Stanford A型主动脉夹层术后死亡和严重并发症的危险因素

Risk factors of mortality and morbidity after surgical procedure for Stanford type A aortic dissection

目的探讨单中心Stanford A型主动脉夹层(TAAD)患者术后死亡及严重并发症的独立危险因素。方法回顾性分析2012年5月至2015年5月阜外医院行手术治疗341例TAAD患者的临床资料,其中男246例、女95例,平均年龄29~73(47.42±11.54)岁。根据术后有无出现死亡或严重并发症将患者分为两组:并发症组(87例)和无并发症组(254例)。比较分析两组患者围术期资料。结果并发症组患者平均年龄显著高于无并发症组患者[(49.91±11.22)岁vs.(46.57±11.54)岁,P=0.019]。并发症组患者术前出现器官缺血性损伤比例显著高于无并发症组患者:脑缺血(18.4%vs.5.9%,P=0.001)、脊髓损伤(16.1%vs.4.7%,P=0.001)、急性肾损伤(31.0%vs.10.6%,P=0.000)。夹层累及动脉分支血管比例显著高于无并发症组患者:冠状动脉受累(52.9%vs.17.1%,P=0.000)、弓上动脉受累(73.6%vs.53.9%,P=0.001)、腹腔干动脉受累(37.9%vs.22.0%,P=0.003)、肠系膜上动脉受累(18.4%vs.9.8%,P=0.030)、单侧或双侧肾动脉受累(27.6%vs.9.8%,P=0.000)。并发症组体外循环时间、主动脉阻断时间、深低温停循环时间均显著长于无并发症组[(205.05±63.65)min vs.(167.67±50.24)min,(108.11±34.79)min vs.(90.75±27.33)min,(22.55±8.09)min vs.(18.76±9.56)min,P<0.05]。年龄、术前合并脑缺血性损伤、术前合并急性肾损伤、术前肢体感觉和(或)运动功能障碍、夹层累及冠状动脉、体外循环时间均为TAAD患者术后死亡和严重并发症发生的独立危险因素;对于夹层累及冠状动脉患者而言,积极同期行冠状动脉旁路移植术可显著降低术后出现并发症的风险,是T A A D患者术后并发症的独立保护性因素[OR=0.167(0.060,0.467),P=0.001]。结论探寻TAAD患者术后各种并发症的高危因素,可为术前识别手术高危人群及术后更加积极预防各种并发症提供重要的临床依据。

Objective To assess the independent risk factors of in-hospital mortality and morbidity after surgical procedure for Stanford type A aortic dissection （TAAD）. Methods Between May 2013 and May 2015, 341 TAAD patients were treated with surgical procedure in Fu Wai Hospital. There were 246 males and 95 females with a mean age of 47.42±11.54 years （range 29-73 years）. Among them, 87 patients suffered severe complications or death after the procedure （complication group） and the other 254 patients recovered well without any severe complications （no complication group）. Perioperative clinical data were compared between the two groups. Results Mean age of patients in the complication group was significantly higher than that of the no complication group （49.91±11.22 yearsvs. 46.57±11.54 years,P=0.019）. The incidence of preoperative ischemic organ injury in the complication group was significantly higher than that in the no complication group： cerebral ischemia （18.4%vs. 5.9%,P=0.001）, spinal cord injury （16.1%vs. 4.7%,P=0.001）, acute kidney injury （31.0%vs. 10.6%,P=0.000）. The incidence of branch vessels involvement in the complication group was significantly higher than that in the no complication group： coronary artery involvement （52.9%vs. 17.1%,P=0.000）, supra-aortic vessels involvement （73.6%vs. 53.9%,P=0.001）, celiac artery involvement （37.9%vs. 22.0%,P=0.003）, mesenteric artery involvement （18.4%vs. 9.8%,P=0.030）, and unilateral or bilateral renal artery involvement （27.6%vs. 9.8%,P=0.000）. Surgical time of patients in the complication group was significantly longer than that of the no complication group, including cardiopulmonary bypass time （205.05±63.65 minvs. 167.67±50.24 min,P〈0.05） and cross-clamp time （108.11±34.79 minvs. 90.75±27.33 min,P〈0.05）. Multiple regression analysis found that age, preoperative concomitant cerebral ischemic injury, preoperative concomitant acute renal injury, preoperative limb sensory and/or motor dysfunction, coronary artery involvement, cardiopulmonary bypass time were independent risk factors of postoperative death and severe complications in TAAD patients. However, risk of postoperative mortality and morbidity significantly decreased after the concomitant coronary artery bypass graft [OR=0.167 （0.060, 0.467）,P=0.001]. Conclusion The high risk factors of postoperative complication in TAAD patients are explored to provide an important clinical basis for preoperative identification of patients at high risk and we need pay more attention to the prevention of these postoperative complications.