Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School, Houston, TX, USA.
J Vasc Surg. 2013 Apr;57(4):1023-9. doi: 10.1016/j.jvs.2012.10.079. Epub 2013 Jan 18.
Management of limb and other malperfusion syndromes is controversial in acute type A aortic dissection. We assessed our hypothesis that urgent proximal aortic repair resolves most cases of limb ischemia without additional peripheral revascularization.
We retrospectively reviewed operative cases of acute type A aortic dissection from 1999 to 2011. Our standard technique involved urgent replacement of the ascending aorta and hemiarch. Persistent limb ischemia after aortic repair was treated by bypass surgery. Comparisons between groups both with and without limb ischemia were made.
We repaired 335 cases during the study period. Sixty-one patients had limb ischemia (18.2%), of whom 51 were classified with lower limb ischemia (15.2%). All patients with upper limb ischemia survived to discharge without limb loss or death. Only 11 of the 51 patients with lower limb ischemia (21.6%) required peripheral revascularization after aortic repair. There was one case of lower limb loss resulting from delayed recognition of persistent ischemia. Renal dysfunction occurred in 21% of patients with isolated lower limb ischemia and in 31% of patients with uncomplicated dissection (P = .29). In-hospital mortality was 13.7% overall and 8.0% in patients with isolated lower limb ischemia (P = .89). There was no difference in long-term survival between isolated limb ischemia and uncomplicated cases (P = .54).
Most cases of limb ischemia resolve after immediate repair of acute type A aortic dissection. There is no difference in renal dysfunction or in-hospital or long-term mortality between patients with isolated limb ischemia and those with nonmalperfusion dissection. If ischemia persists, limb salvage is successful if revascularization is expeditious.
在急性A型主动脉夹层中，肢体和其他灌注不良综合征的治疗存在争议。我们评估了我们的假设，即紧急近端主动脉修复可解决大多数肢体缺血病例，而无需额外的外周血运重建。
我们回顾性分析了 1999 年至 2011 年期间急性 A 型主动脉夹层的手术病例。我们的标准技术包括紧急替换升主动脉和半弓。主动脉修复后持续的肢体缺血通过旁路手术治疗。对有和无肢体缺血的两组进行了比较。
研究期间共修复了 335 例病例。61 例患者出现肢体缺血（18.2%），其中 51 例为下肢缺血（15.2%）。所有上肢缺血患者均存活至出院，无肢体丧失或死亡。只有 51 例下肢缺血患者中的 11 例（21.6%）在主动脉修复后需要进行外周血运重建。有 1 例因持续缺血的延迟识别而导致下肢丧失。孤立性下肢缺血患者的肾功能不全发生率为 21%，非复杂性夹层患者为 31%（P=0.29）。总的院内死亡率为 13.7%，孤立性下肢缺血患者为 8.0%（P=0.89）。孤立性肢体缺血和非灌注不良病例的长期生存率无差异（P=0.54）。
急性 A 型主动脉夹层立即修复后，大多数肢体缺血病例可得到缓解。孤立性肢体缺血和非灌注不良病例之间在肾功能不全、院内死亡率或长期死亡率方面无差异。如果缺血持续存在，如果血运重建迅速，肢体挽救是成功的。
