肾动脉供血形式与DeBakeyⅢb型主动脉夹层胸主动脉腔内修复术后肾萎缩的关系探讨

Association between different blood supply forms of renal artery and renal atrophy after thoracic endovascular aortic repair for DeBakey typeⅢb aortic dissection

背景肾萎缩是DeBakeyⅢb型主动脉夹层胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)后常见并发症。肾动脉灌注不良可能是肾萎缩的易感因素。目的明确不同肾动脉供血形式与DeBakeyⅢb型主动脉夹层TEVAR后肾萎缩的关系。探索TEVAR对肾动脉供血形式的影响。方法纳入2011年6月-2017年7月于解放军总医院第一医学中心、新疆维吾尔自治区人民医院、中山市人民医院、河南省胸科医院接受TEVAR治疗的DeBakeyⅢb型主动脉夹层患者180例。将肾动脉的供血形式分为T型(肾动脉由真腔供血)、B型(肾动脉附近存在裂口,由真假腔共同供血)、D型(夹层内膜瓣延伸至肾动脉管腔内)、F型(肾动脉由假腔供血)。研究术前术后供血形式的变化。根据TEVAR后是否发生肾萎缩,将患者分为肾萎缩组(55例)和非肾萎缩组(125例)。比较两组患者临床资料的差异。随访截止时间为2020年9月7日。应用Cox回归分析DeBakeyⅢb型主动脉夹层TEVAR后肾萎缩的独立危险因素。结果B型、D型、F型供血的肾动脉在术后转变为T型的占比分别为15.87%、17.31%和7.32%。肾萎缩组男性患者占比(80.00%vs 91.20%,P=0.035)和有吸烟史占比(38.18%vs 55.20%,P=0.035)低于非肾萎缩组,体质量指数中位值(26.70 kg/m^(2) vs 24.69 kg/m^(2),P=0.013)高于非肾萎缩组。多因素回归分析显示,与T型供血形式的肾动脉相比,D型和F型是TEVAR后DeBakeyⅢb型主动脉夹层肾萎缩的独立危险因素(HR=4.361,95%CI:2.32~8.213,P=0.006;HR=2.448,95%CI:1.189~5.022,P=0.020)。结论肾动脉的供血形式与DeBakeyⅢb型主动脉夹层TEVAR后肾萎缩存在相关性。其中,D型供血形式的肾动脉发生肾萎缩的风险最大。单纯TEVAR治疗难以有效改善肾动脉的异常供血。

Background Renal atrophy is a common complication of DeBakey typeⅢb aortic dissection after thoracic endovascular aortic repair(TEVAR).Renal artery malperfusion may be a risk factor of renal atrophy.Objective To certify the association between different blood supply forms of renal artery and renal atrophy TEVAR for DeBakey typeⅢb aortic dissection and explore the effect of TEVAR on renal artery’s blood supply.Methods From June 2011 to July 2017,180 patients with DeBakey typeⅢb aortic dissection receiving TEVAR in the First Medical Center of Chinese PLA General Hospital,Xinjiang People’s Hospital,Zhongshan People’s Hospital or Henan Chest Hospital were enrolled.The renal artery’s blood supplies were categorized as type T(renal artery’s blood supplied by the true lumen),type B(renal artery’s blood supplied by both lumens with a tear near the renal artery),type D(the intimal flap of the aortic dissection extending into the renal artery),type F(renal artery’s blood supplied by the false lumen).Changes of blood supply from pre-to post-operation were analyzed.Based on the incidence of renal atrophy after receiving TEVAR,patients were divided as renal atrophy group(n=55)and non-renal atrophy group(n=125).Clinical data were compared between the two groups.The deadline for follow-up is September 7,2020.Cox regression analysis was conducted to determine the independent risk factors of renal atrophy after TEVAR in DeBakeyⅢtype b aortic dissection.Results The proportions of type B,D,F renal artery’s blood supply transformed to type T after TEVAR were 15.87%,17.31%and 7.32%.The proportions of male patients(80.00%vs 91.20%,P=0.035)and the smoking history(38.18%vs 55.20%,P=0.035)in the renal atrophy group were lower than those in the non-renal atrophy group,while the median BMI was higher than that in the non-renal atrophy group(26.70 vs 24.69,P=0.013).Compared with type T renal artery’s blood supply,type D(HR=4.361,95%CI:2.32-8.213,P=0.006)and type F(HR=2.448,95%CI:1.189-5.022,P=0.020)were independent risk factors of renal atrophy after TEVAR for DeBakey typeⅢb aortic dissection by multi-factor regression analysis.Conclusion The renal artery’s blood supply is associated with renal atrophy after TEVAR for DeBakey typeⅢb aortic dissection.The renal artery with type D blood supply presents the highest risk of renal atrophy.TEVAR alone cannot effectively modify the abnormal blood supply of the renal artery.