Cambria R P, Brewster D C, Gertler J, Moncure A C, Gusberg R, Tilson M D, Darling R C, Hammond G, Mergerman J, Abbott W M
Surgical Service, Massachusetts General Hospital, Boston 02114.
J Vasc Surg. 1988 Feb;7(2):199-209.
Three hundred twenty-five cases of spontaneous aortic dissection seen at two institutions between 1965 and 1986 were reviewed to assess the incidence, morbid sequelae, and specific management of aortic branch compromise. Noncardiac vascular complications occurred in 33% of the study group, and in these patients the overall mortality rate (51%) was significantly (p less than 0.001) higher than in patients without (29%) such complications. Although aortic rupture was the strongest correlate of mortality (90%), death specifically related to vascular occlusion was common when such occlusion occurred in the carotid, mesenteric, and renal circulation. There was a strong correlation between stroke and carotid occlusion (22/26 cases), yet specific carotid revascularization was only used during the chronic phase of the disease. Similarly, peripheral operation was ineffective in reducing the mortality rate in the setting of mesenteric (87%) and renal (50%) ischemia. Fifteen patients required either fenestration or graft replacement of the abdominal aorta for acute obstruction, rupture, or chronic aneurysm development. Thirty-eight patients (12%) demonstrated some degree of lower extremity ischemia, and one third of these required a direct approach on the abdominal aorta or iliofemoral segments to restore circulation. Selected patients with acute aortic dissection may require peripheral vascular operation in accordance with a treatment strategy that directs initial attention to the immediate life-threatening complications.
回顾了1965年至1986年间在两家机构中所见的325例自发性主动脉夹层病例，以评估主动脉分支受累的发生率、病态后遗症及具体处理方法。33%的研究组患者出现非心脏血管并发症，这些患者的总体死亡率（51%）显著高于（p<0.001）无此类并发症的患者（29%）。虽然主动脉破裂是死亡率的最强相关因素（90%），但当血管闭塞发生在颈动脉、肠系膜和肾循环时，与血管闭塞具体相关的死亡很常见。中风与颈动脉闭塞之间存在很强的相关性（22/26例），但仅在疾病的慢性期进行特定的颈动脉血运重建。同样，在肠系膜缺血（87%）和肾缺血（50%）的情况下，外周手术在降低死亡率方面无效。15例患者因急性梗阻、破裂或慢性动脉瘤形成需要对腹主动脉进行开窗或移植置换。38例患者（12%）表现出一定程度的下肢缺血，其中三分之一的患者需要对腹主动脉或髂股段采取直接手术来恢复血运。根据将初始注意力导向直接危及生命的并发症的治疗策略，部分急性主动脉夹层患者可能需要进行外周血管手术。
