王雪鋼,白斗,武少輝,張效杰,蔣嵐杉
作者單位: 621000 四川省綿陽(yáng)市中心醫(yī)院血管外科
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急性Stanford B型主動(dòng)脈壁間血腫13例臨床分析
王雪鋼,白斗,武少輝,張效杰,蔣嵐杉
【摘要】目的分析急性Stanford B型主動(dòng)脈壁間血腫的臨床特點(diǎn)及診治情況。方法2013年6月—2014年8月共收治13例急性Stanford B型主動(dòng)脈壁間血腫患者,入院初始均采用降壓、止痛、鎮(zhèn)靜為主的藥物治療,通過(guò)CT血管造影(CTA)嚴(yán)密觀察,對(duì)于病情發(fā)展者選擇主動(dòng)脈腔內(nèi)修復(fù)術(shù)。結(jié)果藥物治療過(guò)程中,5例患者血腫均較穩(wěn)定,經(jīng)藥物治療后緩解出院;2例10 d后血腫增大而進(jìn)行腔內(nèi)修復(fù)術(shù);6例伴發(fā)有主動(dòng)脈潰瘍而選擇腔內(nèi)手術(shù)。5例藥物治療患者隨訪3~14個(gè)月,CTA示壁間血腫均有不同程度吸收,未再次出現(xiàn)胸背部疼痛癥狀。8例腔內(nèi)治療者隨訪6個(gè)月,血腫大部分已吸收,未發(fā)生內(nèi)漏、支架移位等并發(fā)癥。結(jié)論對(duì)急性Stanford B型主動(dòng)脈壁間血腫可在CTA嚴(yán)密觀察下,首先進(jìn)行降壓、止痛、鎮(zhèn)靜為主的藥物治療,若血腫增大或伴發(fā)主動(dòng)脈潰瘍等情況,則應(yīng)及時(shí)行腔內(nèi)修復(fù)術(shù)。
【關(guān)鍵詞】主動(dòng)脈壁間血腫,Stanford B型,急性;藥物治療;腔內(nèi)修復(fù)術(shù)
主動(dòng)脈壁間血腫(aortic intramural hemotoma,AIH)通常被視為主動(dòng)脈夾層(aortic dissection,AD)的一種先癥病變或特殊類型,它與穿透性粥樣硬化主動(dòng)脈潰瘍(penetrating atherosclerotic aortic ulcer,PAU)和AD統(tǒng)稱為急性主動(dòng)脈綜合征(acute aortic syndromes, AAS)。在急性主動(dòng)脈綜合征中AIH占10%~30%[1],在臨床上其實(shí)并不少見(jiàn),其病因復(fù)雜,機(jī)制尚不明確。對(duì)于局限于降主動(dòng)脈的Stanford B型壁間血腫,治療仍存爭(zhēng)議,但已有少量病例報(bào)道采用腔內(nèi)支架治療取得了良好效果[2]?,F(xiàn)將筆者對(duì)急性Stanford B主動(dòng)脈壁間血腫的治療經(jīng)驗(yàn)總結(jié)報(bào)道如下。
1臨床資料
1.1一般資料2013年6月—2014年8月共收治Stanford B型主動(dòng)脈壁間血腫患者13例,均符合急性Stanford B型主動(dòng)脈壁間血腫診斷標(biāo)準(zhǔn)[3]:(1)發(fā)病時(shí)間<14 d;(2)CT血管造影(CTA)未見(jiàn)明確的內(nèi)膜撕裂口和直接的血流交通;(3)血腫厚度>5 mm。均經(jīng)行CTA檢查確診。其中男8例,女5例;年齡47~76(64.5±2.3)歲;入院時(shí)收縮壓均>150 mmHg,平均收縮壓(162±8)mmHg;發(fā)病至就診時(shí)間(17.2±4.5)h。
1.2臨床特征所有患者均有不同程度的胸背部疼痛,血壓明顯升高(收縮壓>150 mmHg),CTA均提示Stanford B型主動(dòng)脈壁間血腫,心電圖未見(jiàn)明顯異常(無(wú)1例心肌梗死患者),3例患者心臟彩超提示有少量胸腔積液。
