Division of Vascular Surgery, University of Minnesota Medical Center, Minneapolis, MN.
Division of Vascular Surgery, University of Minnesota Medical Center, Minneapolis, MN.
J Vasc Surg. 2023 Jun;77(6):1618-1624. doi: 10.1016/j.jvs.2023.02.004. Epub 2023 Feb 14.
Acute dissection involving the ascending aorta and extending beyond the innominate artery (DeBakey type I) may be associated with acute ischemic complications owing to branch artery malperfusion. The purpose of this study was to document the prevalence of noncardiac ischemic complications associated with type I aortic dissections that persisted after initial ascending aortic and hemiarch repair, necessitating vascular surgery intervention.
Consecutive patients presenting with acute type I aortic dissections between 2007 and 2022 were studied. Patients who underwent initial ascending aortic and hemiarch repair were included in the analysis. Study end points included the need for additional interventions after ascending aortic repair and death.
There were 120 patients (70% men; mean age, 58 ± 13 years) who underwent emergent repair for acute type I aortic dissections during the study period. Forty-one patients (34%) presented with acute ischemic complications. These included 22 (18%) with leg ischemia, 9 (8%) with acute strokes, 5 (4%) with mesenteric ischemia, and 5 (4%) with arm ischemia. After proximal aortic repair, 12 patients (10%) had persistent ischemia. Nine patients (8%) required additional interventions for persistent leg ischemia (n = 7), intestinal gangrene (n = 1), or cerebral edema (craniotomy, n = 1). Three other patients with acute stroke had permanent neurologic deficits. All other ischemic complications resolved after the proximal aortic repair despite mean operative times exceeding 6 hours. Comparing patients with persistent ischemia with those whose symptoms resolved after central aortic repair, there were no differences in demographics, distal extent of dissection, mean operative time for aortic repair, or need for venous-arterial extracorporeal bypass support. Overall, 6 of the 120 patients (5%) suffered perioperative deaths. Hospital deaths occurred in 3 of the 12 patients (25%) with persistent ischemia vs none of 29 patients who had resolution of the ischemia after aortic repair (P = .02). Over a mean follow-up of 51 ± 39 months, no patient required an additional intervention for persistent branch artery occlusion.
One-third of patients with acute type I aortic dissections had associated noncardiac ischemia, prompting a vascular surgery consultation. Limb and mesenteric ischemia most often resolved after the proximal aortic repair and did not require further intervention. No vascular interventions were performed in patients with stroke. Although the presence of acute ischemia at presentation did not increase hospital or 5-year mortality rates, persistent ischemia after central aortic repair seems to be a marker for increased hospital mortality after type I dissections.
升主动脉夹层并延伸至无名动脉（DeBakey Ⅰ型）可能会因分支动脉灌注不良而导致急性缺血性并发症。本研究旨在记录在初次升主动脉和半弓修复后仍持续存在的Ⅰ型主动脉夹层相关的非心源性缺血性并发症，并需要血管外科干预。
连续研究了 2007 年至 2022 年间急性Ⅰ型主动脉夹层的连续患者。分析包括接受初次升主动脉和半弓修复的患者。研究终点包括升主动脉修复后需要额外干预和死亡。
研究期间，共有 120 名（70%为男性；平均年龄 58±13 岁）患者因急性Ⅰ型主动脉夹层而行紧急修复。41 名（34%）患者出现急性缺血性并发症。其中包括 22 例（18%）下肢缺血、9 例（8%）急性脑卒中、5 例（4%）肠系膜缺血和 5 例（4%）手臂缺血。近端主动脉修复后，12 名患者（10%）仍存在缺血。9 名（8%）患者因持续性下肢缺血（n=7）、肠坏死（n=1）或脑水肿（开颅手术，n=1）需要额外干预。其他 3 名急性脑卒中患者有永久性神经功能缺损。尽管主动脉修复的平均手术时间超过 6 小时，但所有其他缺血性并发症在近端主动脉修复后均得到缓解。与主动脉修复后症状缓解的患者相比，持续性缺血患者的人口统计学特征、夹层的远端范围、主动脉修复的平均手术时间或静脉-动脉体外循环支持的需求无差异。总的来说，120 名患者中有 6 名（5%）在围手术期死亡。3 名（25%）持续性缺血患者发生院内死亡，而 29 名主动脉修复后缺血缓解的患者无院内死亡（P=0.02）。在平均 51±39 个月的随访中，没有患者因持续性分支动脉闭塞而需要进一步介入治疗。
三分之一的急性Ⅰ型主动脉夹层患者伴有非心源性缺血，需要血管外科会诊。肢体和肠系膜缺血在近端主动脉修复后大多得到缓解，不需要进一步干预。脑卒中患者无需进行血管介入治疗。尽管急性缺血的存在在发病时不会增加住院或 5 年死亡率，但在中心主动脉修复后仍存在持续性缺血似乎是Ⅰ型夹层后增加院内死亡率的一个标志。
