Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA.
Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands.
Eur J Cardiothorac Surg. 2022 Mar 24;61(4):805-813. doi: 10.1093/ejcts/ezab555.
Malperfusion syndrome accompanying aortic dissection is an independent predictor of death with in-hospital mortality rates >60%. Asymmetrically decreased renal enhancement on computed tomography angiography is often considered evidence of renal malperfusion. We investigated the associations between renal enhancement, baseline laboratory values and the diagnosis of renal malperfusion, as defined by invasive manometry, among patients with aortic dissection.
In this retrospective cohort study, we included all patients who were referred to our institution with acute dissection and suspected visceral malperfusion between 2010 and 2020. We determined asymmetric renal enhancement by visual assessment and quantitative density measurements of the renal cortex. We collected invasive renal artery pressures during invasive angiography at the aortic root and in the renal arteries. Logistic regression was performed to evaluate independent predictors of renal malperfusion.
Among the 161 patients analysed, the majority of patients were male (78%) and had type A dissection (52%). Invasive angiography confirmed suspected renal malperfusion in 83% of patients. Global asymmetric renal enhancement was seen in 42% of patients who did not have renal malperfusion during invasive angiography. Asymmetrically decreased renal enhancement was 65% sensitive and 58% specific for renal malperfusion. Both global [odds ratio (OR) 4.43; 1.20-16.41, P = 0.03] and focal (OR 11.23; 1.12-112.90, P = 0.04) enhancement defects were independent predictors for renal malperfusion.
In patients with aortic dissection, we found that differential enhancement of the kidney as seen on the computed tomography angiography is predictive, but not prescriptive for renal malperfusion. While detection of renal malperfusion is aided by computed tomography angiography, its diagnosis requires close monitoring and often invasive assessment.
伴发于主动脉夹层的灌注不良综合征是院内死亡率超过 60%的独立死亡预测因素。CT 血管造影上的肾脏增强程度不对称性降低通常被认为是肾灌注不良的证据。我们研究了主动脉夹层患者中，肾脏增强程度、基线实验室值与诊断为肾灌注不良（通过有创压力测量定义）之间的相关性。
在这项回顾性队列研究中，我们纳入了 2010 年至 2020 年期间因急性夹层和疑似内脏灌注不良而被转诊到我院的所有患者。我们通过视觉评估和对肾皮质的定量密度测量来确定不对称的肾脏增强。我们在主动脉根部和肾动脉进行有创血管造影时采集了有创肾动脉压力。我们采用逻辑回归来评估肾灌注不良的独立预测因素。
在分析的 161 例患者中，大多数患者为男性（78%），且患有 A 型夹层（52%）。有创血管造影在 83%的疑似肾灌注不良患者中得到了证实。在没有进行有创血管造影的肾灌注不良患者中，有 42%的患者出现了全局不对称性肾增强。不对称性降低的肾增强对肾灌注不良的敏感性为 65%，特异性为 58%。全局（比值比 4.43；1.20-16.41，P=0.03）和局灶性（比值比 11.23；1.12-112.90，P=0.04）增强缺陷均是肾灌注不良的独立预测因素。
在主动脉夹层患者中，我们发现 CT 血管造影上观察到的肾脏差异增强可预测，但不能预测肾灌注不良。虽然 CT 血管造影有助于检测肾灌注不良，但需要密切监测，通常还需要有创评估。
