Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.
Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.
Ann Thorac Surg. 2022 Apr;113(4):1183-1190. doi: 10.1016/j.athoracsur.2021.05.008. Epub 2021 May 27.
This study assessed the safety of direct axillary artery (AX) cannulation for acute type A dissection (ATAD) repair, including the impact of innominate artery dissection (IAD).
Of 281 consecutive patients who underwent ATAD repair from 2007 to 2020, preoperative computed tomography was available in 200 (IAD, n = 101; non-IAD, n = 99). IAD with compromised true lumen was defined as dissection in which the false lumen was greater than 50% of the IA diameter (n = 75 of 101).
AX cannulation was attempted in 188 patients (94.0%), with a 1.6% vascular injury rate (3 patients), comprising bypass to the distal AX in 2 patients and local dissection in 1 patient. Deep hypothermic circulatory arrest was used for the distal repair in 89.5% of patients. Right AX cannulation was used in 80.2% of patients with IAD and in 88.9% without IAD (P = .075). Patients with IAD had more cerebral (21.8% vs 5.1%, P = .001) and arm malperfsion (11.9% vs 4.0%, P = .075). Operative death and stroke were comparable between non-IAD (8.1% vs 7.9%, P = 1.00) and IAD (4.0% vs 5.3%, P = .689) groups. The right AX was successfully used in 77.3% of IAD patients with a compromised true lumen, with comparable hospital outcomes to noncompromised IAD patients. Upper extremity malperfusion, multiorgan malperfusion, low ejection fraction, and female sex were predictors for noncannulation of the right AX.
Routine direct AX cannulation strategy is safe in ATAD repair. Right AX cannulation can be used in most patients with IAD, even with a compromised true lumen, with low mortality, stroke, and vascular injury rates.
本研究评估了直接经腋动脉（AX）插管在急性 A 型夹层（ATAD）修复中的安全性，包括对无名动脉夹层（IAD）的影响。
在 2007 年至 2020 年间连续进行的 281 例 ATAD 修复中，200 例患者术前可进行计算机断层扫描（IAD，n=101；非 IAD，n=99）。定义真腔受损的 IAD 为假腔大于 IA 直径的 50%（n=101 中的 75 例）。
188 例（94.0%）患者尝试 AX 插管，血管损伤率为 1.6%（3 例），包括 2 例旁路至远端 AX，1 例局部夹层。89.5%的患者采用深低温循环停循环进行远端修复。IAD 患者中 80.2%采用右侧 AX 插管，非 IAD 患者中 88.9%采用右侧 AX 插管（P=0.075）。IAD 患者的脑（21.8%比 5.1%，P=0.001）和手臂（11.9%比 4.0%，P=0.075）并发症发生率更高。非 IAD（8.1%比 7.9%，P=1.00）和 IAD（4.0%比 5.3%，P=0.689）组的手术死亡率和卒中发生率相当。77.3%的真腔受损 IAD 患者成功使用右侧 AX，其住院结局与非受损 IAD 患者相当。上肢灌注不良、多器官灌注不良、射血分数低和女性是右侧 AX 无法插管的预测因素。
在 ATAD 修复中，常规直接 AX 插管策略是安全的。右侧 AX 插管可用于大多数 IAD 患者，即使真腔受损，死亡率、卒中率和血管损伤率也较低。
