急性Stanford B型主动脉夹层治疗研究进展
Research Progress in the Treatment of Acute Stanford Type B Aortic Dissection
DOI: 10.12677/ACM.2022.123332, PDF, HTML, XML, 下载: 321  浏览: 491 
作者: 申世轩:郑州大学人民医院河南省人民医院心外科,河南 郑州;张海涛*:国家心血管病中心中国医学科学院阜外医院成人心外科恢复室,北京
关键词: B型主动脉夹层TEVAR技术治疗Type B Aortic Dissection TEVAR Technique Treatment
摘要: 急性Stanford B型主动脉夹层(Acute Stanford type B Aortic Dissection, ATBAD)由于发病率和死亡率高,需要多学科方法评估、了解其特征、快速分类,进行药物控制、主动脉开窗术、腔内修复术等治疗。然而何时提供何种治疗方式最佳通常不明确。本文从单纯性、复杂性ATBAD的治疗上入手,对国内外最新治疗进展进行综述,以期对ATBAD患者提供更多获益。
Abstract: Due to the high incidence and mortality of Acute Stanford type B Aortic Dissection (ATBAD), a multidisciplinary approach is required to evaluate, understand its characteristics and classify it quickly, and drug control, aortic fenestration, endovascular repair and other treatments need to be performed. However, it is often unclear when and which treatments are best offered. This article starts from the treatment of simple and complex ATBAD, and reviews the latest treatment progress at home and abroad, in order to provide more benefits for ATBAD patients.
文章引用:申世轩, 张海涛. 急性Stanford B型主动脉夹层治疗研究进展[J]. 临床医学进展, 2022, 12(3): 2310-2314. https://doi.org/10.12677/ACM.2022.123332

1. 引言

ATBAD是一种威胁国人生命的常见危重症。药物治疗(降血压、调节心率)一直是ATBAD的基础治疗方式,随着经验逐渐积累、支架设计、手术技术的不断改进,ATBAD的治疗取得了长足的发展。尽管手术技术和围术期管理取得了进步,但这仍然是一个临床难题。单纯性ATBAD治疗上主要以控制血压、心率为标准治疗方式,目前有研究表明可能有一部分高危急性单纯性夹层患者也可以从胸主动脉腔内修复术(Thoracic Endovascular Aortic Repair, TEVAR)中受益 [1]。在复杂性ATBAD治疗上,TEVAR已作为首选方式得到了广泛的认可 [2]。TEVAR正在迅速超越传统的开放式手术干预,成为接受胸降主动脉干预患者的理想手术方式,并且正在探索是否适用于升主动脉和主动脉弓病变 [3]。这种转变代表了技术进步、医生在主动脉内移植方面的丰富经验以及与TEVAR相关的较低发病率和死亡率。早期TEVAR通过覆盖入口撕裂、促进假腔血栓形成和诱导主动脉壁重塑来降低主动脉相关事件并提高长期主动脉特异性存活率。但目前仍缺乏足够支持数据,引起了围绕ATBAD最佳治疗策略的争议。

2. 定义与分类

ATBAD是指初始症状出现2周内,主动脉内膜破裂处常位于近段降主动脉,夹层的范围仅限于降主动脉或延伸入腹主动脉,但不累及升主动脉,约占夹层病例数的33% [4]。急性B型夹层可分为单纯性和复杂性,目前研究并未对表现为复杂性和单纯性夹层的患者进行明确区分。单纯性ATBAD一般指无并发症的B型夹层。2017年欧洲血管外科学会(European Society for Vascular Surgery, ESVS)对复杂性ATBAD定义为:存在以下症状的B型夹层:快速主动脉扩张、主动脉破裂、低血压/休克、内脏/肢体缺血、截瘫/下肢轻瘫、主动脉周围血肿、复发性或难治性疼痛或顽固性高血压 [5]。

3. 单纯性急性B型主动脉夹层的治疗

Wheat等人于1965年首次提出了抗冲击药物治疗的概念,即通过规范的药物治疗减小血流冲击力,降低主动脉破裂风险,从而预防夹层破裂 [6]。根据当前的国际指南,优化心血管控制(血压和心率)一直是单纯性ATBAD的主要治疗方式,首选的药物是β受体阻滞剂,它可以通过降低左心室射血力来降低血压。有文献报道,单纯性ATBAD的致死率较低,接受药物治疗的患者在1个月时的生存率为89%,在1年内为84%,在5年内高达80% [7] [8]。早期许多共识性声明建议仅对急性单纯性B型主动脉夹层进行最佳药物治疗 [9] [10] [11] [12]。

另有研究指出,药物治疗的短期结局优于开放手术,但长期结局优势不显著,接受最佳药物治疗(best medical treatment, BMT)的患者1年,5年和10年死亡率分别为10%,20%和30%,仅用药物治疗的1年假性管腔血栓形成率为35%,此外,在4年时,主动脉的动脉瘤变性率为25%~50%,到6年时,高达59%的患者已经接受了外科手术干预,长期并发症已引起对单纯性ATBAD血管内治疗的更多兴趣 [13] [14]。Yong-Lin Qin等人研究指出,TEVAR用于单纯性ATBAD患者,与BMT组比较,早期死亡率并无差异,并且可降低晚期发病率和死亡率,验证了TEVAR在单纯性ATBAD的可行性 [15]。仅接受药物治疗的单纯性ATBAD患者的自然病程,随着时间的推移,大多数患者的药物治疗将失败,6 年无干预生存率为41%,并且指出接受主动脉干预(TEVAR或开放手术)的患者比仅接受药物治疗的患者具有显著的生存优势 [14]。

