背景:胸主动脉腔内修复术(TEVAR)是一种用于治疗B型主动脉夹层的微创技术。在治疗累及LSA的患者时,需要重建左锁骨下动脉(LSA)。LSA重建后的最佳抗血小板治疗目前尚不确定。
方法:本研究回顾性分析了245例在TEVAR期间接受左锁骨下动脉血运重建的B型主动脉夹层患者。245名患者中,单抗血小板治疗(SAPT)组159例(64.9%),只接受阿司匹林,双联抗血小板治疗(DAPT)组86例(35.1%),接受阿司匹林联合氯吡格雷治疗。在6个月的随访中,主要终点包括出血事件(一般出血和出血性中风),而次要终点包括缺血事件(左上肢缺血,缺血性卒中,和血栓形成事件),以及死亡和泄漏事件。对出血和缺血事件进行单变量和多变量Cox回归分析。使用Kaplan-Meier方法生成生存曲线。
结果:在六个月的随访中,DAPT组的出血性事件发生率较高(8.2%vs.30.2%,P<0.001)。在缺血事件中没有观察到显著差异,死亡,或不同抗血小板治疗方案中的渗漏事件。多因素Cox回归分析显示,DAPT(HR:2.22,95%CI:1.07-4.60,P=0.032)和既往慢性病(HR:3.88,95%CI:1.24-12.14,P=0.020)显著影响出血性事件的发生。这项研究中的慢性病包括抑郁症,白癜风,和胆囊结石症.颈动脉锁骨下旁路术(CSB)组(HR:0.29,95%CI:0.12-0.68,P=0.004)和单分支支架(SBSG)组(HR:0.26,95%CI:0.13-0.50,P<0.001)的缺血事件发生率低于开窗TEVAR(F-TEVAR)。超过6个月的生存分析显示出血性事件期间与SAPT相关的出血风险较低(P=0.043)。
结论:在接受同步TEVAR术后LSA血流重建的B型主动脉夹层患者中,SAPT方案的出血风险显着降低,6个月内无明显缺血代偿。既往有慢性疾病的患者出血风险较高。与F-TEVAR组相比,CSB组和SBSG组的缺血风险较低。
BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is a minimally invasive technique used to treat type B aortic dissections. Left subclavian artery (LSA) reconstruction is required when treating patients with involvement of LSA. The best antiplatelet therapy after LSA reconstruction is presently uncertain.
METHODS: This study retrospectively analyzed 245 type B aortic dissection patients who underwent left subclavian artery revascularization during TEVAR. Out of 245 patients, 159 (64.9%) were in the single antiplatelet therapy (SAPT) group, receiving only
aspirin, and 86 (35.1%) were in the dual antiplatelet therapy (DAPT) group, receiving
aspirin combined with clopidogrel. During the 6-month follow-up, primary endpoints included hemorrhagic events (general bleeding and hemorrhagic strokes), while secondary endpoints comprised ischemic events (left upper limb ischemia, ischemic stroke, and thrombotic events), as well as death and leakage events. Both univariate and multivariate Cox regression analyses were performed on hemorrhagic and ischemic events, with the Kaplan-Meier method used to generate the survival curve.
RESULTS: During the six-month follow-up, the incidence of hemorrhagic events in the DAPT group was higher (8.2% vs. 30.2%, P < 0.001). No significant differences were observed in ischemic events, death, or leakage events among the different antiplatelet treatment schemes. Multivariate Cox regression analysis showed that DAPT (HR: 2.22, 95% CI: 1.07-4.60, P = 0.032) and previous chronic conditions (HR:3.88, 95% CI: 1.24-12.14, P = 0.020) significantly affected the occurrence of hemorrhagic events. Chronic conditions in this study encompassed depression, vitiligo, and cholecystolithiasis. Carotid subclavian bypass (CSB) group (HR:0.29, 95% CI: 0.12-0.68, P = 0.004) and single-branched stent graft (SBSG) group (HR:0.26, 95% CI: 0.13-0.50, P < 0.001) had a lower rate of ischemic events than fenestration TEVAR (F-TEVAR). Survival analysis over 6 months revealed a lower risk of bleeding associated with SAPT during hemorrhagic events (P = 0.043).
CONCLUSIONS: In type B aortic dissection patients undergoing LSA blood flow reconstruction after synchronous TEVAR, the bleeding risk significantly decreases with the SAPT regimen, and there is no apparent ischemic compensation within 6 months. Patients with previous chronic conditions have a higher risk of bleeding. The CSB group and SBSG group have less ischemic risk compared to F-TEVAR group.