Trimarchi S, Tolenaar J L, Tsai T T, Froehlich J, Pegorer M, Upchurch G R, Fattori R, Sundt T M, Isselbacher E M, Nienaber C A, Rampoldi V, Eagle K A
Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy.
J Cardiovasc Surg (Torino). 2012 Apr;53(2):161-8.
In-hospital outcome of acute type B dissection (ABAD) is strongly related to preoperative aortic conditions. In order to clarify the influence of the clinical presentation on the outcome, we analyzed the patients of the International Registry of Acute Aortic Dissection (IRAD). All patients affected by complicated ABAD, enrolled in the IRAD from 1996-2004, were included. Complications were defined as the presence of shock, periaortic hematoma, spinal cord ischemia, preoperative mesenteric ischemia/infarction, acute renal failure, limb ischemia, recurrent pain, refractory pain or refractory hypertension (group I). All other patients were categorized as uncomplicated (group II). A comprehensive analysis was performed of all clinical variables in relation to in-hospital outcome.
The overall in-hospital mortality among 550 patients was 12.4%. Mortality in group I (250 patients) was 20.0 %, compared to 6.1% in group II (300 patients) (P<0.001). Univariate predictors of ABAD complications were Marfan syndrome, abrupt onset of pain, migrating pain, any focal neurological deficits, need for higher number of diagnostic examinations and use of magnetic resonance and/or aortogram, abdominal vessels involvement at aortogram, larger descending aortic diameter, especially >6 cm, pleural effusion, and widened mediastinum on chest X-ray. Univariate predictors of a non complicated status were normal chest X-ray and medical management. In group I, in-hospital mortality following surgical and endovascular intervention were 28.6% and 10.1% (P=0.006), respectively. Independent predictors of overall in-hospital mortality included age >70 years, female gender, ECG showing ischemia, preoperative acute renal failure, preoperative limb ischemia, periaortic hematoma, and surgical management. The only independent variable protective for mortality was magnetic resonance as diagnostic test.
ABAD is a heterogeneous disease that produces dissimilar clinical subsets, each of which can have specific clinical signs, management and in-hospital results. In IRAD ABAD uncomplicated patients, medical therapy was associated with best hospital outcome, while endovascular interventions were associated with better results than surgery when invasive treatments were required. Although selection bias may be possible, and irrespective of treatments, knowledge of significant risk factors for mortality may contribute to a better management and a more defined risk-assessment in patients affected by ABAD.
急性B型主动脉夹层（ABAD）的院内结局与术前主动脉状况密切相关。为了阐明临床表现对结局的影响，我们分析了国际急性主动脉夹层注册研究（IRAD）中的患者。纳入了1996年至2004年在IRAD登记的所有患有复杂性ABAD的患者。并发症定义为存在休克、主动脉周围血肿、脊髓缺血、术前肠系膜缺血/梗死、急性肾衰竭、肢体缺血、复发性疼痛、难治性疼痛或难治性高血压（I组）。所有其他患者被归类为非复杂性（II组）。对所有与院内结局相关的临床变量进行了综合分析。
550例患者的总体院内死亡率为12.4%。I组（250例患者）的死亡率为20.0%，而II组（300例患者）为6.1%（P<0.001）。ABAD并发症的单因素预测因素包括马凡综合征、疼痛突然发作、游走性疼痛、任何局灶性神经功能缺损、需要更多的诊断检查以及使用磁共振和/或主动脉造影、主动脉造影显示腹部血管受累、降主动脉直径较大，尤其是>6 cm、胸腔积液以及胸部X线显示纵隔增宽。非复杂性状态的单因素预测因素是胸部X线正常和药物治疗。在I组中，手术和血管内介入后的院内死亡率分别为28.6%和10.1%（P=0.006）。总体院内死亡率的独立预测因素包括年龄>70岁、女性、心电图显示缺血、术前急性肾衰竭、术前肢体缺血、主动脉周围血肿以及手术治疗。对死亡率具有保护作用的唯一独立变量是作为诊断检查的磁共振。
ABAD是一种异质性疾病，产生不同的临床亚组，每个亚组都可能有特定的临床体征、治疗方法和院内结果。在IRAD的ABAD非复杂性患者中，药物治疗与最佳的医院结局相关，而在需要进行侵入性治疗时，血管内介入的结果优于手术。尽管可能存在选择偏倚，且无论治疗方法如何，了解死亡率的重要危险因素可能有助于更好地管理受ABAD影响的患者并进行更明确的风险评估。
