Evaluation of risk factors for transient neurological dysfunction and adverse outcome after repair of acute type A aortic dissection in 122 consecutive patients
Evaluation of risk factors for transient neurological dysfunction and adverse outcome after repair of acute type A aortic dissection in 122 consecutive patients
复制标题
DOI：
10.1093/ejcts/ezs412
复制
发表时间：
2012-11-01
影响因子：
3.4
通讯作者：
Strauch, Justus T.
中科院分区：
文献类型：
--
作者：
Haldenwang, Peter L.;Wahlers, Thorsten;Strauch, Justus T.
本回顾性研究的目的是评估导致急性A型主动脉夹层（ATAAD）修复术后神经系统并发症和早期死亡的术前和术中因素，共有122例ATAAD患者（85例男性，年龄：58.6 ± 12.5岁），从2003年8月至2010年8月连续接受治疗。采用逻辑回归模型分析术前和术中变量，以确定暂时性神经功能障碍（TND）和不良结局（AO）的危险因素，不良结局定义为卒中和30天死亡率，30天死亡率为16.4%。41例患者（33.6%）出现一过性神经功能障碍，20例（16.4%）发生术后卒中。平均低温停循环（HCA）温度为24 +/- 4 ℃。99例（82%）患者进行了选择性脑灌注（SCP），平均SCP流速为10.3 ml/kg/min。下体缺血（LBI）持续时间为36 +/- 27 min，HCA为8.7 +/- 15.5 min，SCP为34 +/- 28 min。男性[比值比（OR）：3.30，95%置信区间（CI）：1.15-9.47]，糖尿病（OR：3.95，95% CI：1.18-13.24），意识受损（OR：6.65，95%CI：1.41-31.48）和明显动脉粥样硬化（OR：6.68，95%CI：1.31-34.09）是TND的危险因素，而高体重指数（BMI）是TND的危险因素（OR：1.14，95% CI：1.01-1.3），术前灌注不良综合征（OR：2.28，95%CI：0.84-6.18）和左室射血分数< 50%（OR：3.84，95%CI：1.41-10.43）被检测为AO的独立预测因素。位于主动脉弓或降主动脉的夹层入口单独增加了术后卒中的风险。长时间的LBI增加了AO的风险（OR：1.02，95% CI：1.00-1.04），而股动脉插管显示出增加卒中发生率的趋势（OR：4.2，95% CI：0.8-21.3）。无论采用标准化的神经保护技术，ATAAD的治疗仍然是一种高风险手术。术前射血分数降低、灌注不良综合征或高体重指数可能会增加围手术期不良结局的风险。位于主动脉弓或降主动脉的夹层“入口”可能会增加术后卒中的风险。术中应避免股动脉插管和LBI时间延长超过45分钟。特别是在明显的术前脑和/或终末器官灌注不良的患者中，插管方式以及整个神经保护管理应单独选择，尊重其局限性。
The aim of this retrospective study was to assess pre- and intraoperative factors leading to neurological complications and early death following repair of acute type A aortic dissection (ATAAD).There were 122 patients (85 male, age: 58.6 +/- 12.5 years) with ATAAD, treated consecutively from August 2003 to August 2010. Pre- and intraoperative variables were analysed using a logistic regression model in order to identify risk factors for temporary neurological dysfunction (TND) and adverse outcome (AO), defined as stroke and 30-day mortality.The 30-day mortality rate was 16.4%. Forty-one patients (33.6%) suffered transient neurological dysfunction and 20 (16.4%) had a postoperative stroke. Mean hypothermic circulatory arrest (HCA) temperature was 24 +/- 4 degrees C. Selective cerebral perfusion (SCP) was performed in 99 (82%) patients, with a mean SCP flow rate of 10.3 ml/kg/min. The duration of lower body ischaemia (LBI) was 36 +/- 27 min, of HCA 8.7 +/- 15.5 min and of SCP 34 +/- 28 min, respectively. Male gender [odds ratio (OR): 3.30, 95% confidence interval (CI): 1.15-9.47], diabetes (OR: 3.95, 95% CI: 1.18-13.24), compromised consciousness (OR: 6.65, 95% CI: 1.41-31.48) and manifest arterial atherosclerosis (OR: 6.68, 95% CI: 1.31-34.09) were detected as risk factors for TND, whereas a high body mass index (OR: 1.14, 95% CI: 1.01-1.3), a preoperative malperfusion syndrome (OR: 2.28, 95% CI: 0.84-6.18) and left ventricular ejection fraction < 50% (OR: 3.84, 95% CI: 1.41-10.43) were detected as independent predictors for an AO. A dissection entry localized in the aortic arch or the descending aorta independently increased the risk for a postoperative stroke. A prolonged LBI increased the risk for AO (OR: 1.02, 95% CI: 1.00-1.04), whereas femoral cannulation showed a trend to an increased stroke incidence (OR: 4.2, 95% CI: 0.8-21.3).Regardless of standardized neuroprotective techniques, treatment of ATAAD remains a high-risk operation. Preoperatively, the presence of a reduced ejection fraction, a malperfusion syndrome or a high body mass index may increase the perioperative risk for an adverse outcome. A dissection 'entry' localized in the aortic arch or the descending aorta may increase the risk for postoperative stroke. Intraoperatively, cannulation of the femoral artery and extension of the LBI time over 45 min should be avoided. Especially in patients with manifest preoperative cerebral and/or end-organ malperfusion, the cannulation modality as well as the entire neuroprotective management should be chosen individually, respecting its limitations.