冠状动脉自发性夹层的临床特点与治疗策略

Clinical feature and therapy strategy of spontaneous coronary artery dissection

目的回顾分析冠状动脉自发性夹层（SCAD）患者的临床资料，探讨治疗策略。方法回顾分析2010年7月至2013年3月单中心冠状动脉造影患者4517例，检出SCAD13例，借用冠状动脉夹层分型系统对病变进行分类，分析不同类型SCAD的发生率、影像特点及随访临床事件。结果13例SCAD患者中，2例（2／13，15．4％）发生2处夹层，共存在15处夹层。12例（92．3％）发生临床事件，包括心肌梗死10例（76．9％）与心绞痛2例（15．4％）。发生于右冠状动脉夹层9处（9／15，60％），前降支6处（6／15，40％），左回旋支未见夹层。A型病变1处（6．7％），B型2处（13．3％），D型8处（53．3％），E型2处（13．3％），F型1处（6．7％），壁间血肿1处（6．7％）。4例5处保守治疗，9例10处病变给予经皮冠状动脉介入治疗（PCI），9处病变PCI治疗成功，1处未成功改为冠状动脉旁路移植术。1例D型夹层患者药物治疗6个月后复查冠状动脉造影，夹层无明显变化，无心绞痛发作；l例D型夹层患者药物治疗3个月，仍有心绞痛，给予PCI治疗；1例A型夹层患者PCI后12个月复查冠状动脉造影未见夹层复发，无再狭窄。其余患者电话随访6～12个月无临床事件。结论SCAD可以按照NHLB1分型。A、B、E型及壁间血肿采取PCI治疗相对容易。D型夹层占比例最高。D、F型治疗难度最大。关键在于早期确诊。可以根据病变的类型、长度，选择性地采取PCI治疗，保守治疗是否可以自愈仍需长期随访。

Objective To summarize the clinical and image feature of spontaneous coronary artery dissection （SCAD） and discuss the strategy on therapy for SCAD. Methods The data of coronary angiography from 7/2010 to 3/2013 in single center were reviewed. Patients with SCAD were selected. Dissection was classified by National Heart, Lung and Blood Institute（NHLBI） type. The incidence rate and image trait of SCAD and follow-up results were observed. Relative published papers were reviewed and the therapy strategy was discussed based on SCAD. Results A total of 4517 patients were reviewed, and 13 patients with SCAD were included with mean age （54 -＋ 12） years old （34 -76）, 9 （69.2%） males and 4 （30.8%） femals. Two （2/13, 15.4% ） patients with 2 vessels dissection and a total of 15 dissection lesions were found. Clinical events including myocardial infarction （ 10/13, 76. 9% ）, angina （ 2/13, 15.4% ） were occurred in 12（92. 3% ） patients. Dissection was most frequently located in the right coronary artery （9/15,60%） followed the left anterior descending coronary artery （6/15,40%）, and none in the left circumflex coronary artery. All the lesions were distributed into 6 types： type A 1 （6. 7% ）, type B 2（13.3%）, type D 8（53.3%）, type E 2 （13.3%）, type F 1 （6. 7%）, and intramural hematoma 1 （6. 7% ）. Conservative therapy was given to 4 patients. 10 lesions were treated by interventional therapy with stenting successfully to 9 lesions and 1 lesion failed in stenting. One patient with type D dissection who was treated by conservative therapy had no angina and the dissection no progress at six months coronary angiography follow-up. One patient had recurrent angina after 3 months conservative therapy, then stenting therapy was given. One patient with type A dissection who was treated by stenting could maintain no recurrence and restenosis at 12 months follow-up. Conclusions Spontaneous coronary artery dissection can be classified by NHLBI type, type A, B, E dissection and intramural hematoma can be treated by intervention easily relatively. The key is that dissection can be discovered earlier. Type D has the highest occurrence rate.Intervention for type D and F was difficult.Selective interventional therapy was feasible according to the type and long of lesion.The results of conservative therapy need long follow-up.