性与缺血性 a BAD 患者的早期和晚期结局无统计学差异。30 天内死亡 6 例（9%）：非缺血组 2 例（5%），缺血组 4 例（16%）。主要并发症（1 例中风，2 例截瘫，1 例逆行 A 型夹层，1 例肠缺血）仅发生在非缺血组。平均随访 28 个月。3 例（8%）非缺血患者和 1 例（4%）缺血患者出现晚期内漏。7 例（18%）非缺血患者和 4 例（16%）缺血患者需要再次干预。TEVAR 是治疗 a BAD 的有效且安全的方法。在缺血性 a BAD 中早期干预可能在缺血性和非缺血性 a BAD 结局无显著差异中发挥了重要作用。在 TEVAR 期间通过分支血管支架直接内脏再灌注可能对缺血性 a BAD 获得良好结局至关重要。
