有关主动脉夹层的文献不能穿刺的，心包积液提示已存在血容量下降。穿刺后压力骤减，可导致进一步出血，迅速危及生命。见下述文献DIAGNOSIS AND MANAGEMENT OF PATIENTS WITH AORTIC DISSECTION Hu seyin Ince, Christoph A Nienaber主动脉夹层的诊断和治疗Cardiovascular disease is the leading cause of death in Western society and is on the rise in developing countries. Aortic diseases constitute an emerging share of the burden. New diagnostic imaging modalities, increasing life expectancy, longer exposure to elevated blood pressure, and the proliferation of modern non-invasive imaging modalities have all contributed to the growing awareness of acute and chronic aortic syndromes and pathologies.15 心血管疾病是西方社会患者的主要死因，在发展中国家的发病率也在不断上升；其中主动脉疾病日益凸现。日益更新的影像学诊断方法、不断增长的对生命的期望、长期的高血压和不断发展的非侵入性影像检查方法使得我们对急、慢性主动脉综合症的表现和病理学机制日益了解。Acute aortic syndrome includes aortic dissection, intramural haematoma (IMH), and symptomatic aortic ulcer. Propagation of the dissection can proceed in anterograde or retrograde fashion from the initial tear involving side branches and causing complications such as malperfusion syndromes, tamponade, or aortic valve insufficiency.6 Common predisposing factors in the International Registry of Aortic Dissection (IRAD) were hypertension in 72% of cases, followed by atherosclerosis in 31% and previous cardiac surgery in 18% (table 1). Analysis of the young patients with dissection (,40 years of age) revealed that younger patients were less likely to have a history of hypertension (34%) or atherosclerosis (1%), but were more likely to have Marfan syndrome, bicuspid aortic valve, and/or prior aortic surgery.7急性主动脉综合征包括：主动脉夹层、壁内血肿和有症状的主动脉（粥样斑块）溃疡。夹层可能从破裂口原处及相关分支向远端及近端发展，导致相应并发症如：低灌注综合症、心包填塞、主动脉关闭不全。国际主动脉夹层官方记录（IRAD）显示，最常见的危险因素为高血压，占病例的 72；其次为动脉粥样硬化，占 31；心脏手术史，占 18。针对年轻患者的分析显示年轻患者（80 岁） 、患者拒绝以及上述情况同时并存。DISTAL (TYPE AORTIC DISSECTION 远端（B 型）主动脉夹层Patients with uncomplicated aortic dissections confined to the descending thoracic aorta (Stanford type B or DeBakey type III) are at present preferentially treated conservatively, but may be considered candidates for a reconstructive strategy such as endovascular scaffolding in the near future. Medical treatment focuses initially on haemodynamic monitoring, b-blockade, and arterial vasodilators if needed to keep systolic blood pressure ,120 mm Hg, and on pain control with morphine sulfate. Once the patient is stable, oral b-blockers and other antihypertensive medications are continued under close follow-up with imaging and clinical assessment in intervals of six months. In a series of 384 patients with type B dissections, 73% were managed medically in IRAD; in-hospital mortality for these patients was10%,25 and long-term survival rate with medical treatment turned out to be 60% at five years and around 40% at 10 years.26 27 Survival appeared better in patients with noncommunicating distal dissections. 目前，单纯降主动脉夹层（Stanford type B or DeBakey type III）的患者更倾向于保守治疗，并为短期内的血管重建术如血管内支架成形术做准备。治疗药物首先为血流动力稳定剂、 受体阻滞剂和血管扩张剂，使收缩压稳定在 120 mm Hg，其次可以使用吗啡止痛。一旦病情稳定，可改用口服 受体阻滞剂或降血压药物维持治疗，并每 6 月进行影像学和临床评估以密切随访。在 IRAD 报告的 384 例 Stanford B 型患者中，73%通过药物控制，院内的死亡率为 10。药物控制的长期生存率为 5 年 60，10 年接近 40。非交通性远端夹层的患者生存率更高。At present endovascular interventions for acute type B aortic dissections are generally limited to relief of life-threatening complications such as impending aortic rupture, ischaemia of limbs and organ systems, persistent or recurrent intractable pain, progression of dissection, aneurysm expansion, and uncontrolled hypertension28 (fig 3). Because of extensive mortality and morbidity, classic surgery for acute type B aortic dissections has been relegated to a niche manoeuvre.25 The European Society of Cardiology Task Force on Acute Aortic Dissection released recommendations for the indications for stent graft and/or fenestration in 2001 (table 3).18 Additionally, in high-risk patients not suitable for surgery because of age, comorbid conditions, or personal preference, endovascular repair offers palliative treatment to those who otherwise would have been left to follow the natural history of the disease.目前，急性 B 型动脉夹层的血管内治疗主要是为了处理一些威胁生命的并发症如：将要发生主动脉破裂，存在肢体或内脏器官缺血、持续性或反复性剧痛、夹层进展、动脉瘤扩大和难治性高血压。由于存在较高的死亡率和致残率，急性 B 型动脉夹层经典术式的地位有所下降。欧洲心脏病协会急性主动脉夹层工作组 2001 发布了血管内支架和（或）开窗术的推荐手术适应症。此外，对由于年龄过大、并发其他疾病、个人选择等因素而无法进行（开放）外科手术治疗的高危患者，血管内治疗能够缓解其病情，否则此部分患者将任其按自然病程发展恶化。INTRAMURAL HAEMATOMA主动脉壁内血肿Similar to classic type A aortic dissection, surgery is advocated in patients with type A IMH while distal or type B IMH is initially followed with medical treatment. Whereas intramural bleeding of the ascending aorta had a lower mortality with surgery (14% v 36%), patients with haemorrhage of the descending aorta had a similar mortality with medical or surgical treatment (14% v 20%).29 At present, many experts recommend aortic repair for acute IMH of the ascending aorta similar to type A dissection and aggressive blood pressure lowering medication for IMH in the descending aorta similar to type B dissection.30类似地，A 型主动脉壁内血肿也提倡进行手术治疗，远端的或 B 型主动脉壁内血肿也提倡首