【作者】 贾鑫；

【导师】 郭伟；

【作者基本信息】 中国人民解放军军医进修学院 ， 外科学， 2012， 博士

【摘要】 目的本研究为国内首个关于B型主动脉夹层的多中心、前瞻性注册研究，主要比较主动脉腔内修复术（TEVAR）和药物保守治疗（OMT）对于B型夹层的早期和中期结果。方法本研究纳入自2007年1月至2010年12月国内四家血管中心收治的335名B型主动脉夹层患者，其中32例为复杂型夹层，303例诊断为非复杂型夹层，其中208例纳入TEVAR治疗组，95例纳入OMT治疗组。男性246例，女性89例，平均年龄53.7±18.1岁。ASA评分大于III级者51例（15.2％，51/335）。合并严重并发症包括12例肾脏缺血，8例肠缺血，16例先兆破裂，11例下肢缺血，1例截瘫。初始影像学资料显示，第一破口距LSA开口距离为32.6±28.9mm，294例（87.8%）夹层同时累及胸腹主动脉，41例（12.2％）夹层局限撕裂至胸主动脉水平，初始胸主动脉最大直径41.2±19.1mm；腹主动脉最大直径28.1±19.3mm。结果本组病例TEVAR操作技术成功率100％，40％（96/240）患者需要覆盖左侧锁骨下动脉，有15例（6.25％）患者需要腹膜外入路。复杂型夹层组中，6例患者住院期间死亡，死亡率为18.7％（6/32），脊髓损伤发生于3名（9.4％，3/32）患者。Logistic多因素逐步回归分析显示，ASA评分大于III级为围手术期死亡率独立危险因素。OMT组围手术期没有死亡及严重不良事件发生。非复杂TEVAR组中，2例（0.9％，2/208）患者术中发生逆行A型夹层，2例（0.9％，2/208）患者发生急性心急梗塞，6例（0.9％，2/208）患者术后发生肱动脉穿刺点假性动脉瘤。Logistic多因素逐步回归分析显示，年龄大于75岁为围手术期不良事件发生的独立危险因素。所有病例平均随访时间28.5±16.3月（范围1－58月），68％患者随访时间超过24月。Kaplan-Meier生存曲线分析显示，复杂型夹层48月生存率为61.7％，非主动脉相关生存率48月估计为70％，无主动脉相关不良事件的生存率48月为56.3％。TEVAR组48月生存率为82.7％，而OMT组48月生存率为69.1％，Log-rank检验两组没有统计学差异（P=0.0678）。非主动脉相关死亡的生存率曲线分析，TEVAR组48月生存率为88.1％；OMT组48月为73.8％，Log-rank检验两组间有统计学差异（P=0.0392）。TEVAR组中，有94.9％（151/159）患者主动脉没有进一步增长，胸主动脉最大直径自基线值41.5＋11.1mm缩小至37.3＋12.8mm；OMT组中，有39.7％（27/68）患者主动脉没有持续增长，胸主动脉直径增加的患者比例明显高于TEVAR组（P＝0.001）。OMT组主动脉最大直径自基线值40.7＋8.6mm增长至48.1＋9.3mm，同TEVAR组差别有统计学意义（P＝0.002）。TEVAR组胸主动脉完全血栓和重塑率达到88.4％（157/177），而在OMT组则只有22.1％（15/68），两组间差别有统计学意义（P＝0.001）。结论本研究初步表明，与OMT治疗相比，TEVAR治疗可以显著降低主动脉相关死亡率，可能会提高整体生存率和降低主动脉相关不良事件发生率，虽然后面两个参数在本研究中未呈现统计学差异。另外，与OMT治疗相比，TEVAR治疗可以促进夹层假腔血栓形成，提高胸主动脉重塑率，减少胸主动脉直径增长的风险。更多还原

【Abstract】 Objective: This prospective multi-center comparative study examined earlyand midterm results of medication and stentgraft therapies on the type Baorta dissection in China.Methods:335patients collected from four centers in China from January2007to Dec2010with type B aorta dissection were prospectively enrolledand treated by either optimal medication therapy (OMT) or thoracicendovascular aorta repair (TEVAR). There were246male and89femalepatients with an age of53.7±18.1years. American Society ofAnesthesiologists (ASA) classification greater than class III was present in15.2%patients. The baseline maximum diameter of thoracic aorta was41.2±19.1mm, the distance from the left subclavian artery to the proximal entrytear was32.6±28.9mm, and dissection extended beyond the celiac axis in87.8%of cases.Results: there were208patients in the TEVAR group and95patients in theOMT group. Procedural success was100%, and there was no death duringindex hospitalization in both groups. In the TEVAR group, two patients(0.9%) suffered from retrograde type A dissection, six (2.9%) from brachialaccess pseudo-aneurysm, and two (0.9%) suffered from paraplegia orparaparesis. For in-hospital outcome, multivariate analysis showed that agegreater than75years and ASA class greater than III were independentpredictors of major early adverse events. Average follow-up time for hospitalsurvivors was28.5±16.3months (range1.0–58). In the OMT group, fivepatients died for rupture of enlarged false lumen, and six patients expiredsuddenly for unknown reasons. Fourteen cases required crossover to TEVAR (n=12) or surgical conversion (n=2). In the TEVAR group, ninepatients required reintervention or surgical conversion, and one died ofpostoperative multi-organ failure. One patient expired for delayedretrograde type A dissection, and four expired suddenly for unknownreasons. The Kaplan-Meier analysis of survival probability at two years andfour years was87.5%and82.7%with TEVAR and77.5%and69.1%respectively with OMT (log-rank test P=0.0678). The estimated cumulativefreedom from aorta-related death at two and four years were91.6%and88.1%with TEVAR and82.8%and73.8%with OMT (log-rank testP=0.0392). The maximum thoracic aorta shrank from42.4±23.1mm to37.3±12.8mm in the TEVAR group, and the maximum thoracic aorta in theOMT group expanded from40.7±18.6mm to48.1±17.3mm. Theincidence of increased thoracic aorta is significantly higher in the OMT(60.3%) than in the TEVAR (5.1%)(P=0.001).Conclusion: This was the first prospective multi-center comparative study onthe treatment of type B aorta dissection in China. TEVAR turned out to havea significantly lower aorta-related mortality compared with OMT, and aseemingly lower overall mortality and adverse events rate. Furthermore,TEVAR was also found to be able to enhance the thoracic remodeling rate.更多还原