急性Stanford A型主动脉夹层孙氏手术中左颈总动脉联合股动脉插管的应用效果及患者术后早期死亡的危险因素分析

Application effect of left common carotid artery combined with femoral artery cannulation in Sun's surgery for acute Stanford type A aortic dissection and analysis of the early postoperative mortality risk factors

目的:探讨左颈总动脉联合股动脉插管方式在急性Stanford A型主动脉夹层患者孙氏手术中的应用效果,以及孙氏手术患者术后早期死亡的影响因素。方法:回顾性队列研究。纳入2017年1月—2022年6月安徽医科大学第一附属医院心脏大血管外科急性Stanford A型主动脉夹层患者132例,其中男94例、女38例,年龄26~79(52.9±12.1)岁。患者均行孙氏手术即主动脉根部重建(置换)+升主动脉置换+全主动脉弓人工血管置换并象鼻支架置入术,按照术中插管方式分为2组:82例采用左颈总动脉联合股动脉插管者为观察组,其中男58例、女24例,年龄29~79(52.8±12.4)岁;50例术中采用腋动脉联合股动脉插管者为对照组,其中男36例、女14例,年龄26~75(53.2±11.5)岁。观察指标:(1)比较2组患者基线资料;(2)对比2组患者围术期指标及并发症发生率;(3)按照患者出院情况分为正常出院组和早期死亡组,对2组患者的基线资料、围手术期观察指标及并发症发生率进行单因素分析,筛选出P<0.10的指标进行多因素logistic回归分析,分析患者孙氏手术后早期死亡的影响因素。结果:所有患者手术顺利。(1)2组患者在性别、年龄、体质量指数、合并症发生率、中重度主瓣反流、肌酐、弓部受累情况等基线资料比较,差异均无统计学意义(P值均>0.05)。(2)观察组的总手术时间、建立体外循环时间、停循环时间、术后麻醉清醒时间、机械通气时间、重症监护室留观时间、术后住院时间、术后第一次乳酸值分别为(499.9±74.4)min、93.0(80.8,113.5)min、26.0(25.0,31.0)min、3.6(2.3,6.3)h、22.5(14.0,57.3)h、3(2,6)d、16(13,21)d、2.9(1.9,4.7)mmol/L,均少于对照组的(570.8±94.6)min、109.0(95.8,130.0)min、38.0(27.8,52.0)min、6.0(4.3,11.8)h、75.5(24.0,116.3)h、7(5,11)d、22(16,29)d、5.1(2.0,10.0)mmol/L,差异均有统计学意义(P值均<0.05);观察组和对照组的主动脉根部处理方式(根部成型术、Wheat术、Bentall术、David术)、体外循环时间、主动脉阻断时间、降温时间、复温时间、术后早期死亡例数,以及并发症(短暂性神经功能障碍、永久性神经功能障碍、截瘫、气管切开或二次插管、二次开胸止血、多器官功能障碍、连续性肾脏替代治疗)发生率等观察指标比较,差异均无统计学意义(P值均>0.05)。(3)单因素分析结果显示,正常出院组与早期死亡组的总手术时间、主动脉阻断时间、停循环时间、术后永久性神经功能障碍、气管切开或二次插管、多器官功能障碍、术后第一次乳酸值比较的P值均<0.10;多因素logistic回归分析结果显示,术后永久性神经功能障碍、术后第一次乳酸值为影响术后早期死亡的独立危险因素(OR=6.526、1.195,95%CI:1.151~37.014、1.055~1.354)。结论:术后永久性神经功能障碍、术后第一次乳酸值是孙氏手术术后早期死亡的独立危险因素;与腋动脉联合股动脉插管相比,左颈总动脉联合股动脉插管方式可以作为一种安全的插管策略应用于急性Stanford A型主动夹层孙氏手术。

Objective This study aimed to explore the application effect of the left carotid combined with femoral cannulation in Sun's surgery for acute Stanford type A aortic dissection and to analyze the risk factors affecting early postoperative mortality.Methods This cohort study included 132 patients with acute Stanford type A aortic dissection diagnosed in the Department of Cardiovascular Surgery,the First Affiliated Hospital of Anhui Medical University from January 2017 to June 2022.Among them,94 were males and 38 were females aged 26-79(52.9±12.1)years.All patients underwent simultaneous aortic root reconstruction(replacement),ascending aortic replacement,total aortic arch artificial vessel replacement,and stent elephant-nose placement surgery(Sun's surgery).They were divided into two groups according to the intraoperative intubation method.The first group was the observation group,which comprised 82 patients treated with left carotid combined femoral artery cannulation.They were 58 males and 24 females aged 29-79(52.8±12.4)years.The second group served as the control group.which included 50 patients who underwent axillary artery combined with femoral artery cannulation during surgery.They were 36 males and 14 females aged 26-75(53.2±11.5)years old.The observation indicators were as follows.(1)Baseline data were compared between two groups of patients.(2)The perioperative indicators and incidence of complications were compared between the two groups of patients.(3)We divided patients into normal discharge group and early death group according to their discharge status.Single-factor analysis was conducted on the baseline data,perioperative clinical data,and incidence of complications of the two groups of patients.Multivariate logistic-regression analysis was performed on indicators with P<0.10.The factors influencing early postoperative death in Sun's surgery were analyzed.Results All patients underwent surgery successfully.(1)No statistically significant difference existed between the two groups of patients in baseline data,such as gender,age,body mass index,incidence of comorbidities,number of moderate to severe aortic valve regurgitation,and involvement of the arch(all P values<0.05).(2)The total surgical time,surgical incision to cardiopulmonary bypass time,circulation arrest time,postoperative general anesthesia wakefulness time,mechanical ventilation time,ICU stay time,postoperative discharge time,and first postoperative lactate value of the observation group were(499.9±74.4)min,93.0(80.8,113.5)min,26.0(25.0,31.0)min,3.6(2.3,6.3)h,22.5(14.0,57.3)h,3(2,6)d,16(13,21)d,and 2.9(1.9,4.7)mmol/L,respectively,which were lower than those of the control group(570.8±94.6)min 109.0(95.8,130.0)min,38.0(27.8,52.0)min,6.0(4.3,11.8)h,75.5(24.0,116.3)h,7(5,11)d,22(16,29)d,and 5.1(2.0,10.0)mmol/L,respectively.The differences between the groups were statistically significant(all P values<0.05).No statistically significant difference existed in the incidence of complications such as aortic root treatment(root shaping surgery,Bentall,Wheat,and David),CPB time,aortic clamping time,cooling time,rewarming time,early postoperative mortality rate,incidence of complication(temporary neurological deficit,permanent neurological deficit,and paraplegia),postoperative tracheal intubation or pneumotomy rate,secondary thoracotomy hemostasis,multiple organ dysfunction syndrome(MODS),and continuous renal replacement therapy between the observation and control groups(all P values>0.05).(3.Results of univariate analysis showed that P values of total surgical time,aortic clamping time,circulatory arrest time,permanent neurological dysfunction after surgery,postoperative tracheal intubation or pneumotomy,MODS,and the first postoperative lactate value were all<0.10 between the normal discharge group and early death group.Results of multivariate logistic-regression analysis showed that the postoperative occurrence of PND and the first postoperative Lac value were independent risk factors affecting early postoperative death(OR=6.526,1.195,95%CI:1.151-37.014,1.055-1.354).Conclusion Postoperative permanent neurological dysfunction and the first postoperative lactate value are the independent risk factors affecting early death after Sun's operation.Compared with axillary combined femoral artery intubation,left common carotid combined femoral artery intubation can be used as A safe intubation strategy for acute Stanford type A active dissection.