Li Jiangtao, Xia Liangtao, Ma Mingjia, Feng Xin, Wei Xiang
Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China; NHC Key Laboratory of Organ Transplantation, Wuhan, China; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China.
J Vasc Surg. 2022 Jan;75(1):56-64.e2. doi: 10.1016/j.jvs.2021.07.231. Epub 2021 Sep 2.
The optimal treatment of intramural hematoma (IMH) involving the ascending aorta remains controversial. This study aimed to analyze the results of the management of patients with acute IMH involving the ascending aorta and extending into the descending thoracic aorta, to compare outcomes of descending thoracic endovascular aortic repair (TEVAR) with that of medical therapy (MT), and to assess the risk factors associated with adverse aortic events.
We retrospectively analyzed all patients diagnosed with acute IMH involving the ascending aorta and extending into the descending thoracic aorta from January 2012 to December 2019. The primary end points during follow-up were aortic disease-related death and adverse aorta-related events that required surgical or endovascular treatment, such as aortic rupture, the progression of aortic disease, or endoleak.
We identified a total of 135 patients with acute IMH involving the ascending aorta and extending into the descending thoracic aorta, of whom 104 underwent descending TEVAR (group 1) and 31 were managed with MT (group 2). Freedom from adverse aorta-related events at 1, 3, and 5 years was significantly higher for patients who underwent descending TEVAR compared with those managed with MT (89.2%, 88.2%, and 84.0% vs 74.2%, 74.2%, and 74.2%, respectively; P = .026). The 1-, 3-, and 5-year survival rates for patients in the descending TEVAR group was 100%, 100%, and 100%, respectively, which was significantly higher than the survival of the MT group: 93.5%, 93.5%, and 81.9%, respectively (P = .002). On a univariate analysis among patients receiving MT, those who suffered adverse aorta-related events showed a higher prevalence of renal insufficiency (55.6% vs 9.1%; P = .003). In MT patients, multivariate analysis showed that renal insufficiency was the only independent risk factor associated with adverse aorta-related events (hazard ratio, 8.691; 95% confidence interval, 2.056-36.737; P = .003).
Based on our study, compared with MT, descending TEVAR might be the more favorable treatment for patients with IMH involving the ascending aorta and extending into the descending thoracic aorta. Patients with renal insufficiency are more likely to experience adverse aorta-related events, which implies the need for subsequent intervention or an increased risk of mortality. The risk factor would be helpful for clinical decision-making.
升主动脉壁内血肿（IMH）的最佳治疗方法仍存在争议。本研究旨在分析急性IMH累及升主动脉并延伸至降主动脉的患者的治疗结果，比较降主动脉腔内修复术（TEVAR）与药物治疗（MT）的疗效，并评估与主动脉不良事件相关的危险因素。
我们回顾性分析了2012年1月至2019年12月期间所有诊断为急性IMH累及升主动脉并延伸至降主动脉的患者。随访期间的主要终点是与主动脉疾病相关的死亡以及需要手术或血管腔内治疗的主动脉相关不良事件，如主动脉破裂、主动脉疾病进展或内漏。
我们共确定了135例急性IMH累及升主动脉并延伸至降主动脉的患者，其中104例行降主动脉TEVAR（第1组），31例接受MT治疗（第2组）。与接受MT治疗的患者相比，接受降主动脉TEVAR治疗的患者在1年、3年和5年时无主动脉相关不良事件的比例显著更高（分别为89.2%、88.2%和84.0%，而MT组分别为74.2%、74.2%和74.2%；P = 0.026）。降主动脉TEVAR组患者的1年、3年和5年生存率分别为100%、100%和100%，显著高于MT组的生存率：分别为93.5%、93.5%和81.9%（P = 0.002）。在接受MT治疗的患者进行单因素分析时，发生主动脉相关不良事件的患者肾功能不全的患病率更高（55.6%对9.1%；P = 0.003）。在MT患者中，多因素分析显示肾功能不全是与主动脉相关不良事件相关的唯一独立危险因素（风险比，8.691；95%置信区间，2.056 - 36.737；P = 0.003）。
基于我们的研究，与MT相比，降主动脉TEVAR可能是治疗IMH累及升主动脉并延伸至降主动脉患者的更优选择。肾功能不全的患者更有可能发生主动脉相关不良事件，这意味着需要后续干预或增加死亡风险。该危险因素将有助于临床决策。
