穿透性粥样硬化性主动脉溃疡的多排螺旋CT诊断及治疗策略

Clinical diagnosis and therapeutic strategiesof MDCT in penetrating atherosclerotic ulcer of aorta

目的探讨穿透性粥样硬化性主动脉溃疡(PAU)的多排螺旋CT血管造影(MDCTA)表现及治疗策略,进一步提高对该病的认识。方法对南华大学第一附属医院诊治20例PAU患者的临床、放射学资料进行回顾性归纳总结,并复习相关文献。结果 5例无症状,15例以急性主动脉综合征起病,20例既往均有高血压病史。PAU的特征性CT表现:20例均可见外翻凸起"火山口"状溃疡、内膜钙化斑块和主动脉管壁广泛粥样硬化增厚,单发溃疡8例,多发溃疡12例。PAU的并发症征象:范围不一壁间血肿20例;假性动脉瘤6例;主动脉扩张1例;透壁性主动脉破裂2例。该组患者中5例无症状者采取内科保守治疗并定期影像学随诊观查;15例有症状患者起初采取积极内科保守治疗并密切影像随诊,5例病灶稳定且症状明显好转;8例最终及时选择外科手术治疗后症状消失,包括1例症状持续且溃疡深度增加,5例假性动脉瘤和2例主动脉破裂;1例假性动脉瘤和1例主动脉扩张不允许手术治疗。结论 PAU的临床表现不具有特征性,MDCTA是首选的诊断手段,临床症状明显伴并发症的患者,应密切随访复查并尽早手术治疗。

[ Objective ] To discuss the manifestation of penetrating atherosclerotic aortic ulcer on MDCTA and its therapeutic strategies in order to acknowledge the disease deeply. [Methods] 20 patients of PAU were collected. The radiology and clinical database was analyzed and summarized retrospectively, and reviewed the related litera- ture. [Results] 5 asymptomatic PAU patients were incidentally diagnosed by contrast-enhanced MDCT scanning. 17 patients had acute aortic syndromes, diagnosed by MDCTA interpretation. 20 patients had hypertension disease. Typ- ical radiologic features of 20 patients are an out-pouching ulcer crater, intimal calcification, and in conjunction with the presence of severe atherosclerotic disease, 3 patients had 1 lesion, 17 patients had multiple lesions. The compli- cation signs of PAU included localized or extensive IMH（n =20）, pseudoaneurysm（n =6）, aortic expansion（n =1） and rupture （n =2）. 5 asymptomatic patients received medical therapy and are being followed with serial CTA. 15 symp- tomatic patients initially accepted aggressive medical therapy and also with close observation, the stable lesions and symptom improving of the patients （n =5）. 8 patients were cured after eventually underwent repair with Endovascular Graft Exclusion, included pseudoaneurysm（n =5）, rupture（n =2）, and the instable lesions with persistent symptoms（n =1）. 2 patients, included pseudoaneurysm（n =1） and aortic expansion（n =1）, were poor operative candidate and were not offered surgery. [ Conclusions ] Clinical manifestations of PAU are not typical. MDCTA is very important for diagnosis. Close follow-up imaging and early surgical treatment are needed for those with obvious clinical manifesta- tions and complications.