1.3治療與預(yù)后入院后均使用硝普鈉、艾司洛爾進(jìn)行降壓、控制心率(收縮壓控制在110~130 mmHg,心率控制在70次/min左右);同時(shí)予以止痛、鎮(zhèn)靜對(duì)癥治療,嚴(yán)密觀察病情變化。治療7~10 d后行CTA檢查,其中5例顯示血腫穩(wěn)定,未發(fā)現(xiàn)主動(dòng)脈破口及潰瘍,癥狀緩解后出院;2例血腫有增大,選擇人工血管覆膜支架腔內(nèi)修復(fù)術(shù)治療;6例伴發(fā)有主動(dòng)脈潰瘍,也選擇腔內(nèi)修復(fù)術(shù)手術(shù)治療。見(jiàn)表1。
1.4隨訪結(jié)果5例藥物治療患者隨訪3~14個(gè)月,中位時(shí)間8.4個(gè)月,CTA示壁間血腫均有不同程度吸收,未再次出現(xiàn)胸背部疼痛癥狀。8例腔內(nèi)治療者均隨訪6個(gè)月,血腫大部分已吸收,未發(fā)生內(nèi)漏、支架移位等并發(fā)癥。所有患者未發(fā)展成典型的主動(dòng)脈夾層及主動(dòng)脈瘤。見(jiàn)表1。
表1 13例AIH基本資料及治療、隨訪情況
2討論
2.1病理基礎(chǔ)AIH的主動(dòng)脈內(nèi)膜完整,血腫與主動(dòng)脈管腔之間無(wú)直接血液交通,但在AIH的發(fā)展過(guò)程中可發(fā)生內(nèi)膜破裂。AIH位于中膜與外膜之間,血腫離外膜非常近,因此AIH比典型AD更易破裂,對(duì)于AIH的治療重點(diǎn)就在于預(yù)防血腫繼續(xù)發(fā)展[4]。主動(dòng)脈壁間血腫的預(yù)后,一是與主動(dòng)脈是否有穿透性潰瘍有關(guān);二是與是否仍有撕裂的內(nèi)膜片存在有關(guān);三是與血壓控制是否穩(wěn)定有關(guān)[5]。治療方式的選擇及治療重點(diǎn)也與此息息相關(guān)。另外,Ⅲ、Ⅳ類夾層可以伴有主動(dòng)脈壁間血腫,或者由AIH演變而來(lái)。Evangelis等[6]證明AIH最常見(jiàn)并發(fā)癥是形成主動(dòng)脈瘤或假性動(dòng)脈瘤,完全吸收僅占1/3,僅有少部分發(fā)展為經(jīng)典AD。所以,藥物治療的目的是控制血壓、心率,盡量使血腫在穩(wěn)定的狀況下自我逐步吸收,減少或杜絕向AD發(fā)展。入院后行早期強(qiáng)化藥物治療以恢復(fù)正常血壓和減少左心室射血分?jǐn)?shù)為目標(biāo),從而阻止血腫繼續(xù)延伸或主動(dòng)脈壁破裂,減少外科手術(shù)的干預(yù)[7]。
2.2治療方式有研究者中期隨訪主動(dòng)脈壁間血腫患者后分析,于Stanford A型患者,外科手術(shù)治療可降低病死率,對(duì)大多數(shù)B型主動(dòng)脈壁內(nèi)血腫患者,藥物治療效果好(目前藥物治療主要以控制血壓、心率為主,從而達(dá)到緩解疼痛,穩(wěn)定血腫的目的),介入覆膜支架對(duì)有破裂風(fēng)險(xiǎn)的高危患者臨床效果滿意。劉剛等[8]治療16例壁間血腫患者后指出:A型AIH應(yīng)積極外科手術(shù)替換病變血管,對(duì)于B型AIH可以在嚴(yán)密隨訪下行藥物治療,如果患者同時(shí)合并主動(dòng)脈潰瘍病變,可以選擇腔內(nèi)隔絕治療。另一些研究亦認(rèn)為,穩(wěn)定型或沒(méi)有并發(fā)癥的AIH應(yīng)首先采用內(nèi)科保守治療,而不是有創(chuàng)性干預(yù)治療[9]。本組也是均行藥物保守治療,在治療過(guò)程中發(fā)現(xiàn)血腫有發(fā)展或伴有潰瘍時(shí)才選擇行腔內(nèi)手術(shù)治療,并取得了良好的臨床效果。一項(xiàng)178例AIH的研究發(fā)現(xiàn)A型AIH與主動(dòng)脈夾層病死率無(wú)差別,應(yīng)用藥物治療的A型AIH有較高病死率,而B(niǎo)型AIH病死率低于主動(dòng)脈夾層,但差異無(wú)統(tǒng)計(jì)學(xué)意義[10]。B型患者手術(shù)的風(fēng)險(xiǎn)較大[11,12],30 d內(nèi)病死率達(dá)33%,保守治療病死率僅為8%。
