Stanford B型主动脉夹层腔内修复术后早期死亡患者术前多层螺旋CT特征分析

目的探讨术前多层螺旋CT(MSCT)对Stanford B型主动脉夹层血管腔内修复术后早期死亡的预测价值。方法回顾性分析2014年1月至2018年12月采用腔内修复术治疗的158例急性期和亚急性期Stanford B型主动脉夹层患者临床随访资料和术前MSCT图像。测量和记录破口位置、破口大小、降主动脉最大直径、气管分叉平面主动脉直径、气管分叉平面假腔面积占该平面主动脉管腔总面积百分比、重要分支血管受累情况、假腔状态、腹主动脉是否受累等CT参数。分析术前CT各参数与患者术后30 d死亡的关系。结果腔内修复术紧急干预88例,非紧急干预70例,术后30 d死亡率为9.5%(15/158)。术后30 d死亡单因素分析显示,紧急干预患者术后30 d死亡率显著高于非紧急干预患者13.6%(12/88)对4.3%(3/70),χ2=3.967,P=0.046];术后30 d死亡组患者气管分叉平面假腔面积占该平面主动脉管腔总面积≥50%患者93.3%(14/15)对0.7%(1/143),χ2=135.581,P<0.001]和重要分支血管受累患者66.7%(10/15)对32.9%(47/143),χ2=6.725,P=0.010]显著高于术后30 d生存组患者;两组患者破口位置、破口大小、降主动脉最大直径、气管分叉平面主动脉直径、假腔状态、腹主动脉是否受累比较,差异无统计学意义(P>0.05)。Logistic回归多因素分析显示,紧急干预(OR=1.31,95%CI=1.08~3.53,P=0.026)和气管分叉平面假腔面积占该平面主动脉管腔总面积≥50%(OR=9.53,95%CI=3.69~12.47,P<0.001)是Stanford B型主动脉夹层腔内修复术后30 d死亡的独立危险因素。结论术前MSCT对预测Stanford B型主动脉夹层腔内修复术后患者早期死亡具有重要价值,紧急干预和气管分叉平面假腔面积占主动脉管腔总面积≥50%是术后30 d死亡的独立危险因素。

Analysis of preoperative MSCT features in early death patients with Stanford type B aortic dissection after endovascular repair

Objective To evaluate preoperative multislice spiral CT(MSCT) imaging manifestations in predicting early death of patients with Stanford type B aortic dissection after endovascular repair. Methods The clinical follow-up data and preoperative MSCT imaging materials of 158 patients with acute and subacute Stanford type B aortic dissection, who received endovascular repair treatment during the period from January 2014 to December 2018, were retrospectively analyzed. The following observation indexes on the preoperative CT image were measured and recorded: the anatomical location of the rupture(the distance between the rupture site and the left subclavian artery), the size of the rupture, the maximum diameter of descending aorta, the aortic diameter at the tracheal bifurcation plane, the ratio of false lumen area to total aortic lumen area at the tracheal bifurcation plane, the involvement of main aortic branches, the status of false lumen(including unclosed, partial thrombosis, complete thrombosis) and the involvement of abdominal aorta(such as DeBakey Ⅲa or Ⅲb). The correlation between preoperative CT observation indexes and the incidence of postoperative early death(within 30 days) was analyzed. Results Emergency intervention with endovascular repair(within 48 hours after onset of disease) was carried out in 88 patients and non-emergency intervention with endovascular repair(over 48 hours after onset of disease) was performed in 70 patients. The early mortality rate(within 30 days after treatment) was 9.5%(15/158). Univariate analysis of early mortality showed that the early mortality rate in emergency intervention group was 13.6%(12/88), which was significantly higher than 4.3%(3/70) in non-emergency intervention group(χ2=3.967, P=0.046). The percentage of patients with the ratio of false lumen area to total aortic lumen area at the tracheal bifurcation plane≥50% in early death group was 93.3%(14/15), which was 0.7%(1/143) in non-early death group(χ2=135.581, P<0.001). The percentage of patients who showed involvement of main aortic branches in early death group and non-early death group were 66.7%(10/15) and 32.9%(47/143) respectively, the difference was statistically significant(χ2=6.725, P=0.010). Both the above indexes in early death group were strikingly hither than those in non-early death group. No statistically significant differences in the anatomical location of the rupture, the size of the rupture, the maximum diameter of descending aorta, the aortic diameter at the tracheal bifurcation plane, the status of false lumen and the involvement of abdominal aorta existed between the two groups(P>0.05). Logistic multivariate regression analysis revealed that emergency intervention(OR=1.31, 95%CI:1.08-3.53, P=0.026) and the ratio of false lumen area to total aortic lumen area at the tracheal bifurcation plane ≥50%(OR=9.53, 95%CI: 3.69-12.47, P<0.001) were independent risk factors for early death after endovascular repair of Stanford type B aortic dissection. Conclusion Preoperative MSCT is of great value in predicting the occurrence of early death in patients with Stanford type B aortic dissection after endovascular repair. Emergency intervention and the ratio of false lumen area to total aortic lumen area at the tracheal bifurcation plane ≥50% are independent risk factors for early death after endovascular repair of Stanford type B aortic dissection.