Kawahito Koji, Kimura Naoyuki, Yamaguchi Atsushi, Aizawa Kei
Department of Cardiovascular Surgery, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, 3290498, Japan.
Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University School of Medicine, Saitama, Japan.
Gen Thorac Cardiovasc Surg. 2019 Jul;67(7):594-601. doi: 10.1007/s11748-019-01072-z. Epub 2019 Feb 7.
Although outcomes of acute type A aortic dissection (ATAAD) have improved, malperfusion remains associated with high morbidity and mortality rates, and its optimal therapeutic treatment is unknown. Emergency central repair has been performed as our first-line approach for malperfusion. Here, we analyzed outcomes of ATAAD with malperfusion and reassessed emergency central repair.
In total, 1026 ATAAD patients underwent emergency surgery within 48 h of symptom onset, of whom 318 (30.9%) patients complicated with any preoperative malperfusion were included. Pathophysiology of malperfusion and surgical outcomes were analyzed.
The in-hospital mortality rate was 12.9% for patients with malperfusion and 4.8% for patients without malperfusion (p < 0.0001). Coronary malperfusion was complicated in 7.5% of patients (% dead per group, 19.5%), mesenteric malperfusion in 3.6% (24.3%), renal malperfusion in 8.8% (14.4%), lower leg malperfusion in 12.6% (13.7%), brain malperfusion in 9.7% (12.0%), and spinal malperfusion in 1.1% (18.2%). Mortality rates varied substantially according to the number of affected organ systems (none, 4.8%; one system, 10.4%; two systems, 14.5%; three systems, 30.0%, and four systems; 30.3%; p < 0.0001). In malperfused patients, logistic regression analysis revealed that obesity (body mass index > 30 kg/m), preoperative shock (systolic blood pressure < 80 mmHg), and visceral ischemia were independent predictors for hospital death.
Malperfusion of more organ systems and mesenteric malperfusion resulted in unfavorable prognosis, and effects of central repair were limited in such severe/complex malperfusion. To further improve outcomes of ATAAD with malperfusion, emergency reperfusion of affected organs followed by central repair might be considered.
尽管急性A型主动脉夹层（ATAAD）的治疗效果有所改善，但灌注不良仍与高发病率和死亡率相关，其最佳治疗方法尚不清楚。急诊中心修复一直是我们治疗灌注不良的一线方法。在此，我们分析了ATAAD合并灌注不良的治疗结果，并重新评估了急诊中心修复。
共有1026例ATAAD患者在症状发作后48小时内接受了急诊手术，其中318例（30.9%）患者术前合并任何灌注不良，对其灌注不良的病理生理学和手术结果进行了分析。
灌注不良患者的院内死亡率为12.9%，无灌注不良患者为4.8%（p<0.0001）。7.5%的患者合并冠状动脉灌注不良（每组死亡百分比，19.5%），3.6%合并肠系膜灌注不良（24.3%），8.8%合并肾灌注不良（14.4%），12.6%合并小腿灌注不良（13.7%），9.7%合并脑灌注不良（12.0%），1.1%合并脊髓灌注不良（18.2%）。死亡率根据受影响器官系统的数量有很大差异（无，4.8%；一个系统，10.4%；两个系统，14.5%；三个系统，30.0%，四个系统；30.3%；p<0.0001）。在灌注不良的患者中，逻辑回归分析显示肥胖（体重指数>30kg/m）、术前休克（收缩压<80mmHg）和内脏缺血是医院死亡的独立预测因素。
更多器官系统的灌注不良和肠系膜灌注不良导致预后不良，在这种严重/复杂的灌注不良情况下，中心修复的效果有限。为了进一步改善ATAAD合并灌注不良的治疗结果，可考虑在中心修复前对受影响器官进行紧急再灌注。
