Ito Eisaku, Ohki Takao, Toya Naoki, Fukushima Soichiro, Murakami Yuri, Nakagawa Hikaru, Nishie Ryosuke, Misawa Takeyuki
Division of Vascular Surgery, The Jikei University Kashiwa Hospital, Kashiwa, Japan.
Department of Vascular Surgery, The Jikei University School of Medicine, Tokyo, Japan.
Ann Vasc Surg. 2020 Oct;68:361-368. doi: 10.1016/j.avsg.2020.04.036. Epub 2020 Apr 23.
The Investigation of Stent Grafts in Aortic Dissection with extended length of follow-up trial showed that pre-emptive thoracic endovascular aneurysm repair (TEVAR) for the uncomplicated type B dissection (TBAD) in the subacute phase promotes aortic remodeling and avoids aortic-related death 5 years after onset. However, there are some patients with complete aortic remodeling (CAR) with optimal medical treatment (OMT) and severe complications after TEVAR such as retrograde type A dissection. Therefore, which patients should undergo pre-emptive TEVAR and optimal surgical timing are still under debate. We reported that aortic wall enhancement (AWE) after endovascular aneurysm repair for abdominal aortic aneurysm was associated with sac shrinkage. However, there is no report about the relationship between AWE and aortic dissection. Herein, we evaluated the relationship between AWE and acute TBAD.
From March 2012 to May 2018, consecutive patients with acute TBAD were retrospectively collected. We retrospectively analyzed 35 patients with acute TBAD who were treated with OMT and without pre-emptive TEVAR in the subacute phase. AWE was defined as an increase of more than 20 Hounsfield units in mean computed tomography (CT) values, comparing images in delayed contrast-enhanced scans with those in plain scans evaluated within 3 months from onset. The measurement points were all slices including the wall of the false lumen. The patients with traumatic dissection, type A dissection, acute complicated type B dissection, chronic (>12 weeks) dissection, and those lost to follow-up within 3 months from onset were excluded. The primary end point was spontaneous CAR under OMT, as determined by the latest contrast-enhanced CT scan.
The median follow-up period from onset was 86 weeks and there were 25 cases (71.4%) with AWE. Under OMT, CAR was observed in 20 patients (57.1%); this was significantly associated with abdominal branch dissection (6/15 [40%] vs. 2/20 [10%], P = 0.050), number of tears more than 2 at onset (11/15 [73%] vs. 4/20 [20%], P = 0.003), multiple tears at 1 month after onset (9/15 [60%] vs. 4/20 [20%], P = 0.020), maximal false lumen diameter at 1 month after onset (14 vs. 8 mm, P = 0.025), and AWE within 3 months of onset (7/15 [47%] vs. 18/20 [90%], P = 0.010). Multivariate analysis demonstrated a significant difference with multiple tears at onset (P = 0.014) and AWE within 3 months of onset (P = 0.047).
AWE was associated with CAR under OMT for acute TBAD which is out of indication of pre-emptive TEVAR. Presence of AWE may be useful in predicting prognosis of TBAD.
“主动脉夹层覆膜支架长期随访研究”表明，对于亚急性期单纯B型主动脉夹层（TBAD）患者，早期进行胸主动脉腔内修复术（TEVAR）可促进主动脉重塑，并避免发病5年后出现与主动脉相关的死亡。然而，有些患者经最佳药物治疗（OMT）后实现了完全主动脉重塑（CAR），但接受TEVAR后出现了严重并发症，如逆行性A型夹层。因此，哪些患者应接受早期TEVAR以及最佳手术时机仍存在争议。我们曾报道，腹主动脉瘤腔内修复术后的主动脉壁强化（AWE）与瘤腔缩小有关。然而，尚无关于AWE与主动脉夹层关系的报道。在此，我们评估了AWE与急性TBAD之间的关系。
回顾性收集2012年3月至2018年5月期间连续收治的急性TBAD患者。我们回顾性分析了35例在亚急性期接受OMT且未进行早期TEVAR治疗的急性TBAD患者。AWE定义为延迟对比增强扫描图像与发病后3个月内进行的平扫图像相比，平均计算机断层扫描（CT）值增加超过20亨氏单位。测量点为包括假腔壁在内的所有层面。排除创伤性夹层、A型夹层、急性复杂性B型夹层、慢性（>12周）夹层以及发病后3个月内失访的患者。主要终点为由最新对比增强CT扫描确定的OMT下的自发CAR。
从发病开始的中位随访期为86周，有25例（71.4%）出现AWE。在OMT治疗下，20例患者（57.1%）观察到CAR；这与腹部分支夹层（6/15 [40%] 对2/20 [10%]，P = 0.050）、发病时撕裂口超过2处（11/15 [73%] 对4/20 [20%]，P = 0.003）、发病后1个月出现多处撕裂（9/15 [60%] 对4/20 [20%]，P = 0.020）、发病后1个月时最大假腔直径（14对8 mm，P = 0.025）以及发病后3个月内出现AWE（7/15 [47%] 对18/20 [90%]，P = 0.010）显著相关。多因素分析显示发病时多处撕裂（P = 0.014）和发病后3个月内出现AWE（P = 0.047）存在显著差异。
对于不符合早期TEVAR指征的急性TBAD患者，AWE与OMT下的CAR相关。AWE的存在可能有助于预测TBAD的预后。
