Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
Ann Vasc Surg. 2021 Apr;72:617-626. doi: 10.1016/j.avsg.2020.10.031. Epub 2020 Nov 26.
Ascending aortic thrombus (AAT) in a nonaneurysmal aorta is an extremely rare event and has potentially catastrophic complications, with a life-threatening risk of myocardial infarction and cerebral embolization. This systematic review aims to elucidate the clinical manifestations and to compare the outcomes of anticoagulation therapy versus open aortic surgery for AAT.
The MEDLINE/PubMed databases were extensively searched between 1995 and 2019. All relevant publications on AAT in adults were reviewed, and individual patient data were pooled in this meta-analysis. The primary outcome was AAT resolution. The adverse outcome variables were recurrent arterial embolic events, complications related to open aortic surgery, and mortality during the study period. Chi-squared test and logistic regression analysis were used to compare groups and identify any predictors of mortality.
Overall, 107 patients from 101 articles were included, of whom 29 patients who received anticoagulation therapy and 59 who underwent open aortic surgery were included in the outcome analysis. Among 29 patients treated with initial anticoagulation therapy, the persistence of AAT was observed in 11 patients (38%) and recurrent arterial embolization was developed in 6 patients (21%). All 11 patients in the anticoagulation group underwent secondary aortic surgery for the persistence of AAT with uneventful postoperative course. Compared with patients treated with primary aortic surgery, patients treated with initial anticoagulation therapy had higher risk of recurrent embolization (P = 0.002). No significant difference existed in the mortality rates between the groups (P = 0.106). Hemodynamic instability was an independent predictor of mortality (P = 0.008).
Anticoagulation therapy and open aortic surgery for AAT show similar results; however, open aortic surgery reliably removes AAT and reduces the risk of recurrent embolization compared with anticoagulation therapy. Furthermore, the preoperative hemodynamic status significantly influences the clinical outcome and is a strong predictor of prognosis.
非动脉瘤性升主动脉血栓（AAT）极为罕见，但可能会引发危及生命的心肌梗死和脑栓塞等灾难性并发症。本系统综述旨在阐明其临床表现，并比较抗凝治疗与开放式主动脉手术治疗 AAT 的结果。
本研究广泛检索了 1995 年至 2019 年期间的 MEDLINE/PubMed 数据库。对所有关于成人 AAT 的相关文献进行了回顾，并对该meta 分析中的个体患者数据进行了汇总。主要结局为 AAT 消退。次要结局为复发性动脉栓塞事件、开放式主动脉手术相关并发症和研究期间的死亡率。采用卡方检验和逻辑回归分析比较组间差异，并识别任何死亡的预测因素。
共有 101 篇文章中的 107 例患者纳入研究，其中 29 例接受抗凝治疗，59 例接受开放式主动脉手术，纳入结局分析。在接受初始抗凝治疗的 29 例患者中，11 例（38%）患者的 AAT 持续存在，6 例（21%）患者发生复发性动脉栓塞。所有 11 例抗凝组患者均因 AAT 持续存在而接受二次主动脉手术，术后均无不良事件。与接受主动脉手术治疗的患者相比，接受初始抗凝治疗的患者复发性栓塞的风险更高（P = 0.002）。两组患者的死亡率无显著差异（P = 0.106）。血流动力学不稳定是死亡的独立预测因素（P = 0.008）。
抗凝治疗和开放式主动脉手术治疗 AAT 的结果相似；然而，与抗凝治疗相比，开放式主动脉手术更可靠地清除 AAT，并降低复发性栓塞的风险。此外，术前血流动力学状态显著影响临床结局，是预后的有力预测因素。
