Hasan Irsa, Brown James A, Serna-Gallegos Derek, Zhu Jianhui, Garvey Joseph, Yousef Sarah, Sultan Ibrahim
Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa.
Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
JTCVS Open. 2023 May 6;15:1-13. doi: 10.1016/j.xjon.2023.04.015. eCollection 2023 Sep.
Data regarding management of lower-extremity malperfusion in the setting of type A aortic dissection are limited. This study aimed to compare acute type A aortic dissection with lower-extremity malperfusion outcomes in patients undergoing lower-extremity revascularization with no revascularization.
Consecutive patients undergoing acute type A aortic dissection surgery were identified from a prospectively maintained database. Perioperative variables were compared between patients with and without lower-extremity malperfusion. Factors associated with lower-extremity malperfusion, revascularization, and mortality were determined using univariable Cox regression and Firth's penalized likelihood modeling.
From January 2007 to December 2021, 601 patients underwent proximal aortic repair for acute type A aortic dissection at a quaternary care center. Of these, 85 of 601 patients (14%) presented with lower-extremity malperfusion and were more often male ( = .02), had concomitant moderate or greater aortic insufficiency ( = .05), had lower ejection fraction ( = .004), had preoperative dialysis dependence ( = .01), and had additional cerebral, visceral, and renal malperfusion syndromes ( < .001). Kaplan-Meier estimated survival fared worse with lower-extremity malperfusion compared with no lower-extremity malperfusion at 1, 5, and 10 years (84% vs 77%, 74% vs 71%, 65% vs 52%, respectively, = .03). In the lower-extremity malperfusion group, 15 of 85 patients (18%) underwent lower-extremity revascularization without significant differences in postoperative morbidity and mortality compared with patients not undergoing revascularization. Need for peripheral revascularization was associated with peripheral vascular disease (hazard ratio, 3.7 [1.0-14.0], = .05) and pulse deficit (hazard ratio, 5.6 [1.3-24.0], = .02) at presentation.
Patients presenting with type A aortic dissection and lower-extremity malperfusion have worse overall survival compared with those without lower-extremity malperfusion. However, not all patients with type A aortic dissection and lower-extremity malperfusion require revascularization.
关于A型主动脉夹层合并下肢灌注不良的治疗数据有限。本研究旨在比较接受下肢血运重建与未进行血运重建的急性A型主动脉夹层患者的下肢灌注不良结局。
从一个前瞻性维护的数据库中识别出连续接受急性A型主动脉夹层手术的患者。比较有和没有下肢灌注不良患者的围手术期变量。使用单变量Cox回归和Firth惩罚似然模型确定与下肢灌注不良、血运重建和死亡率相关的因素。
2007年1月至2021年12月，一家四级医疗中心有601例患者接受了急性A型主动脉夹层的近端主动脉修复术。其中，601例患者中有85例（14%）出现下肢灌注不良，且男性更为常见（P = 0.02），伴有中度或更严重的主动脉瓣关闭不全（P = 0.05），射血分数较低（P = 0.004），术前依赖透析（P = 0.01），并伴有额外的脑、内脏和肾灌注不良综合征（P < 0.001）。Kaplan-Meier估计生存率显示，下肢灌注不良患者在1年、5年和10年时的生存率低于无下肢灌注不良患者（分别为84%对77%、74%对71%、65%对52%，P = 0.03）。在下肢灌注不良组中，85例患者中有15例（18%）接受了下肢血运重建，与未进行血运重建的患者相比，术后发病率和死亡率无显著差异。外周血运重建的需求与就诊时的外周血管疾病（风险比，3.7 [1.0 - 14.0]，P = 0.05）和脉搏缺失（风险比，5.6 [1.3 - 24.0]，P = 0.02）相关。
与无下肢灌注不良的患者相比，出现A型主动脉夹层并伴有下肢灌注不良的患者总体生存率更差。然而，并非所有A型主动脉夹层并伴有下肢灌注不良的患者都需要血运重建。
