Baldawi Mohanad, Baldawi Mustafa, Krafcik Brianna, Al-Jubouri Mustafa, Markowiak Stephen, Osman Mohamed, Brunicardi Francis C, Nazzal Munier
Department of Surgery, University of Toledo, Toledo, OH.
University of Toledo College of Medicine and Life Sciences, Toledo, OH.
Ann Vasc Surg. 2019 Oct;60:171-177. doi: 10.1016/j.avsg.2019.03.038. Epub 2019 Jun 13.
Postoperative mortality after open and endovascular repair of thoracic aortic dissection (AD) has been the focus of previous research. However, a little has been published on the far less common isolated abdominal aortic dissection (IAAD). The aim of our study was to identify risk factors associated with 30-day postoperative mortality in patients with IAAD.
The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was queried for patients who underwent open or endovascular AD repair from January 2010 to December 2015. Information regarding patient demographics, comorbidities, preoperative laboratory values, procedure details, and postoperative complications were analyzed, and predictors of 30-day mortality were identified. Risk stratification by the type of aortic repair and surgery setting was performed, and patient characteristics associated with mortality in each setting were determined. We employed chi-squared test, Student's t-test, and Mann-Whitney U test for the univariate analysis, while the multivariate analysis was performed using a stepwise binary logistic regression test.
There were 229 patients who met the specified criteria, 15 died within 30 days postoperatively, and 214 survived beyond the same period (mortality rate was 6.5%). Among preoperative factors, a history of chronic obstructive pulmonary disease (COPD), preoperative ventilator dependence, preoperative transfusion of ≥1 unit packed RBCs, emergent operation, and advanced American Society of Anesthesiologists (ASA) class were associated with increased risk of mortality. Postoperative complications associated with a higher risk of mortality were acute kidney injury, mechanical ventilation ≥48 hours, unplanned intubation, myocardial infarction, septic shock, and blood transfusion. On multivariate analysis, risk factors independently associated with increased risk of mortality were a history of COPD (adjusted odds ratio [AOR], 10.5; P = 0.013), postoperative acute renal failure (AOR, 12.8; P = 0.003) and septic shock (AOR, 15.3; P = 0.014).
Multiple preoperative and postoperative factors are associated with a high risk of death after IAAD repair. A better control of COPD and prevention of postoperative acute renal failure and septic shock may result in better outcomes.
胸主动脉夹层（AD）开放手术和血管腔内修复术后的死亡率一直是以往研究的重点。然而，关于极少见的孤立性腹主动脉夹层（IAAD）的报道却很少。我们研究的目的是确定IAAD患者术后30天死亡率的相关危险因素。
查询美国外科医师学会国家外科质量改进计划（ACS NSQIP）中2010年1月至2015年12月期间接受开放或血管腔内AD修复的患者。分析患者人口统计学、合并症、术前实验室检查值、手术细节及术后并发症等信息，确定30天死亡率的预测因素。根据主动脉修复类型和手术环境进行风险分层，并确定每种环境下与死亡率相关的患者特征。单因素分析采用卡方检验、学生t检验和曼 - 惠特尼U检验，多因素分析采用逐步二元逻辑回归检验。
有229例患者符合指定标准，15例术后30天内死亡，214例存活超过此期限（死亡率为6.5%）。术前因素中，慢性阻塞性肺疾病（COPD）病史、术前依赖呼吸机、术前输注≥1单位浓缩红细胞、急诊手术及美国麻醉医师协会（ASA）分级较高与死亡风险增加相关。与较高死亡风险相关的术后并发症有急性肾损伤、机械通气≥48小时、非计划插管、心肌梗死、感染性休克和输血。多因素分析显示，与死亡风险增加独立相关的危险因素为COPD病史（调整优势比[AOR]，10.5；P = 0.013）术后急性肾衰竭（AOR，12.8；P = 0.003）和感染性休克（AOR，15.3；P = 0.014）。
IAAD修复术后，多个术前和术后因素与高死亡风险相关。更好地控制COPD以及预防术后急性肾衰竭和感染性休克可能会带来更好的结果。
