Emergency endovascular stent-grafting for life-threatening acute type B aortic dissections.
Emergency endovascular stent-grafting for life-threatening acute type B aortic dissections.
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DOI：
10.1016/j.athoracsur.2004.03.107
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发表时间：
2004-01
期刊：
影响因子：
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通讯作者：
L. Duebener;P. Lorenzen;G. Richardt;M. Misfeld;A. Nötzold;F. Hartmann;H. Sievers;V. Geist
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文献类型：
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作者：
L. Duebener;P. Lorenzen;G. Richardt;M. Misfeld;A. Nötzold;F. Hartmann;H. Sievers;V. Geist
背景关于急性B型主动脉夹层患者的最佳治疗方法仍存在相当大的争议。患有复杂疾病的患者对于心血管治疗尤其具有挑战性。降主动脉急性夹层早期手术并发症危及生命，死亡率高。血管内支架移植术正在发展成为一种主要用于慢性期B型主动脉夹层的替代治疗方法。目前尚不清楚是否血管内支架植入术是安全和有效的急性B型主动脉dispens.METHODSIn 10例患者（7男，3女;平均年龄，59.2岁;范围，46至65岁），血管内支架植入术是在11.0 ± 5.9小时（范围，4至24小时）的诊断并发症。急性干预的适应症包括破裂、血胸、危及生命的灌注不良和顽固性疼痛。在手术暴露股动脉后，采用逆行血管内途径，将由聚酯覆膜镍钛合金（Talent，World Medical;平均直径，40 ± 4 mm;长度，10 cm）组成的自膨式支架假体置入锁骨下动脉远端的降主动脉中。在出院前和随访时，使用计算机断层扫描进行主动脉成像。10例患者中有9例（90%）的主动脉入口可以用血管内支架完全闭塞。早期死亡率为20%（2/10）：1例患者在支架远端内膜层破裂后死亡，1例患者因持续性灌注不良在腹主动脉开窗术后死于失血性休克。3例患者（30%）需要连续手术治疗：适应症包括急性发生逆行性A型主动脉夹层、断裂导丝导致的急性支架脱位和继发性泄漏以及血管内支架植入术后6个月降主动脉瘤晚期形成。没有手术或晚期deaths. CONCLUSION我们的经验提供了一些证据，早期死亡率危及生命的急性B型主动脉夹层可能会减少紧急血管内支架植入术，这种形式的治疗是一个有前途的治疗选择。在复杂急性B型主动脉夹层危及生命的情况下，改进，特别是支架设计和应用，可能会进一步改善患者的预后。
BACKGROUNDThere is still a considerable controversy regarding optimal treatment for patients with acute type B aortic dissection. Patients with complicated disease are particularly challenging for cardiovascular treatment. Early surgery for acute dissections of the descending aorta with life-threatening complications is known to carry a high mortality. Endovascular stent grafting is developing as an alternative treatment mainly for chronic stages of type B aortic dissection. It is not clear whether endovascular stent grafting is safe and effective in emergency treatment of acute type B aortic dissection.METHODSIn 10 patients (7 men, 3 women; mean age, 59.2 years; range, 46 to 65 years), endovascular stent grafting was performed within 11.0 ± 5.9 hours (range, 4 to 24 hours) of diagnosis of complications. Indications for acute intervention included contained rupture, hematothorax, life-threatening malperfusion, and refractory pain. Using a retrograde endovascular route after surgical exposure of the femoral artery, self-expanding stent prostheses consisting of polyester-covered Nitinol (Talent, World Medical; mean diameter, 40 ± 4 mm; length, 10 cm) were placed into the descending aorta distal to the subclavian artery. Before discharge and on follow-up visits, imaging of the aorta was performed using computed tomography.RESULTSIn 9 of 10 patients (90%), the primary entry could be completely occluded with the endovascular stent. Early mortality was 20% (2 of 10): 1 patient died after disruption of the intimal layer distal to the stent, and 1 patient died in hemorrhagic shock after surgical fenestration of the abdominal aorta for persistent malperfusion. Three patients (30%) required consecutive surgical treatment: indications included acute development of retrograde type A aortic dissection, acute stent dislocation by fractured wires and secondary leakage, and late formation of an aneurysm of the descending aorta 6 months after endovascular stent grafting. There were no surgical or late deaths.CONCLUSIONSOur experience provides some evidence that early mortality of life-threatening acute type B aortic dissection may be reduced by emergency endovascular stent grafting and that this form of treatment is a promising therapeutic option. Refinements, especially in stent design and application, may further improve the prognosis of patients in the life-threatening situation of complicated acute type B aortic dissection.