Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Ann Thorac Surg. 2024 Dec;118(6):1308-1316. doi: 10.1016/j.athoracsur.2024.07.042. Epub 2024 Aug 23.
Tissue necrosis from persistent mesenteric ischemia after aortic dissection may progress to sepsis and death without emergency laparotomy. However, the signs of mesenteric necrosis are common in patients experiencing nonsurvivable multisystem failure after aortic catastrophe. This study examined when and whether laparotomy offers a chance for meaningful survival in these patients.
A total of 145 patients treated for acute type A or type B aortic dissection with mesenteric ischemia were identified from a single institution from 2006 to 2022. Of those patients, 29 underwent laparotomy, all for compelling clinical indications. Detailed clinical characteristics were studied with respect to short- and long-term outcomes in these patients.
Among the patients who underwent laparotomy, 45% (13 of 29) survived to discharge compared with 71% (103 of 145) of all patients with mesenteric malperfusion. Serum lactate and arterial pH were both very strongly associated with survival after laparotomy. Among survivors and nonsurvivors, the mean lactate level before laparotomy was 6.3 mmol/L vs 13.4 mmol/L (P = .024), and the mean pH was 7.39 vs 7.20 (P < .001). In particular, a lactate value higher than 8 mmol/L (odd ratio, 16.5; 95% CI, 2.0-192; P = .003) and a pH lower than 7.30 (odds ratio, 14.4; 95% CI, 1.87-128; P = .003) were highly predictive of mortality. Survival to discharge after laparotomy for patients with both severe lactatemia and severe acidosis (defined earlier) was 9% (1 of 11) compared with 90% (9 of 10) for patients with neither severe lactatemia nor acidosis.
The degree of lactic acidosis can effectively identify patients for whom laparotomy is futile and those for whom it is not after aortic dissection with mesenteric ischemia.
主动脉夹层后持续性肠系膜缺血导致的组织坏死，如果不进行紧急剖腹手术，可能会发展为脓毒症和死亡。然而，在主动脉灾难后经历不可避免的多系统衰竭的患者中，肠系膜坏死的迹象很常见。本研究探讨了在这些患者中何时以及剖腹手术是否有机会获得有意义的生存。
从 2006 年至 2022 年，从一家机构中确定了 145 名接受急性 A 型或 B 型主动脉夹层合并肠系膜缺血治疗的患者。其中 29 例行剖腹手术，均有明确的临床指征。研究了这些患者的详细临床特征及其短期和长期结局。
在接受剖腹手术的患者中，45%（29 例中的 13 例）存活至出院，而所有肠系膜灌注不良患者的存活率为 71%（145 例中的 103 例）。手术前后的血清乳酸和动脉 pH 均与剖腹手术后的生存密切相关。在幸存者和非幸存者中，手术前的平均乳酸水平分别为 6.3mmol/L 和 13.4mmol/L（P=0.024），平均 pH 值分别为 7.39 和 7.20（P<0.001）。特别是，乳酸值高于 8mmol/L（比值比，16.5；95%置信区间，2.0-192；P=0.003）和 pH 值低于 7.30（比值比，14.4；95%置信区间，1.87-128；P=0.003）是死亡率的高度预测指标。对于乳酸血症和酸中毒均严重的患者（定义为之前），剖腹手术后出院存活率为 9%（11 例中的 1 例），而乳酸血症和酸中毒均不严重的患者的存活率为 90%（10 例中的 9 例）。
乳酸酸中毒的程度可以有效地识别出主动脉夹层合并肠系膜缺血后剖腹手术无效和有效的患者。
