Preece Ryan, Srivastava Vivek, Akowuah Enoch, Kendall Simon
Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK.
Interact Cardiovasc Thorac Surg. 2017 Oct 1;25(4):643-646. doi: 10.1093/icvts/ivx169.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was should limb revascularization take priority over dissection repair in acute type A aortic dissection (ATAAD) presenting as isolated acute limb ischaemia? Altogether 133 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Six studies showed that aortic repair alone resulted in the reperfusion of 60-100% of ischaemic lower limbs and recommended a strategy prioritizing aortic repair. In those with persistent isolated limb ischaemia post-aortic repair, expeditious peripheral revascularization procedures produced excellent patient outcomes comparable to those of ATAAD patients without malperfusion syndromes. In the remaining study, aortic repair was delayed in order to prioritize percutaneous reperfusion therapy aimed at treating the peripheral malperfusion. However, this resulted in one-third of patients not surviving to aortic surgery. We conclude that delaying aortic repair for limb reperfusion procedures results in unacceptably high mortality rates and that repair alone results in high reperfusion rates of ischaemic limbs. We therefore strongly recommend that aortic repair be the primary therapy for ATAAD patients even when limb ischaemia is the presenting feature. Limbs should be reassessed immediately after aortic repair and revascularization procedures undertaken urgently if any pulse deficits remain.
根据结构化方案撰写了一篇心脏外科最佳证据主题文章。所探讨的问题是，在以孤立性急性肢体缺血为表现的急性A型主动脉夹层（ATAAD）中，肢体血运重建是否应优先于夹层修复？通过报告的检索共找到133篇论文，其中7篇代表了回答该临床问题的最佳证据。现将这些论文的作者、期刊、发表日期和国家、研究的患者群体、研究类型、相关结局及结果制成表格列出。六项研究表明，仅进行主动脉修复可使60% - 100%的缺血下肢实现再灌注，并推荐优先进行主动脉修复的策略。在主动脉修复后仍存在持续性孤立肢体缺血的患者中，迅速进行外周血运重建手术可产生与无灌注不良综合征的ATAAD患者相当的良好患者结局。在其余一项研究中，为优先进行旨在治疗外周灌注不良的经皮再灌注治疗而延迟了主动脉修复。然而，这导致三分之一的患者未能存活至接受主动脉手术。我们得出结论，为肢体再灌注程序而延迟主动脉修复会导致不可接受的高死亡率，且仅修复就能使缺血肢体获得高再灌注率。因此，我们强烈建议，即使肢体缺血是主要表现，主动脉修复也应作为ATAAD患者的主要治疗方法。主动脉修复后应立即重新评估肢体情况，若仍有脉搏缺失，应紧急进行血运重建手术。
