创伤性主动脉损伤的临床病理特征及其腔内治疗的疗效分析

Clinicopathologic features of traumatic aortic injury and its applicability to endovascular treatment

摘要:

背景与目的 各类高能量冲击性外伤如车祸、高空坠落等对主动脉造成的损伤往往较为隐匿而难以发现，且使病情更为复杂。在手术治疗严重的外伤前，对损伤的主动脉进行修复是十分必要的。目前胸主动脉腔内修复术（TEVAR）因其创伤小、恢复快的优势得以广泛开展，为避免耽误多发伤的专科治疗提供较大帮助。本研究通过分析创伤性主动脉损伤（TAI）的病变特点，并比较TAI与Stanford B型主动脉夹层行TEVAR的疗效，探讨其治疗策略。方法 回顾性分析中南大学湘雅医院2015年11月—2020年12月内行TEVAR治疗的20例TAI患者（TAI组），以及同期行TEVAR治疗的50例非创伤性Stanford B型主动脉夹层患者（非TAI组）资料，比较两组患者的临床资料和随访情况。结果 两组在性别、年龄等方面差异无统计学意义（均P>0.05），TAI组高血压患者比例低于非TAI组（40.0% vs. 74.0%，P<0.05）。TAI组的局限型撕裂、第一破口多位于主动脉峡部的比例高于非TAI组（80.0% vs. 34.0%；70.0% vs. 24.0%，均P<0.05），而破口数量≥2、弓上受累及破口与左锁骨下动脉（LSA）的距离<15 mm的比例低于非TAI组（30.0% vs. 78.0%；10.0% vs. 52.0%；40.0% vs. 72.0%，均P<0.05），TAI组支架放大率大于非TAI组（P<0.05）。TAI组住院时间明显长于非TAI组（16.80 d vs. 11.20 d，P<0.05），且其术后并发症发生率高于非TAI组（20.0% vs. 4.0%，P<0.05）。随访结果显示，两组在并发症发生率、存活时间等方面差异无统计学意义（均P>0.05），但TAI组假腔体积变化率及血栓吸收率均高于非TAI组（95.0% vs. 72.0%；90.0% vs. 58.0%，均P<0.05）。结论 TAI因不同机制的多发伤使得病情急、重且复杂，故而修复血管时应根据损伤情况进行个体化治疗方案，包括手术时机的选择、支架的长度、支架放大率、锚定区的判断及考虑LSA是否保留或封闭等。TEVAR术后，TAI患者的假腔体积变化率及假腔血栓吸收情况明显优于非TAI患者，反映了TAI中期主动脉重塑良好，进而说明TAI行TEVAR能获得较好的治疗效果，但远期疗效仍需进一步探寻。

Abstract:

Background and Aims The aortic injury caused by various high-energy trauma such as car accidents and falls from great heights are often insidious and difficult to determine, which make the condition more complex. Repair of the injured aorta is necessary before surgical intervention for severe trauma. At present, thoracic endovascular aortic repair (TEVAR) has been widely conducted because of its advantage of minimal invasiveness and quick recovery, which provides great help to avoid delaying the specialized treatment of multiple injuries. This study was performed to investigate treatment strategies for traumatic aortic injury (TAI) through analyzing its pathological features and comparing the efficacy of TEVAR for TAI and the Stanford type B aortic dissection.Methods The data of 20 TAI patients (TAI group) undergoing TEVAR during November 2015 to December 2020, and 50 patients with non-traumatic Stanford B aortic dissection (non-TAI group) undergoing TEVAR during the same period in Xiangya Hospital of Central South University were retrospectively analyzed. The clinical variables between the two groups of patients were compared.Results No significant difference was identified in sex and age between the two groups (both P>0.05), but the proportion of patients with hypertension was lower in TAI group than that in non-TAI group (40.0% vs. 74.0%, P<0.05). The proportions of cases with localized tear and the primary tear at the aortic isthmus were higher in TAI group than those in non-TAI group (80.0% vs. 34.0%; 70.0% vs. 24.0%, both P<0.05), while the proportions of cases with the tear number ≥2, the involvement of the supra-arch branches, and the distance from the primary tear to the left subclavian artery (LSA) <15 mm were lower in TAI group than those in non-TAI group (30.0% vs. 78.0%; 10.0% vs. 52.0%; 40.0% vs. 72.0%, all P<0.05). In addition, the oversize of the stent graft was larger in TAI group than that in non-TAI group (P<0.05). The length of hospital stay was significantly longer in TAI group than that in the non-TAI group (16.80 d vs. 11.20 d, P<0.05), and the incidence of postoperative complications was higher in TAI group than that in the non-TAI group (20.0% vs. 4.0%, P<0.05). The follow-up results showed that there were no statistical differences in terms of complication rates and survival time between the two groups (both P>0.05), but the rates of volume changes in the false lumen and thrombus absorption were higher in TAI group than those in non-TAI group (95.0% vs. 72.0%; 90.0% vs. 58.0%， both P<0.05).Conclusion TAI is in urgent, critical and complex situations due to multiple injuries resulting from different causes, so the vascular repair should be performed individually based on the injury types, including the choice of surgical timing, the length of stents, oversize, the judgment of the landing zone and preservation or revascularization of the LSA. After TEVAR, the rates of volume changes in the false lumen and thrombus absorption were significantly higher in TAI patients than those in non-TAI patients, which reflects the appropriate remodeling of the aorta in the mid-term of the TAI, and thereby demonstrates the favorable efficacy of TEVAR in the treatment of TAI. However, its long-term efficacy still needed to be further assessed.