Buech Joscha, Radner Caroline, Fabry Thomas G, Horke Konstanze M, Ali Ahmad, Saha Shekhar, Hagl Christian, Pichlmaier Maximilian A, Peterss Sven
Department of Cardiac Surgery, LMU University Hospital, Munich, Germany.
German Center for Cardiovascular Research (DZHK), Partner Site of Munich Heart Alliance, Munich, Germany.
J Cardiovasc Surg (Torino). 2022 Apr;63(2):117-123. doi: 10.23736/S0021-9509.22.12276-7. Epub 2022 Mar 3.
Malperfusion in acute aortic dissection is not uncommonly observed and associated with a highly significant increase in mortality and morbidity. Of the various malperfusion syndromes, visceral and renal involvement is the most challenging in terms of correct and timely diagnosis as well as the choice of management strategy. The aim of this study was to identify the pathology and associated fate of each visceral and renal vessel in acute type A dissections.
Over a 12-year period, 167 consecutive patients with acute dissection type A extending into the thoracoabdominal aorta were included and radiographic images analyzed with a focus on individual branch vessel pathology and dependent organ perfusion.
Sixty-five patients (39%) were diagnosed with radiological signs of malperfusion on the CT Images. Of those, 20% expired during the hospital stay, compared to 8% without malperfusion. The left renal artery was the most frequently affected by dissection (31%) or false lumen supply (28%). False lumen perfusion was more often associated with manifest malperfusion than an extension of the dissection flap into the branch vessel. During the study period, there was no preference of surgical procedure treating the malperfusion.
Malperfusion of the visceral/renal branches of a dissected aorta represents a manifest indicator for postoperative mortality and morbidity. Neither clinical outcome, nor the fate of individual vessels can reliably be predicted prior to proximal reconstruction and thus, surgical strategy cannot generally be defined alone by radiological findings.
急性主动脉夹层中的灌注不良并不罕见，且与死亡率和发病率的显著升高相关。在各种灌注不良综合征中，内脏和肾脏受累在正确及时的诊断以及治疗策略的选择方面最具挑战性。本研究的目的是确定急性A型夹层中每个内脏和肾血管的病理情况及相关转归。
在12年期间，纳入了167例连续的急性A型夹层累及胸腹主动脉的患者，并对影像学图像进行分析，重点关注各个分支血管的病理情况和相关器官的灌注。
65例患者（39%）在CT图像上被诊断有灌注不良的影像学征象。其中，20%在住院期间死亡，而无灌注不良者的死亡率为8%。左肾动脉最常受到夹层累及（31%）或假腔供血（28%）。与夹层瓣延伸至分支血管相比，假腔灌注更常与明显的灌注不良相关。在研究期间，治疗灌注不良的手术方式没有偏好。
主动脉夹层的内脏/肾分支灌注不良是术后死亡率和发病率的明显指标。在近端重建之前，既无法可靠预测临床结局，也无法预测单个血管的转归，因此，手术策略通常不能仅由影像学结果来确定。
