急性A型主动脉夹层伴肠系膜灌注不良的再灌注与中心修复优先策略比较：一项单中心回顾性队列研究
Comparison of reperfusion- and central repair-first strategies for acute type A dissection with mesenteric malperfusion: a single-center retrospective cohort study.
作者信息
Gao Xia, Chen Yu-Xin, Ma Wei-Guo, Zhang Li, Cui Cong, Wang Ping-Fan, Yuan Yi-Qiang
机构信息
Departments of Cardiovascular Surgery and Cardiology, Henan Chest Hospital, Zhengzhou University, Zhengzhou, China.
Division of Cardiac Surgery, Yale Medical School, New Haven, CT, USA.
出版信息
Int J Surg. 2024 Oct 1;110(10):6667-6675. doi: 10.1097/JS9.0000000000001746.
BACKGROUND
We seek to compare the early and late outcomes of reperfusion-first vs. central repair-first strategies in patients with acute type A dissection (ATAAD) complicated by mesenteric malperfusion.
METHODS
Among 68 patients, reperfusion-first strategy with superior mesenteric artery (SMA) stenting was adopted in 31 and central repair-first in 37, based on rupture risk and circulatory compromise, severity, time and mechanisms of mesenteric ischemia. Early and late outcomes were compared between two strategies. Follow-up was 100% at 3.3±1.4 years.
RESULTS
Mean age was 50.6±11.4 years (59 males, 86.8%). The reperfusion-first group were more likely to have celiac artery involvement (74.2% vs. 48.6%, P =0.033) and peritoneal irritation signs (19.4% vs. 2.7%, P =0.025), while central repair-first group had more tamponade (27% vs. 3.2%, P =0.008). Early mortality was 48.6% (18/37) with central repair-first strategy vs. 19.4% (6/31) in reperfusion-first group ( P =0.012). Reperfusion-first patients had fewer gastrointestinal complications (12.9% vs. 54.1%, P <0.001) and respiratory failure (3.2% vs. 24.3%, P =0.017). At 5 years, SMA stent patency was 84%, and survival was significantly higher in reperfusion-first patients (80.6% vs. 45.9%, P =0.009), with similar freedom from adverse events between two groups (74.9% vs. 76.0%, P =0.812). Tamponade [hazard ratio (HR), 3.093; P =0.023], peritoneal irritation signs (HR, 8.559; P =0.006), and lactate (mmol/l) (HR, 1.279; P <0.001) were predictors for all-cause mortality.
CONCLUSIONS
In this series of ATAAD patients with mesenteric malperfusion, the reperfusion-first strategy with SMA stenting significantly reduced the mortality risk and achieved favorable late survival and freedom from adverse events. These results argue favorably for the use of the reperfusion-first strategy in acute type A dissection with mesenteric malperfusion.
背景
我们旨在比较急性A型主动脉夹层（ATAAD）合并肠系膜灌注不良患者中再灌注优先与中心修复优先策略的早期和晚期结局。
方法
在68例患者中，根据破裂风险、循环障碍、肠系膜缺血的严重程度、时间和机制，31例采用肠系膜上动脉（SMA）支架置入的再灌注优先策略，37例采用中心修复优先策略。比较两种策略的早期和晚期结局。随访率为100%，时间为3.3±1.4年。
结果
平均年龄为50.6±11.4岁（59例男性，占86.8%）。再灌注优先组更易出现腹腔干受累（74.2%对48.6%，P =0.033）和腹膜刺激征（19.4%对2.7%，P =0.025），而中心修复优先组心包填塞更多见（27%对3.2%，P =0.008）。中心修复优先策略组的早期死亡率为48.6%（18/37），而再灌注优先组为19.4%（6/31）（P =0.012）。再灌注优先组患者的胃肠道并发症（12.9%对54.1%，P <0.001）和呼吸衰竭（3.2%对24.3%，P =0.017）较少。5年时，SMA支架通畅率为84%，再灌注优先组患者的生存率显著更高（80.6%对45.9%，P =0.009），两组间不良事件发生率相似（74.9%对76.0%，P =0.812）。心包填塞[风险比（HR），3.093；P =0.023]、腹膜刺激征（HR，8.559；P =0.006）和乳酸（mmol/L）（HR，1.279；P <0.001）是全因死亡率的预测因素。
结论
在这一系列合并肠系膜灌注不良的ATAAD患者中，采用SMA支架置入的再灌注优先策略显著降低了死亡风险，并实现了良好的晚期生存且无不良事件。这些结果有力地支持了在合并肠系膜灌注不良的急性A型主动脉夹层中使用再灌注优先策略。
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