Reed Amy B, Self Patrick, Rosenberg Michael, Faizer Rumi, Valentine R James
Division of Vascular Surgery, Department of Surgery, University of Minnesota Medical Center, Minneapolis, Minn.
Division of Interventional Radiology, Department of Radiology, University of Minnesota Medical Center, Minneapolis, Minn.
J Vasc Surg. 2020 Oct;72(4):1206-1212. doi: 10.1016/j.jvs.2019.11.055. Epub 2020 Feb 5.
Pre-emptive thoracic endovascular aortic repair (TEVAR) improves late survival and limits progression of disease after type B aortic dissection, but the potential value of pre-emptive TEVAR has not been evaluated after type A dissection extending beyond the aortic arch (DeBakey type I). The purpose of this study was to compare disease progression and need for aortic intervention in survivors of acute, extended type A (ExTA) dissections after initial repair of the ascending aorta versus acute type B aortic dissections.
Consecutive patients presenting with ExTA or type B dissections between 2011 and 2018 were studied. Forty-three patients with ExTA and 44 with type B dissections who survived to discharge and had follow-up imaging studies were included in the analysis. Study end points included progression of aortic disease (>5 mm growth or extension), need for intervention, and death.
The groups were not different for age, sex, atherosclerotic risk factors, or extent of dissection distal to the left subclavian artery. Following emergent ascending aortic repair, five ExTA patients (12%) underwent TEVAR within 4 months after discharge. Despite optimal medical treatment, 29 type B patients (66%) underwent early or late TEVAR (P < .001). During a mean follow-up of 38 ± 30 months, 38 ExTA patients (88%) did not require intervention-23 (53%) of whom showed no disease progression. In comparison, during a mean follow-up of 18 ± 6 months, 14 type B patients (32%) did not require intervention-nine (20%) of whom showed no disease progression (P = .003). There was one aortic-related late death in the ExTA group and two in the type B group. Compared with ExTA patients, type B patients had significantly worse intervention-free survival and intervention/growth-free survival (log rank, P < .001).
In contrast with type B dissections, these midterm results demonstrate that one-half of ExTA aortic dissections show no disease progression in the thoracic or abdominal aorta, and few require additional interventions. After initial repair of the ascending aorta, pre-emptive TEVAR does not seem to be justified in patients with acute, ExTA dissections.
预防性胸主动脉腔内修复术（TEVAR）可提高B型主动脉夹层患者的远期生存率并限制疾病进展，但对于累及主动脉弓以外的A型夹层（DeBakey I型），预防性TEVAR的潜在价值尚未得到评估。本研究的目的是比较急性扩展性A型（ExTA）夹层患者在升主动脉初次修复后与急性B型主动脉夹层患者的疾病进展情况及主动脉干预需求。
对2011年至2018年间连续出现ExTA或B型夹层的患者进行研究。分析纳入了43例ExTA患者和44例B型夹层患者，这些患者均存活至出院且有随访影像学检查。研究终点包括主动脉疾病进展（直径增长>5 mm或病变扩展）、干预需求及死亡。
两组在年龄、性别、动脉粥样硬化危险因素或左锁骨下动脉远端夹层范围方面无差异。在急诊升主动脉修复术后，5例ExTA患者（12%）在出院后4个月内接受了TEVAR。尽管进行了最佳药物治疗，29例B型患者（66%）接受了早期或晚期TEVAR（P <.001）。在平均38±30个月的随访期间，38例ExTA患者（88%）无需干预，其中23例（53%）疾病无进展。相比之下，在平均18±6个月的随访期间，14例B型患者（32%）无需干预，其中9例（20%）疾病无进展（P =.003）。ExTA组有1例与主动脉相关的晚期死亡，B型组有2例。与ExTA患者相比，B型患者的无干预生存率和无干预/无病变进展生存率显著更差（对数秩检验，P <.001）。
与B型夹层不同，这些中期结果表明，半数ExTA主动脉夹层患者的胸主动脉或腹主动脉疾病无进展，且很少需要额外干预。在升主动脉初次修复后，对于急性ExTA夹层患者而言，预防性TEVAR似乎并无必要。