但是,目前尚无前瞻性、随机对照试验评估BMT与BMT + TEVAR治疗单纯性ATBAD的结果。第一个回顾性比较BMT与BMT + TEVAR治疗单纯性B型夹层的随机对照试验(randomized controlled trial, RCT)是INSTEAD试验,招募了140例患有慢性夹层的患者,他们在症状发作后2至52周(集中在10至12周)进行了TEVAR,TEVAR的短期预后没有改善,但是,在5年的随访中,TEVAR的主动脉特异性死亡率较低(6.9%比19.3%,p = 0.04),并发症更少(27.0%对46.1%,p = 0.04) [16]。对于单纯性ATBAD,评价TEVAR优于BMT的数据有限,大多数评估TEVAR 用于单纯性ATBAD的研究均无控制的前瞻性或回顾性的队列研究。此外,也没有统一报告和确定夹层发作与并发症发生后的干预时间。

由此可见,尽管进行了最佳药物治疗(BMT),但单纯性ATBAD患者仍有严重疾病进展的风险,需要延迟干预。药物控制仍然是单纯性ATBAD的一线治疗方案,然而,药物管理的带来的单纯性ATBAD长期预后不佳以及对TEVAR的信心日益增强,自然导致研究人员争论早期 TEVAR是否可以减少单纯性ATBAD的长期并发症。只有在单纯性ATBAD的急性期(2周)进行前瞻性、随机对照试验,并具有足够的能力监测长期死亡率差异,才能确定是否所有患者都应早期行TEVAR治疗。

4. 复杂性急性B型主动脉夹层的治疗

积极的降压和抗冲击治疗仍然是治疗复杂性ATBAD的优先处理措施,然而对于复杂病例,例如脏器缺血,尤其是肠系膜动脉缺血,需要在短时间内进行手术处理。手术主要包括开胸手术、主动脉开窗手术、介入手术、TEVAR。开胸手术是最早应用于复杂夹层的技术,它涉及创建远端管腔折返部位以减轻真腔的压缩来解决灌注不良问题,相比TEVAR,传统开放手术病死率高、术后严重并发症多 [17]。主动脉开窗术比全主动脉置换术的侵入性更小,不需要体外生命支持并保留肋间动脉、腰动脉,从而降低截瘫的风险,外科主动脉开窗术是治疗ATBAD缺血性并发症的一种有效且持久的选择,特别是适用于没有主动脉扩张的患者 [18],但开窗手术难度较大,推广困难,烟囱技术容易出现gutter内漏、远期支架内闭塞发生率高。介入手术包括在夹层近端置换病变主动脉以恢复真腔血流量,并在左心体外循环下进行。TEVAR的微创、图像引导特性为开放手术提供了一种有吸引力的替代方案,主要包括在近端入口撕裂处(以及整个胸主动脉)支架置入主动脉以减少流入假腔并恢复稳健的真腔流量。

Giovanni Dialetto等人研究发现,TEVAR是治疗复杂性ATBAD的有效选择,早期死亡率依然很高,但TEVAR是治疗复杂 B 型主动脉夹层的有效选择,即使在术前状况较差的患者中,TEVAR比单纯药物治疗取得了更好的治疗效果 [19]。Ahmad Zeeshan等人研究比较了TEVAR与常规开放手术和药物治疗复杂性ATBAD的结果,TEVAR组较常规开放手术和药物治疗组在1年、3年、5年的生存率分别提高了24%、27%、35%,证实了TEVAR可明显提高早期预后和中期生存率 [20]。Joseph E Bavaria等人也在一项TEVAR治疗复杂性ATBAD的五年随访中,证实了TEVAR在复杂性ATBAD中主动脉重塑效果、生存率、二次干预和不良事件发生率中的优势 [21]。有文献指出,传统的复杂性ATBAD 开放修补术的死亡率,中风率和肾衰竭率分别为 15%至 30%,10%和20% [22] [23]。相反,TEVAR 被证明具有以下优点:提供的院内死亡率低至7.3%,住院中风发病率低至1.9%至6.4%,30天死亡率仅为8% [22] [24]。多个临床试验研究表明:复杂性ATBAD患者行TEVAR治疗的住院死亡率和长期结果优势 [25] [26]。目前多个共识、声明建议TEVAR作为治疗复杂型ATBAD的首选治疗方法 [2] [9] [13] [27]。

但是,目前复杂性ATBAD情况下比较血管内修复与开放修复的随机对照试验较少,目前尚无前瞻性试验证明传统手术方式和TEVAR干预的长期疗效,可用的数据大多数仅评估短期和中期结果。随着长期数据的获得,TEVAR的再干预率似乎比传统的开放式干预要高。尽管TEVAR对复杂性ATBAD患者有益,但内脏灌注不良的患者预后较差 [28] [29]。研究报道,内脏缺血患者的死亡率很高,手术和血管内治疗后的死亡率相似 [29]。Elizabeth L Norton等人研究表明,ATBAD伴有灌注不良的患者可以通过血管内开窗/支架置入术进行管理,具有良好的短期和长期结果 [30]。这些结果表明,内脏缺血的早期诊断和干预似乎至关重要。

5. 总结

药物控制依然是ATBAD的基础治疗方案,TEVAR在单纯性ATBAD中似乎可改善主动脉重塑并减少疾病进展,但仍缺乏大规模前瞻性临床试验验证其长期效果。在复杂性ATBAD中TEVAR较传统手术方式发病率、死亡率以及远期并发症的减少,已成为一线治疗方案。TEVAR治疗ATBAD的前景光明,随着未来医疗技术水平、支架技术、影像学等多学科的不断发展,ATBAD患者的诊疗也将会进一步提高。

NOTES

*通讯作者。

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