Department of Vascular Surgery, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China.
Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.
J Vasc Surg. 2021 Aug;74(2):528-536.e2. doi: 10.1016/j.jvs.2020.12.099. Epub 2021 Feb 4.
Despite its association with static mesenteric malperfusion, the morphologic characteristics and optimal management of acute type B aortic dissection (ABAD) with superior mesenteric artery (SMA) involvement are poorly understood. We studied the associated risk factors and reported the outcomes of endovascular treatment.
From May 2016 to May 2018, we examined 212 consecutive patients with ABAD in our center. Those with SMA involvement (SMAI) were included in the present study and divided into those with and without mesenteric malperfusion (MMP) according to the clinical findings. After thoracic endovascular aortic repair (TEVAR) with or without SMA revascularization, we compared the clinical data, imaging results, and outcomes for those with and without MMP.
Computed tomography angiography confirmed 44 cases of SMAI: 12 (27.3%) with MMP and 32 (72.7%) without MMP. The patients with MMP had presented more frequently with lower extremity malperfusion (33.3% vs 3.1%; P = .023) than had those without MMP, with an odds ratio of 14.15 (P = .047). Multivariate analysis showed that patients with a low true lumen (TL)/false lumen (FL) diameter ratio of the SMA (TL/FL-SMA <1) had a greater risk of developing MMP than those with a high TL/FL-SMA ratio of >1 (odds ratio, 8.49; 95% confidence interval, 1.24-58.26; P = .029). SMA TL thrombosis was a significant predictor of the requirement for additional SMA revascularization after TEVAR among patients with MMP (P = .045). During a mean 10-month follow-up period, complete FL thrombosis in the SMA was seen in 11 patients (25%; 33.3% with MMP vs 21.9% without MMP; P = .43). The overall mortality rate was 6.82% (16.7% in the MMP group and 3.1% in the non-MMP group; P = .09).
In the present study, limb ischemia and the TL/FL-SMA ratio were two independent predictors for the development of MMP in patients with ABAD and SMAI. We found that TEVAR can be safely performed for these patients, and SMA TL thrombosis predicted for the need for SMA revascularization.
尽管肠系膜下动脉（SMA）受累与慢性肠系膜动脉缺血相关，但急性 B 型主动脉夹层（ABAD）伴 SMA 受累的形态学特征和最佳治疗方法仍知之甚少。我们研究了相关的危险因素，并报告了血管内治疗的结果。
2016 年 5 月至 2018 年 5 月，我们对中心 212 例连续 ABAD 患者进行了检查。本研究纳入了 SMA 受累（SMAI）患者，并根据临床表现分为合并和不合并肠系膜动脉缺血（MMP）的患者。行胸主动脉腔内修复术（TEVAR）联合或不联合 SMA 血运重建后，比较了 MMP 有或无患者的临床资料、影像学结果和结局。
CT 血管造影证实 44 例 SMAI：12 例（27.3%）合并 MMP，32 例（72.7%）不合并 MMP。MMP 患者下肢灌注不良更为常见（33.3% vs 3.1%；P=0.023），比值比为 14.15（P=0.047）。多变量分析显示，SMA 的真腔（TL）/假腔（FL）直径比值低（TL/FL-SMA<1）的患者发生 MMP 的风险高于 TL/FL-SMA 比值高（比值比，8.49；95%置信区间，1.24-58.26；P=0.029）的患者。MMP 患者 TEVAR 后 SMA 再血管化的需求是 SMA TL 血栓形成的显著预测因素（P=0.045）。在平均 10 个月的随访期间，11 例患者（25%；33.3%的 MMP 患者 vs 21.9%的非 MMP 患者；P=0.43）出现 SMA 完全 FL 血栓形成。总的死亡率为 6.82%（MMP 组 16.7%，非 MMP 组 3.1%；P=0.09）。
在本研究中，肢体缺血和 TL/FL-SMA 比值是 ABAD 和 SMAI 患者发生 MMP 的两个独立预测因素。我们发现这些患者可以安全地进行 TEVAR，SMA TL 血栓形成预测需要 SMA 再血管化。
