目的:探讨血管内超声(IVUS)在复杂性B型主动脉夹层(TBD)伴灌注不良(MP)诊断和治疗中的价值。特别是IVUS在治疗策略方面的价值,再手术率,研究了急性肾损伤(AKI)和假腔血栓形成(FLT)。
方法:回顾性分析2019年4月至2022年8月接受血管内治疗的25例TBD合并MP患者。17例术中应用血管造影和IVUS(IVUS组),8例未使用IVUS的血管造影(对照组)进行最后的术中控制。IVUS用于评估真实的管腔塌陷,并确定是否需要额外的裸露支架置入。分析了患者图表中的详细信息和手术记录。血管内技术包括胸部血管内主动脉修复术(TEVAR),主要入口密封,以及-如果需要-使用PETTICOAT(临时扩展以诱导完整附件)技术对入口泪液远端真腔进行裸露支架。
结果:所有患者均表现为胸部和腹部局部疼痛(48%)。在所有患者中,使用TEVAR覆盖了夹层的近端入口撕裂。13例(52%)采用PETTICOAT技术,而大多数联合手术应用于IVUS组(12对1;p=0,02)。共有3例患者(对照组1例;IVUS组12,5%和2例;11,8%)接受了肠切除术。共有8例患者(32%)接受了主动脉再手术(住院期间3例)。术前发现IVUS与对照组无统计学差异,再次手术率和术后并发症。5例患者死亡(4例住院期间),对照组为1,IVUS组为4;p=0,53。随访包括临床和计算机断层扫描血管造影(CTA)检查。两组之间关于FLT的发生和扩展无统计学差异。
结论:IVUS组和对照组的生存率无差异。IVUS的使用扩展了PETTICOAT技术的适应症,具有统计学上的显着差异。与对照组相比,IVUS组中呈现较温和形式的AKI。此外,观察到IVUS与避免主动脉再手术之间有更强的相关性,虽然没有达到统计学意义。
BACKGROUND: To present the value of intravascular ultrasound (IVUS) in diagnosis and treatment of complicated type B aortic dissection with
malperfusion. Especially, the value of IVUS regarding the treatment strategy, reoperation rate, acute kidney injury, and false lumen thrombosis was investigated.
METHODS: Retrospective analysis of 25 type B aortic dissection cases with
malperfusion treated with endovascular therapy from April 2019 to August 2022. In 17 cases, angiography and IVUS were applied during the operation (IVUS group), and in 8 cases, angiography was used without IVUS (control group) for final intraoperative control. IVUS was used to assess the true lumen collapse and to decide if additional bare stenting was necessary or not. Details from patients\' charts and documentation from surgeries were analyzed. The endovascular technique included thoracic endovascular aortic repair with primary entry sealing and-if needed-bare stenting of the true lumen distal of the entry tears using the Provisional Extension To Induce Complete Attachment (PETTICOAT) technique.
RESULTS: All patients presented with pain localized mostly (48%) in thorax and abdomen. In all patients, the proximal entry tear of the dissection was covered using thoracic endovascular aortic repair. The PETTICOAT technique was applied in 13 cases (52%), whereas most combined procedures were applied in the IVUS group (12 compared to 1; P = 0.02). A total of 3 patients (1 in the control group, 12.5% and 2 in the IVUS group, 11.8%) underwent a bowel resection. Totally 8 patients (32%) underwent a reoperation in aorta (3 during the hospital stay). There were no statistical differences between IVUS and control group regarding the preoperative findings, the reoperation rates, and the postoperative complications. Five patients died (4 during the hospital stay); 1 in control and 4 in IVUS group; P = 0.53. The follow-up included a clinical and a computed tomography angiography examination. No statistically significant difference regarding occurrence and extension of false lumen thrombosis was observed between the 2 groups.
CONCLUSIONS: The IVUS and control groups showed no difference in survival rates. The use of IVUS extended the indication for PETTICOAT technique with statistically significant difference. A milder form of acute kidney injury presented in the IVUS group compared to the control group. In addition, a stronger correlation between IVUS and the avoidance of an aorta reoperation was observed, although it did not reach statistical significance.