A型主动脉夹层发病形态学危险因素的研究进展.pdf

综述A 型主动脉夹层发病形态学危险因素的研究进展孙连杰 王国庆 冯祥祯 刘高利266011 青岛市市立医院心脏外科(孙连杰);266000 青岛大学附属医院心外科(王国庆、冯祥祯、刘高利)通信作者:刘高利,电子信箱:gaoliliu DOI:10.3969/j.issn.1007-5410.2023.05.020 【摘要】A 型主动脉夹层起病急、病死率高。目前指南建议升主动脉直径5.0 cm 作为预防性升主动脉置换手术指征,但仍有 40%的 A 型夹层发病时低于该标准,单纯依靠直径来制定手术指征并不完善。随着影像重建技术的进步,一些新的指标被开发出来,本文对 A 型夹层发病的形态学指标进行综述。【关键词】主动脉夹层;主动脉形态;危险因素Research progress of morphological risk factors of type A aortic dissection Sun Lianjie,Wang Guoqing,Feng Xiangzhen,Liu GaoliDepartment of Cardiovascular Surgery,Qingdao Municipal Hospital,Qingdao 266011,China(Sun LJ);Department of Cardiovascular Surgery,The Affiliated Hospital of Qingdao University,Qingdao 266000,China(Wang GQ,Feng XZ,Liu GL)Corresponding author:Liu Gaoli,Email:gaoliliu 【Abstract】Type A aortic dissection has an acute onset and high mortality.At present,the guidelines recommend that the diameter of ascending aorta 5.0 cm be used as the indication for preventive ascending aorta replacement surgery,but 40%of type A dissection patients are lower than this standard.It is not perfect to rely solely on the diameter to formulate the surgical indication.With the advancement of imaging reconstruction technology,some new indicators have been developed.This article reviews the morphological indicators of type A dissection.【Key words】Aortic dissection;Aortic morphology;Risk factors 主动脉夹层是一种危重的急性主动脉疾病,是指各种原因导致主动脉内膜和部分中膜撕裂形成主动脉内膜破口(intimal tear),血液由撕裂破口进入中膜并在压力驱动下向近端及远端扩展,造成中膜部分剥离,在内膜与中膜之间形成一个新的血管腔隙(false lumen)。急性主动脉夹层起病急,病情凶险1。随夹层的累及范围不同可造成包括主动脉瓣关闭不全、急性心肌梗死、心包压塞、急性脑卒中、器官灌注不良综合征等各种严重的并发症。对于主动脉夹层有多种分类方法2-5,目前临床通用分型仍为按照夹层累及范围划分的 Stanford 分型,其将主动脉夹层分为 A、B 两型。主动脉破口位于升主动脉或主动脉弓,夹层累及升主动脉者为 A 型;破口位于左锁骨下动脉以远,夹层范围局限于降主动脉者即为 B 型。与 B 型相比,A型因累及升主动脉,可能造成急性心肌梗死、心包压塞、急性心力衰竭等多种致命并发症,同时其破裂大出血的风险更大,死亡率更高6。未经治疗者死亡率每小时增加 1%2%7,单纯药物治疗总死亡率达 57%,一经确诊应急诊手术治疗,然而术后死亡率仍然较高(16%25%)8-10。因此,预防显得尤为重要。预防性升主动脉置换术是防止 A 型夹层发生的主要措施,通过择期手术的方式使用人工血管替换病变主动脉,大大降低了 A 型夹层的发生风险及死亡率11-12。手术指征的把握尤为重要,最佳手术时机为夹层发生前一刻,过早地进行手术会对患者造成不必要的手术创伤及风险,然而 A 型夹层患者发病前往往无任何临床症状,这使得准确识别 A型夹层发生风险变得困难,通过胸主动脉 CT 血管成像(computed tomographic angiography,CTA)获得主动脉形态学指标是判断 A 型夹层发生风险的主要标准。本文将对 A 型夹层发病的形态学危险因素进行综述。1 升主动脉直径目前认为 A 型夹层发生主要与升主动脉直径扩张有关,根据拉普拉斯定律,主动脉的扩大增加了主动脉壁张力,促进了 A 型夹层的发生。最大升主动脉直径越大,A 型夹层的发生风险越大,当升主动脉扩张到一定程度时,夹层便会发生。1997 年耶鲁团队8通过对在耶鲁大学医学院治疗的230 例胸主动脉瘤患者的数据进行分析发现,相比于 4.04.9 cm 的主动脉瘤,主动脉直径大于 6.0 cm 时升主动脉瘤505中国心血管杂志 2023 年 10 月第 28 卷第 5 期 Chin J Cardiovasc Med,October 2023,Vol.28,No.5的危险增加 32.1%,故推荐 5.5 cm 作为选择性切除升主动脉瘤的标准,这一标准作为预防性升主动脉置换的指征欧洲心脏病学会指南延续了十几年13-14。不过,该研究基于对升主动脉或主动脉弓动脉瘤患者的异质性队列分析,包括结缔组织病和退行性病因。在该队列中,主动脉直径6.0 cm时发生急性夹层或破裂:7.1%的主动脉直径or=5.5 cm is not a good predictor of type A aortic dissection:observations from the International Registry of Acute Aortic Dissection(IRAD)J.Circulation,2007,116(10):1120-1127.DOI:10.1161/CIRCULATIONAHA.107.702720.17Paruchuri V,Salhab KF,Kuzmik G,et al.Aortic size distribution in the general population:explaining the size paradox in aortic dissectionJ.Cardiology,2015,131(4):265-272.DOI:10.1159/000381281.18Zafar MA,Li Y,Rizzo JA,et al.Height 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