Prospective study of the natural history of thoracic aortic aneurysms
Prospective study of the natural history of thoracic aortic aneurysms
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DOI：
10.1016/s0003-4975(97)00414-1
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发表时间：
1997-06-01
影响因子：
4.6
通讯作者：
Griepp, RB
中科院分区：
文献类型：
--
作者：
Juvonen, T;Ergin, MA;Griepp, RB
背景决定是否建议切除中等大小的胸降段和胸腹部动脉瘤，需要权衡相对较高的死亡率和与手术相关的截瘫的重大风险与动脉瘤自发破裂的可能性，几乎总是致命的结果。为了更好地确定动脉瘤破裂的风险，我们对那些没有接受过中大型降胸和胸腹联合动脉瘤手术的患者进行了一项前瞻性研究。患者在第二次计算机断层扫描时入组：三维计算机生成的重建允许确定每个研究的几个尺寸参数，包括降主动脉和腹部最大扩张部位的直径和横截面积以及总胸腹表面积。系列研究的比较允许计算这些尺寸的年变化率。在114例患者中，8例死于与动脉瘤无关的原因，26例死于动脉瘤破裂，20例符合先前确定的手术标准，60例未手术或破裂存活。多变量回归分析确定降主动脉和腹主动脉的最大直径是破裂的独立危险因素，以及年龄较大，存在甚至不典型的疼痛和慢性阻塞性肺疾病史。分段指数模型能够构建一个方程，该方程允许计算已知风险因素值的患者的破裂率，以及给定个体在指定时间间隔内的破裂概率。因为使用这个公式--基于容易确定的风险因素（年龄、疼痛、慢性阻塞性肺病、最大胸主动脉和最大腹主动脉直径）--允许对每个患者在给定时间间隔内相当准确地估计动脉瘤破裂的风险，我们目前的做法是，当1年内计算的破裂风险超过择期手术的预期死亡率时，建议手术，而不是依赖于几乎完全基于动脉瘤大小的一般手术指南。(C)1997年，美国胸外科医师协会（Society of Thoracic Surgeons）
Background. The decision whether or not to recommend resection of moderately large descending thoracic and thoracoabdominal aneurysms requires weighing the relatively high mortality and significant risk of paraplegia associated with operation against the likelihood that the aneurysm will rupture spontaneously, with an almost invariably fatal outcome. To better define the risk of aneurysm rupture, we undertook a prospective study of patients who had not had operation on their moderately large descending thoracic and thoracoabdominal aneurysms.Methods. Patients were enrolled at the time of their second computed tomographic scans: three-dimensional computer-generated reconstructions allowed determination of several dimensional parameters for each study, including diameters and cross-sectional areas at the site of maximal dilatation in the descending aorta and in the abdomen as well as total thoracoabdominal surface area. Comparisons of serial studies permitted calculation of yearly rates of change in these dimensions.Results. Of 114 patients, 8 died of causes unrelated to the aneurysm, 26 died of rupture, 20 met previously determined criteria for operation, and 60 survived without operation or rupture. Multivariate regression analysis identified maximal diameter in the descending and in the abdominal aorta as independent risk factors for rupture, as well as older age, the presence of even uncharacteristic pain, and a history of chronic obstructive pulmonary disease. A piecewise exponential model enabled construction of an equation allowing calculation of rate of rupture in patients in whom the values of the risk factors are known, and also of the probability of rupture in a given individual over a specified time interval.Conclusions. Because using this equation--based on easily determined risk factors (age, pain, chronic obstructive pulmonary disease, maximal thoracic and maximal abdominal aortic diameter)--allows the risk of aneurysm rupture within a given interval to be estimated fairly accurately for each individual patient, it is our current practice to recommend operation when the calculated risk of rupture within 1 year exceeds the anticipated mortality of elective operation, rather than relying on general operative guidelines based almost exclusively on aneurysm size. (C) 1997 by The Society of Thoracic Surgeons.