Vendramin Igor, Isola Miriam, Piani Daniela, Onorati Francesco, Salizzoni Stefano, D'Onofrio Augusto, Di Marco Luca, Gatti Giuseppe, De Martino Maria, Faggian Giuseppe, Rinaldi Mauro, Gerosa Gino, Pacini Davide, Pappalardo Aniello, Livi Ugolino
Azienda Sanitaria Universitaria Friuli Centrale, Cardiothoracic Department, Udine, Italy.
Department of Medical Area (DAME), University of Udine, Udine, Italy.
JTCVS Open. 2022 Mar 26;10:22-33. doi: 10.1016/j.xjon.2022.03.001. eCollection 2022 Jun.
The study objective was to evaluate the surgical results in patients with acute type A aortic dissection and cerebral malperfusion.
From 2000 to 2019, 234 patients with type A aortic dissection and cerebral malperfusion were stratified into 3 groups: 50 (21%) with syncope (group 1), 152 (65%) with persistent loss of focal neurological function (group 2), and 32 (14%) with coma (group 3). Results were evaluated and compared by univariable and multivariable analyses.
Median age was higher in group 1, and incidence of cardiogenic shock was higher in group 3. The femoral artery was the most common cannulation site, whereas the axillary artery was used in 18% of group 1, 30% of group 2, and 25% of group 3 patients ( = .337). Antegrade cerebral perfusion was performed in more than 80% of patients, and ascending aorta/arch replacement was performed in 40% of group 1, 27% of group 2, and 31% of group 3 ( = .21). In-hospital mortality was 18% in group 1, 27% in group 2, and 56% in group 3 ( = .001). Survival at 5 years is 57.0% in group 1, 57.7% in group 2, and 38.7% in group 3 ( = .0005). On multivariable analysis, age, cardiopulmonary bypass time, and group 3 versus group 2 were independent risk factors for mortality, whereas axillary cannulation was a protective factor.
Patients with aortic dissection and cerebral malperfusion without preoperative coma showed acceptable mortality, and those with coma had a high in-hospital mortality regardless of the type of brain protection. Overall axillary artery cannulation appeared to be a protective factor.
本研究目的是评估急性A型主动脉夹层合并脑灌注不良患者的手术结果。
2000年至2019年，234例A型主动脉夹层合并脑灌注不良患者被分为3组：50例（21%）出现晕厥（第1组），152例（65%）出现局灶性神经功能持续丧失（第2组），32例（14%）出现昏迷（第3组）。通过单变量和多变量分析评估并比较结果。
第1组患者的年龄中位数较高，第3组心源性休克的发生率较高。股动脉是最常用的插管部位，而第1组18%、第2组30%和第3组25%的患者使用了腋动脉（P = 0.337）。超过80%的患者进行了顺行性脑灌注，第1组40%、第2组27%和第3组31%的患者进行了升主动脉/主动脉弓置换（P = 0.21）。第1组的院内死亡率为18%，第2组为27%，第3组为56%（P = 0.001）。第1组5年生存率为57.0%，第2组为57.7%，第3组为38.7%（P = 0.0005）。多变量分析显示，年龄、体外循环时间以及第3组与第2组相比是死亡的独立危险因素，而腋动脉插管是一个保护因素。
术前无昏迷的主动脉夹层合并脑灌注不良患者死亡率可接受，而昏迷患者无论采用何种脑保护方式，院内死亡率都很高。总体而言，腋动脉插管似乎是一个保护因素。
