大动脉炎手术与腔内治疗的效果及其影响因素

Outcome and influencing factors of bypass and endovascular treatment for Takayasu arteritis

目的研究中国人种族中,大动脉炎腔内治疗及转流手术疗效的比较,以及影响因素的分析,为国人大动脉炎治疗方式的选择及术后合并症的预防提供数据参考。方法研究对象选取从2002年1月至2014年7月,在首都医科大学附属北京安贞医院血管科诊断为大动脉炎并进行外科治疗的患者,诊断标准采用1990年美国风湿病学会制定标准,对患者随访后进行数据分析。结果共行手术49例次,女性44例,占89.8%,平均发病年龄（27.20±10.35）岁,手术27例,腔内治疗22例（支架置入7例、球囊扩张15例）,共处理病变血管61根。随访时间3~148个月,平均（50.43±42.708）个月,无死亡病例。通畅率方面,3个月通畅率97.8%,6个月通畅率95.6%,1年通畅率88.3%,3年通畅率79.6%,5年通畅率76.1%,10年通畅率57.1%。单纯球囊扩张成形术与球囊扩张＋支架置入术,1年通畅率分别为91.7%和68.6%（P=0.045）。合并症方面,早期合并症仅有2例出血,晚期合并症共出现13例,其中脑梗死1例,血栓栓塞6例,再狭窄5例（支架内再狭窄2例,球囊扩张后再狭窄3例）,人工血管排异反应1例,其中腔内治疗5例,转流手术8例（P=0.002）。累计无合并症比率1年为88.1%,3年为79.0%,5年为75.4%,10年为51.9%。Logistic回归分析提示,随访期间免疫指标异常是术后合并症独立危险因素（OR=7.596,CI：1.091-52.884,P=0.041）。结论转流手术与腔内治疗在3年和5年远期通畅率上,转流手术要明显优于腔内治疗;随访期间免疫指标的异常是术后出现合并症的独立危险因素,因此术后免疫调节显得尤为重要;球囊扩张成形术较球囊扩张加支架置入术有更好的一期通畅率。

Objective This study aimed to compare endovascular treatment and bypass surgery for Takayasu ateritis（ TA）,to analyze influencing factors and to provide reference data for the treatment options of Takayasu arteritis and prevention of postoperative complications. Methods This is a retrospective review of patients with TA referred to us between 2002 and 2014. We used the American Rheumatism Association standards published in 1990 as diagnostic criteria. Results Total number of patients who received surgery was49,including 44 female cases,accounting for 89. 8%,the average age was（ 27. 20 ± 10. 35） years,the bypass surgery was performed for27 cases,endovascular treatment was given to 22 cases（ 7 cases received stent placement,15 cases received percutaneous transluminal angioplasty,PTA）,61 culprit vessels were treated. The average follow-up period was（ 50. 43 ± 42. 708） months（ 3-148 months）,no deaths occurred. The primary patency rates for 3-month,6-month,1-year,3-year,5-year,10-year were 97. 8%,95. 6%,88. 3%,79. 6%,76. 1% and 57. 1%,respectively. The PTA and stent placement,1-year patency rates were 91. 7% and 68. 6%（ P = 0. 045）.Only 2 cases had early complications of hemorrhage. Late complications occurred in a total of 13 cases,including 5 cases after endovascular treatment and 8 cases after bypass（ P = 0. 002）; Cerebral infarction in 1 case,thromboembolism in 6 cases,and restenosis in 5 cases（ stent restenosis in 2 cases,3 cases had restenosis after PTA）,artificial vascular rejection occurred in 1 case. The overall 1-,3-,5-,10-year no complication rates were 88. 1%,79. 0%,75. 4% and 51. 9%,respectively. The Logistic regression analysis showedthat the immune abnormalities in follow-up period were independent risk factors for postoperative complications（ OR： 7. 596,CI： 1. 091-52. 884,P = 0. 041）. Conclusion Endovascular treatment was significantly superior to bypass surgery in terms of late complications;no significant difference was found between bypass surgery and endovascular treatment in long-term patency rate. Abnormalities in immune parameters during the period of follow-up may be independent risk factors of postoperative complications,postoperative immunomodulatory therapy may be particularly important. PTA had a better primary patency than stenting.