Natural history of 40-50 mm root/ascending aortic aneurysms in the current era of dedicated thoracic aortic clinics
Natural history of 40-50 mm root/ascending aortic aneurysms in the current era of dedicated thoracic aortic clinics
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DOI：
10.1093/ejcts/ezw123
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发表时间：
2016-09-01
影响因子：
3.4
通讯作者：
Bolotin, G.
中科院分区：
文献类型：
--
作者：
Gagne-Loranger, Maude;Dumont, Eric;Bolotin, G.
目的：根部/升主动脉瘤的自然病史基于20世纪80年代至90年代的研究。影像学和随访指南基于这些研究。专门的胸主动脉诊所（TAC）确保严格的患者/成像随访和严格的血压（BP）控制。本研究的目的是评估在当前专用TAC.METHOD时代，药物治疗根部/升主动脉瘤的自然史：通过前瞻性收集的数据库确定了251例40-50 mm根部/升主动脉瘤（所有其他主动脉段< 40 mm）患者。在专门的TAC中对患者进行随访。系列（12-18个月间隔）胸腹部计算机断层扫描（CT），严格的BP控制（24小时动脉血压监测）和等长和运动BP monitoring.RESULTS：平均年龄为65.4 +/- 10.9岁，29.5%的患者是女性。59%的患者有高血压。48.2%的患者动脉瘤病因为动脉粥样硬化，25.1%的患者为瓣环扩张，21.5%的患者为二尖瓣相关，5.2%的患者为其他病因。初始动脉瘤直径为46 ± 2.6 mm; 74.1%在46和50 mm之间。平均随访（FU）时间为4.3 ± 2.5年，平均2.8 ± 1.1 CT/患者。在随访期间，主动脉尺寸/年的增加为0.42 +/- 0.82 mm/年（根部/升主动脉）（40-45 mm：0.55 +/- 0.77 mm/年vs 46-50 mm：0.38 +/- 0.84 mm/年; P = 0.14），主动脉弓为0.66 +/- 1.11 mm/年，降主动脉中段为0.45 +/- 1.06 mm/年，主动脉裂孔为0.43 +/- 1.0 mm/年，肾上主动脉为0.39 ± 0.87 mm/年，肾下主动脉为0.41 ± 1.03 mm/年。30例患者（12%）在随访期间接受了手术。手术指征为8例患者的主动脉瓣疾病进展，14例患者的根部/升主动脉进展> 50 mm，8例患者在FU期间进行根部/升主动脉置换术，无进展。1例患者在随访3年后因壁内血肿紧急手术。无主动脉弓远端手术，手术死亡率为0/30（0%）。30%的患者需要同时进行半弓置换。4例患者在随访期间死亡，所有死亡均由非主动脉原因引起。无急性动脉瘤相关事件发生率和5年生存率分别为99.4%和97.6%。结论：本研究表明，在专用TAC主动脉中随访的40-50 mm根部/升段动脉瘤的生长率低于以往报道的系列。无糖尿病相关事件和生存率很高，因此需要长期随访。这些结果挑战了现行指南中关于影像学检查的间隔时间以及主动脉成像的范围和类型。
OBJECTIVE: The natural history of root/ascending aortic aneurysms is based on studies from the 1980s to 1990s. Imaging and follow-up guidelines are based on these studies. Dedicated thoracic aortic clinics (TAC) ensure strict patient/imaging follow-up and tight blood pressure (BP) control. The aim of this study was to evaluate the natural history of medically treated root/ascending aortic aneurysms in the current era of dedicated TAC.METHOD: Two hundred and fifty-one patients with 40-50 mm root/ascending aneurysms (all other aortic segments of < 40 mm) were identified through a prospective collected databank. Patients were followed in a dedicated TAC. Serial (12-18 months interval) thoraco-abdominal computed tomographies (CTs), tight BP control (24 h arterial blood pressure monitoring) and isometric and exercise BP monitoring were performed.RESULTS: The mean age was 65.4 +/- 10.9 years; 29.5% of patients were female. Fifty-nine percent of patients had high BP. Aneurysm aetiology was atherosclerotic in 48.2% of patients, annulo-ectasia in 25.1% of patients, bicuspid valve-related in 21.5% of patients and another aetiology in 5.2% of patients. The initial aneurysm diameter was 46 +/- 2.6 mm; 74.1% being between 46 and 50 mm. The mean follow-up (FU) was 4.3 +/- 2.5 years, with a mean of 2.8 +/- 1.1 CTs/pt. During FU, the increase in aortic size/year was 0.42 +/- 0.82 mm/year for the root/ ascending aorta (40-45 mm: 0.55 +/- 0.77 mm/year vs 46-50 mm: 0.38 +/- 0.84 mm/year; P = 0.14), 0.66 +/- 1.11 mm/year for the arch, 0.45 +/- 1.06 mm/year for the mid-descending aorta, 0.43 +/- 1.0 mm/year for the aortic hiatus, 0.39 +/- 0.87 mm/year for the suprarenal aorta and 0.41 +/- 1.03 mm/year for the infrarenal aorta. Thirty patients (12%) were operated during FU. Surgical indication was disease progression on the aortic valve in 8 patients, root/ascending aorta progression of > 50 mm in 14 patients and a root/ascending aorta replacement during FU without progression in 8 patients. One patient was operated emergently for an intramural haematoma after 3 years of followup. No patient required operation distal to the aortic arch. Operative mortality was 0/30 (0%). Thirty percent of patients required a concomitant hemiarch replacement. Four patients died during FU, with all deaths resulting from non-aortic causes. Freedom from acute aortic-related event and survival at 5 years were respectively 99.4 and 97.6%.CONCLUSION: The present study suggests that the growth rate of 40-50 mm root/ascending aneurysms followed in a dedicated TAC aorta is lower than that shown in previously reported series. Freedom from aortic-related events and survival are high, thus necessitating long-term follow-up. These results challenge the current guidelines in terms of interval between imaging examinations and the extent and type of aortic imaging.