Henke Peter K, Williams David M, Upchurch Gilbert R, Proctor Mary, Cooper Jeanna V, Fang Jianming, Nienaber Christoph A, Isselbacher Eric M, Fattori Rosella, Dasika Nara, Gemmete Joesph, Stanley James C, Wakefield Thomas W, Eagle Kim A
Section of Vascular Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich, USA.
Surgery. 2006 Oct;140(4):532-9; discussion 539-40. doi: 10.1016/j.surg.2006.06.019. Epub 2006 Sep 1.
The goal of the current study is to characterize the presentation, therapy, and outcomes of acute limb ischemia (ALI) associated with type B aortic dissection (AoD).
The prospective/retrospective International Registry for Acute Aortic Dissection (IRAD) database and a single institutional database were queried for all patients with type B AoD from 1996 to 2002. Univariate and multivariate statistics were used to delineate factors associated with morbidity and mortality outcomes.
According to the IRAD data (n = 458), the mean age of patients was 64 years, and 70% were men. The overall mortality was 12%; of these, 6% had ALI. Pulse (3-fold) and neurologic deficits (5-fold) were more common in those with ALI (P < .001). Endovascular, but not surgical therapy, was more commonly performed in patients with ALI compared with those without ALI (31% vs 10%, P = .004). No difference in age, race, gender, or origin of dissection was observed. ALI was associated with acute renal failure (odds ratio [OR] = 2.7; 95% confidence interval [CI] 1.1-7.1; P = .048) and acute mesenteric ischemia/infarction (OR = 6.9; 95% CI 2.5-20; P < .001). Adjusting for patient characteristics, ALI was associated with death (3.5; 95% CI 1.1-10; P = .02). The single institution analysis revealed similar patient demographics and mortality in 93 AoD patients, of whom 28 had ALI. Aortic fenestration or aorto-iliac stenting was the primary therapy in 93%; surgical bypass was used in 7%. Limb salvage was 93% in those with ALI at a mean of 18 months follow-up. The number of organ systems with malperfusion was 2-fold higher at aortography than suspected preprocedure (P = .002). By stepwise regression modeling, mortality was greater in those not taking a beta-blocker (OR = 19; 95% CI 3.1-111; P = .001).
ALI secondary to AoD is predictive of death and visceral ischemia. Endovascular therapy confers excellent limb salvage and allows diagnosis of unsuspected visceral ischemia.
本研究的目的是描述与B型主动脉夹层（AoD）相关的急性肢体缺血（ALI）的临床表现、治疗方法及预后。
查询1996年至2002年期间前瞻性/回顾性国际急性主动脉夹层注册数据库（IRAD）以及一个单机构数据库中所有B型AoD患者的资料。采用单因素和多因素统计分析来确定与发病和死亡结局相关的因素。
根据IRAD数据（n = 458），患者的平均年龄为64岁，70%为男性。总体死亡率为12%；其中，6%患有ALI。ALI患者的脉搏异常（3倍）和神经功能缺损（5倍）更为常见（P <.001）。与无ALI的患者相比，ALI患者更常接受血管内治疗而非手术治疗（31%对10%，P =.004）。在年龄、种族、性别或夹层起源方面未观察到差异。ALI与急性肾衰竭（比值比[OR] = 2.7；95%置信区间[CI] 1.1 - 7.1；P =.048）和急性肠系膜缺血/梗死（OR = 6.9；95% CI 2.5 - 20；P <.001）相关。校正患者特征后，ALI与死亡相关（3.5；95% CI 1.1 - 10；P =.02）。单机构分析显示，93例AoD患者的人口统计学特征和死亡率相似，其中28例患有ALI。93%的患者主要接受主动脉开窗或主动脉 - 髂动脉支架置入治疗；7%的患者采用手术搭桥治疗。在平均18个月的随访中，ALI患者的肢体挽救率为93%。血管造影显示灌注不良的器官系统数量比术前怀疑的多2倍（P =.002）。通过逐步回归模型分析，未服用β受体阻滞剂的患者死亡率更高（OR = 19；95% CI 3.1 - 111；P =.001）。
AoD继发的ALI可预测死亡和内脏缺血。血管内治疗可实现出色的肢体挽救，并有助于诊断未被怀疑的内脏缺血。
