Xue Yunxing, Tang Xinlong, Zhu Xiyu, Lu Yuzhou, Zhang He, Xie Wei, Zhou Qing, Wang Dongjin
Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China.
Department of Thoracic and Cardiovascular Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.
J Thorac Dis. 2021 Mar;13(3):1403-1412. doi: 10.21037/jtd-20-2349.
Acute type A aortic dissection (aTAAD) with preoperative cerebral ischemia (CI) is common and lethal, but the timing and treatment method remain uncertain. We retrospectively reviewed our aTAAD patients with CI and analyzed the outcomes and related risk factors.
From January 2011 to December 2019, 1,173 patients diagnosed with aTAAD from Nanjing Drum Tower Hospital were enrolled. Among them, 131 patients had CI preoperatively (CI group), and 1,042 patients were in the non-CI group. One hundred eight in the CI group and 984 in the non-CI group received central repair surgery. Fifteen patients had postoperative cerebral complications (CC) and 93 had non-CCs. ROC curves were used to identify the safe duration of preoperative CI.
The CI group was older (56.3 . 53.2 years, P=0.013) and had lower rates of pain, chest pain and back pain (77.9% . 94.4%, 75.4% . 87.5% and 30.8% . 42.3%, respectively) than the non-CI group. The CI group had a higher rate of preoperative hypotension and tamponade (13.7% . 6.0%, 26.9% . 10.4%, respectively; P=0.000). More patients in the CI group did not receive central repair surgery, and the CI had higher mortality (28.2% . 15.9%). CI without central repair surgery was a strong risk factor for mortality. CI patients with CC after central repair had a higher mortality, and preoperative coma was the strongest risk factor for postoperative CC.A duration between CI symptoms and central repair surgery of less than 12.75 hours is recommended.
Prompt surgery is effective for aTAAD with CI, and preoperative coma and a safe duration longer than 12.75 hours would predict worse outcomes.
术前合并脑缺血（CI）的急性A型主动脉夹层（aTAAD）常见且致死率高，但手术时机及治疗方法仍不明确。我们回顾性分析了我院aTAAD合并CI患者的临床资料，分析其治疗结果及相关危险因素。
选取2011年1月至2019年12月在南京鼓楼医院确诊为aTAAD的1173例患者。其中，131例患者术前合并CI（CI组），1042例患者未合并CI（非CI组）。CI组108例和非CI组984例患者接受了中心修复手术。15例患者术后出现脑并发症（CC），93例未出现CC。采用ROC曲线确定术前CI的安全持续时间。
CI组患者年龄大于非CI组（56.3岁比53.2岁，P=0.013），疼痛、胸痛及背痛发生率低于非CI组（分别为77.9%比94.4%、75.4%比87.5%、30.8%比42.3%）。CI组术前低血压及心包填塞发生率高于非CI组（分别为13.7%比6.0%、26.9%比10.4%；P=0.000）。CI组未接受中心修复手术的患者更多，死亡率更高（28.2%比15.9%）。未接受中心修复手术的CI是死亡的强危险因素。中心修复术后出现CC的CI患者死亡率更高，术前昏迷是术后CC的最强危险因素。建议CI症状出现至中心修复手术的时间间隔小于12.75小时。
对于aTAAD合并CI患者，及时手术有效，术前昏迷及安全持续时间超过12.75小时提示预后较差。
