SVS腹主动脉瘤指南（一）：术前监测

赵黎明柳人医 2021-07-31

展开全文

Society for Vascular Surgery implementationof guidelines in abdominal aortic aneurysms: preoperative surveillance and threshold for repair

Rae S. Rokosh, Winona W. Wu, Mark K.Eskandari, and Elliot L. Chaikof

1. 无症状的真性腹主动脉瘤的干预仍依据超声，CTA或MRI上测量到的主动脉最大外径：

推荐在垂直于CTA三维重建中心线的横断面上进行直径测量
CT横断面上短轴的距离最接近最大瘤体直径[1]

2. 直径＜4.0cm的无症状真性AAA每年破裂的风险几乎可以忽略不计；

3. Cochrane上一项对UKSAT (UK small aneurysm trial)，ADAM (aneurysm detection and management study)，CAESAR (comparison of surveillance vs aortic endografting for small aneurysm repair)和PIVOTAL (positive impact of endovascular options for treating aneurysm early)研究的分析显示无症状小AAA（4.0-5.4cm）立即进行干预的获益不明显[2]

4. 普遍认为，对于女性最大径达到5cm，对于男性最大径达到5.5cm时，AAA年破裂的风险超过择期手术相关的围手术期风险；

5. 根据AAA直径估计的年破裂风险如下表[3,4]（女性患者适用性较差）：

6. 对于无症状患者推荐采用超声（更倾向于超声）或CT进行监测，术前监测的频率如下表：

7. AAA修复的指证[5]：

男性真性AAA患者≥5.5cm（1A级证据）
女性真性AAA患者≥5cm（2B级证据）
囊性动脉瘤

8. 争议和未来的方向：

传统最大径标准的陷阱：

没有考虑瘤壁血栓或潜在的几何学及生物力学因素可能影响AAA进展直至破裂[6]
没有考虑女性更小的基线主动脉直径

最近的证据提示：在女性中，动脉瘤直径除以体表面积相比单纯动脉瘤直径，在破裂风险方面更有预测价值[7]

验证并运用主动脉大小指数或许可以帮助明确瘤径＜5.5cm能够从早期干预中获益的女性
未来的指南应该阐明囊性动脉瘤，以及结缔组织病导致的AAA或夹层动脉瘤的术前监测方案和干预指证

引用文献：

1. Chaikof EL, Blankensteijn JD, Harris PL,White GH, Zarins CK, Bernhard VM, et al. Reporting standards for endovascularaortic aneurysm repair. J Vasc Surg 2002;35:1048-60.

2. Ulug P, Powell JT, Martinez MA, BallardDJ, Filardo G. Surgery for small asymptomatic abdominal aortic aneurysms.Cochrane Database Syst Rev 2020;7:CD001835.

3. Parkinson F, Ferguson S, Lewis P,Williams IM, Twine CP; South East Wales Vascular Network. Rupture rates ofuntreated large abdominal aortic aneurysms in patients unfit for electiverepair. J Vasc Surg 2015;61:1606-12.

4. Powell JT, Gotensparre SM, Sweeting MJ,Brown LC, Fowkes FG, Thompson SG. Rupture rates of small abdominal aorticaneurysms: a systematic review of the literature. Eur J Vasc Endovasc Surg2011;41: 2-10.

5. Chaikof EL, Dalman RL, Eskandari MK,Jackson BM, Lee WA, Mansour MA, et al. The Society for Vascular Surgerypractice guidelines on the care of patients with an abdominal aortic aneurysm.J Vasc Surg 2018;67:2-77.e72.

6. Vorp DA, Vande Geest JP. Biomechanicaldeterminants of abdominal aortic aneurysm rupture. Arterioscler Thromb VascBiol 2005;25: 1558-66.

7. Lo RC, Lu B, Fokkema MT, Conrad M, Patel VI,Fillinger M, et al. Relative importance of aneurysm diameter and body size forpredicting abdominal aortic aneurysm rupture in men and women. J Vasc Surg 2014;59:1209-16.