國(guó)內(nèi)外大多數(shù)研究主張Stanford A 型AIH應(yīng)盡早手術(shù)治療,Stanford B 型AIH 采用內(nèi)科保守治療,但對(duì)疼痛、血壓難以控制、血腫厚度增大、合并主動(dòng)脈潰瘍、假腔對(duì)真腔有一定壓迫或有各種破裂先兆的Stanford B 型主動(dòng)脈壁間血腫應(yīng)采取積極的腔內(nèi)覆膜支架治療[13]。早期的腔內(nèi)支架植入可以對(duì)局部管壁起到加強(qiáng)的作用同時(shí)降低應(yīng)力的影響,可能對(duì)減少后期動(dòng)脈瘤形成有一定幫助[14]。隨著覆膜支架的廣泛使用,這一腔內(nèi)治療技術(shù)可以作為急診治療降低AD先兆破裂的一個(gè)方法。根據(jù)循證醫(yī)學(xué)經(jīng)驗(yàn)表明凡是懷疑急性主動(dòng)脈綜合征(acute aortic syndrome,AAS)者,為防止猝死,降低病死率,均應(yīng)積極給予外科干預(yù)治療,而且對(duì)有高血壓、糖尿病史患者的中老年人還應(yīng)在治療上更積極主動(dòng)為宜,提早選擇外科干預(yù)或支架被覆技術(shù)[15]。但是必須掌握好手術(shù)的指征及時(shí)機(jī),AIH外科手術(shù)治療的適應(yīng)證是:(1)受累主動(dòng)脈管徑≥60 mm;(2)主動(dòng)脈管徑和血腫厚度增大;(3)出現(xiàn)并發(fā)癥,如AD、主動(dòng)脈潰瘍、主動(dòng)脈瘤或破裂[16]。
對(duì)主動(dòng)脈增強(qiáng)CT提示有造影劑外溢、穿通性潰瘍、局限性?shī)A層形成,或胸腔積液等破裂傾向或形成典型Stanford B型主動(dòng)脈壁內(nèi)血腫傾向的患者[17],解剖條件適合的,可積極采用主動(dòng)脈腔內(nèi)覆膜支架置入術(shù)。本組患者中,筆者也僅僅是對(duì)保守治療過(guò)程中血腫有發(fā)展或伴有主動(dòng)脈潰瘍的患者行手術(shù)治療,對(duì)于血腫穩(wěn)定有吸收趨勢(shì)的則堅(jiān)持藥物保守治療。
綜述,對(duì)于Stanford B型AIH患者,早期以藥物保守治療為主,嚴(yán)密進(jìn)行CT隨訪,目標(biāo)是防止主動(dòng)脈破裂或避免出現(xiàn)經(jīng)典的AD進(jìn)展,以利選擇手術(shù)時(shí)機(jī)并減少實(shí)施復(fù)雜主動(dòng)脈手術(shù)的可能,這與美國(guó)胸心血管外科學(xué)會(huì)指南的治療原則也是一致的[18]。
參考文獻(xiàn)
1Bolger AF.Aortic intramural hemotoma[J].Heart,2008,94(12):1670-1674.
2Iyer VS,Mackenzie KS,Tse LW,et al.Early outcomes after elective and emergent endovascular repair of the thoracic aorta[J].J Vasc Surg,2006,43(4):677-683.
3Krukenberg E.Beitrage zur frage des aneurysma dissecans[J].Beitr Pathol Anat Allg Pathol,1920,67:329-351.
4Uchida K,Imoto K,Takahashi M,et al.Pathologic characteristics and surgical indications of superacute type A intramural hematoma[J].Ann Thorac Surg,2005,79(5):1518-1521.
5李棟林,張鴻坤,金煒,等.急性Stanford B型主動(dòng)脈壁間血腫的治療[J].中華普通外科雜志,2010,25(2):152-154.
6Evangelista A,Dominguez R,Sebastia C,et al.Long-term follow-up of aortic intramural hematoma: predictors of outcome[J].Circulation,2003,108(5):583-589.
