美国血管外科学会/胸外科医师学会B型急性主动脉夹层腔内治疗前后CT血管造影分析

Analysis of CT angiography before and after endovascular treatment of SVS/STS acute type B aortic dissection

目的分析美国血管外科学会(SVS)/胸外科医师学会(STS)B型急性主动脉夹层(AAD)腔内治疗前后的CT血管造影(CTA)特点,并探讨其临床意义。方法回顾性分析2015年3月至2021年3月徐州市立医院介入与血管外科接受覆膜支架腔内隔绝术治疗的83例SVS/STS B型AAD患者的临床资料,对AAD患者进行解剖学分型,观察内膜片随病程延长的形态学变化,记录术前和术后3个月真假腔直径变化及分支动脉的受累情况。两位医师判断内膜片形态变化的一致性检验采用Kappa分析,手术前后真假腔直径比较采用配对样本t检验。结果SVS/STS解剖分型总体较为分散,主要分型有B_(3,10)型10例(12.0%),B_(3,11)型8例(9.6%),B_(3,8)型6例(7.2%)。共发现夹层破口316个,人均破口(3.81±1.55)个。随病程延长,多数患者内膜片形态表现出变厚、变直、变锐利的征象。两位医师判断内膜片是否变厚、变直、变锐利的Kappa系数分别为0.646(95%CI:0.444~0.848,P<0.001)、0.440(95%CI:0.232~0.648,P<0.001)和0.444(95%CI:0.226~0.662,P<0.001)。与术前相比,术后3个月主动脉峡部[真腔:(21.53±4.74)mm比(31.13±2.82)mm,t=-19.863,P<0.001;假腔:(18.89±9.74)mm比(0.18±1.14)mm,t=11.975,P<0.001]、降主动脉中段[真腔:(14.79±4.24)mm比(23.66±4.24)mm,t=-12.773,P<0.001;假腔:(16.67±7.58)mm比(0.18±1.16)mm,t=13.516,P<0.001]和降主动脉远段[真腔:(12.43±2.76)mm比(16.53±4.94)mm,t=-6.226,P<0.001;假腔:(16.50±4.84)mm比(9.94±9.79)mm,t=3.211,P=0.003]真腔直径变大,假腔直径变小,差异具有统计学意义,而腹腔干段和腹主动脉分叉段真假腔直径差异无统计学意义(均P>0.05)。83例患者共有225条分支动脉受夹层累及,其中真腔供血135条(60.0%),真假腔供血66条(29.3%),假腔供血24条(10.7%);开口狭窄14条(6.2%),远端缺血6条(2.7%)。术后3个月,94.2%(212/225)的分支动脉受累情况与术前相似。结论SVS/STS B型AAD解剖分型总体较为分散,大部分患者存在多个内膜破口。随病程延长,内膜片形态发生显著性改变。术后主动脉峡部、降主动脉重塑良好,而腹主动脉未见明显重塑,其分支动脉受累情况也多与术前相似。

Objective To analyze the characteristics of CT angiography(CTA)before and after endovascular treatment of Society for Vascular Surgery(SVS)and Society of Thoracic Surgeons(STS)acute type B aortic dissection and to explore its clinical significance.Methods The clinical data of 83 patients with SVS/STS acute type B aortic dissection who underwent thoracic endovascular repair in the Department of Interventional and Vascular Surgery,Xuzhou Municipal Hospital Affiliated to Xuzhou Medical University from March 2015 to March 2021 were analyzed retrospectively.The patients with acute type B aortic dissection were anatomically classified,morphological changes of intimal flaps with the progression of the disease were observed,and true and false lumen diameter changes and branch arteries involvement were recorded before and three months after operation.Kappa consistency check was performed by two physicians to identify the morphological changes of intimal flaps.Paired t-test was used to compare the true and false lumen diameter before and after operation.Results The anatomical classification of SVS/STS was generally scattered,mainly including 10 cases(12.0%)of B_(3,10),8 cases(9.6%)of B_(3,11),6 cases(7.2%)of B_(3,8).A total of 316 tears were found,with a per capita tear of(3.81±1.55).With the progression of disease,morphology of intimal flaps of most patients showed signs of thickening,straightening,and sharpening.Kappa coefficients of the two physicians to judge whether the intimal flaps thicken,straighten,or sharpen were 0.646(95%CI:0.444~0.848,P<0.001),0.440(95%CI:0.232~0.648,P<0.001)and 0.444(95%CI:0.226~0.662,P<0.001),respectively.Compared with preoperative state,the true lumen diameter of the aortic isthmus,middle and distal descending aorta became larger,and the false lumen diameter became smaller three months after operation,the differences were statistically significant[aortic isthmus true lumen:(21.53±4.74)mm vs(31.13±2.82)mm,t=-19.863,P<0.001;aortic isthmus false lumen:(18.89±9.74)mm vs(0.18±1.14)mm,t=11.975,P<0.001;middle descending aortic true lumen:(14.79±4.24)mm vs(23.66±4.24)mm,t=-12.773,P<0.001;middle descending aortic false lumen:(16.67±7.58)mm vs(0.18±1.16)mm,t=13.516,P<0.001;distal descending aorta true lumen:(12.43±2.76)mm vs(16.53±4.94)mm,t=-6.226,P<0.001;distal descending aorta false lumen:(16.50±4.84)mm vs(9.94±9.79)mm,t=3.211,P=0.003].There were no statistically significant differences between the diameter of the true and false lumen in the celiac trunk and the abdominal aortic bifurcation(all P>0.05).A total of 225 branch arteries were involved in dissection in 83 patients,of which 135(60.0%)were supplied by the true lumen,66(29.3%)were supplied by the true and false lumen,and 24(10.7%)were supplied by the false lumen.And there were 14(6.2%)origin stenosis,and 6(2.7%)distal ischemia.Three months after operation,94.2%(212/225)of the branch arteries involvement was similar to those before operation.Conclusion The anatomical classification of SVS/STS acute type B aortic dissection is generally scattered,and most patients have multiple intimal breaches.With the prolonged course of the disease,the morphology of the intimal flaps change significantly.The postoperative aortic isthmus and descending aorta are remodeled well;the abdominal aorta has not been significantly remodeled,and the involvement of its branch arteries is mostly similar to that before surgery.