7Grimm M,Loewe C,Gottardi R,et al.Novel insights into the mechanisms and treatment of intramural hematoma affecting the entire thoracic aorta[J].Ann Thorac Surg,2008,86(2):453-456.
8劉剛,鄭德志,陳彧,等.主動(dòng)脈壁間血腫的治療與轉(zhuǎn)歸[J].心肺血管病雜志,2013,32(6):717-719.
9Kang DH,Song JK,Song MG,et al.Clinical and echocardiographic outcomes of aortic intramural hemorrhage compared with acute aortic dissection[J].Am J Cardiol,1998,81(2):202-206.
10Harris KM,Braverman AC,Eagle KA,et al.Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection[J].Circulation,2012,126(11 Suppl 1):S91-S96.
11Shimokawa T,Ozawa N,Takanashi S,et al.Intermediate-term results of surgical treatment of acute intramural hematoma involving the ascending aorta[J].Ann Thorac Surg,2008,85(3):982-986.
12Attia R,Young C,Fallouh HB,et al.In patients with acute aortic intramural haematoma is open surgical repair superior to conservative management?[J].Interact Cardiovasc Thorac Surg,2009,9(5):868-871.
13查斌山,朱化剛.主動(dòng)脈壁間血腫的自然病程及CT表現(xiàn)[J/CD].中國(guó)血管外科雜志:電子版,2013,5(2):129-131.
14張學(xué)民,李清樂(lè),李偉,等.主動(dòng)脈壁間血腫的診斷和治療[J].中華普通外科雜志,2008,23(8):639-641.
15杜軍,王宏,馮樹(shù)行.主動(dòng)脈壁間血腫:一種心血管急危重癥[J/CD].中華臨床醫(yī)師雜志:電子版,2012,6(17):5205-5206.
16O’Gara PT,Desanctis RW.Acute aortic dissection and itsvariants:toward a common diagnostic and therapeutic approach[J].Circulation,1995,92(3):1376-1378.
17李臻,錢(qián)同剛.主動(dòng)脈壁內(nèi)血腫15例誤診分析[J].中國(guó)心血管病研究,2012,10(8):600-601.
18Hiratzka LF,Bakris GL,Beckman JA,et al.2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease[J].J Am Coll Cardiol,2010,55(14):e27-e129.
論著·臨床
The treatment experience of 13 cases with Stanford B type aortic intramural hematomaWANGXuegang,BAIDou,WUShaohui,ZHANGXiaojie,JIANGLanshan.DepartmentofVascularSurgery,MianyangCentralHospital,SichuanPro-vince,Mianyang621000,China
Correspondingauthor:JIANGLanshan,E-mail:422242431@qq.com
【Abstract】ObjectiveTo analyze the clinical characteristics, diagnosis and treatment experience of acute B type Stanford aortic intramural hematoma.MethodsFrom June 2013 to August 2014, 13 patients with acute B Stanford type aortic intramural hematoma were enrolled, the initial admission are treated with lower blood pressure, releasing pain and given sedation treatment, CT angiography (CTA) were performed to observe the disease progression, and patients with disease progression were treated with aortic endovascular repair.ResultsIn the course of drug treatment, 5 patients were more stable, after drug treatment, they were discharged from hospital, and 2 patients the intramural hematoma enlarged after 10 days, and they were treated with endovascular repair, 6 cases with aortic ulcer were selected intraluminal surgery. 5 patients with drug treatment were followed up for 3-14 months, the CTA showed that the intramural hematoma was absorbed in different degree, and there was no chest and back pain occurred again. 8 patients were followed up for 6 months, the majority of the hematoma was absorbed, and there were no complications such as peri-stent leakage and stent displacement.ConclusionFor patients with Stanford type B aortic intramural hematoma, under the strict observation by CTA, patients can be treated with medicine first, if hematoma enlargement or comorbid aortic ulcer, endovascular repair should be selected.
【Keywords】Aortic intramural hematoma,Stanford B,acute; Drug therapy; Endovascular repair
收稿日期:(2015-07-03)
【DOI】10.3969 / j.issn.1671-6450.2015.12.003
通信作者:蔣嵐杉,E-mail:422242431@qq.com
作者單位: 621000四川省綿陽(yáng)市中心醫(yī)院血管外科