Stanford B型主动脉夹层肾动脉受累分型及其胸主动脉腔内修复术后肾功能比较及预后研究

Clinical study on the classification of renal artery involvement and comparison of renal function and prognosis of Stanford type B aortic dissection after thoracic aortic endovascular repair

目的探讨Stanford B型主动脉夹层(TBAD)肾动脉受累不同分型及其胸主动脉腔内修复术(TEVAR)的临床疗效比较。方法本研究为回顾性队列研究。选取2002年6月至2021年9月解放军北部战区总医院行TEVAR治疗的TBAD合并肾动脉受累患者330例。根据主动脉CTA影像,将一侧肾动脉受累情况分为5型:真腔型(肾动脉开口完全起自真腔),假腔型(肾动脉开口完全起自假腔),双腔型(肾动脉开口起自真、假双腔),挤压型(肾动脉开口与真腔相连,但肾动脉开口受到内膜片极度挤压),开口型(肾动脉开口有内膜破口)。双侧肾动脉受累分型分为7型:真真型(真腔真腔型),真假型(真腔假腔型),真双型(真腔双腔型),真口型(真腔开口型),假假型(假腔假腔型),假挤型(假腔挤压型),双双型(双腔双腔型)。本研究主要观察指标是不同肾动脉受累分型术后肾功能及不良事件发生率的比较。采用One-way ANOVA检验、Kruskal-Wallis H检验及配对样本秩和检验对双肾动脉受累不同分型组间术后肾功能进行比较。采用χ^(2)检验或Fisher精确概率法检验比较双侧肾动脉受累不同分型组间30 d内及远期临床不良事件。采用Kaplan-Meier法比较术前肾功能重度损伤组与非重度损伤组患者全因病死率。结果患者年龄(53±11)岁,其中男性276例(83.6%),女性54例(16.4%)。患者术前、术后的血清肌酐(术前:H=18.686,P=0.005,术后:H=18.101,P=0.006)和胱抑素C(术前:H=17.566,P=0.007,术后:H=10.433,P=0.016)水平7组间总体比较,差异均有统计学意义,假假型组最高;但其术前术后变化值总体比较,差异均无统计学意义(均P>0.05)。30 d内随访显示,术后急性肾损伤(χ^(2)=15.623,P=0.007)、主动脉相关不良事件(χ^(2)=15.523,P=0.010)、术中内漏发生率(χ^(2)=17.935,P=0.004)7组间总体比较,差异均有统计学意义,假假型组最高(分别为2/9、5/9和5/9)。远期随访显示,全因死亡(χ^(2)=14.772,P=0.011)、非主动脉源性死亡发生率(χ^(2)=15.589,P=0.008)7组间总体比较,差异均有统计学意义。生存分析显示,术前肾功能重度损伤患者术后远期全因病死率高(17.7%比4.8%,P=0.009)。结论肾动脉受累分型不同的TBAD患者肾功能水平存在差异,TEVAR对TBAD患者肾功能无明显影响。术前肾功能重度损伤患者TEVAR远期全因病死率高。

Objective To investigate the different types of renal artery involvement in Stanford type B aortic dissection(TBAD)and the comparison of clinical effecacy after thoracic endovascular aortic repair(TEVAR).Methods This is a retrospective cohort study included 330 patients with TBAD and renal artery involvement treated with TEVAR from June 2002 to September 2021 in General Hospital of Northern Theater Command of the PLA.According to aortic CTA image,unilateral renal artery involvement conditions were divided into 5 types:the true lumen type(renal artery opening completely from the true lumen),false lumen type(renal artery opening completely from the false lumen),double lumen type(renal artery opening from the true and false double lumen),compression type(renal artery opening connected with the true lumen,but the renal artery opening was extremely squeezed by the inner membrane),open type(renal artery opening with intimal tear).There were seven types of bilateral renal artery involvement:true-true type(true lumen-true lumen type),true and false type(true lumen-false lumen type),true-double type(true lumen-double lumen type),true-opening type(true lumen-opening type),false-false type(false lumen-false lumen type),false-compression type(false lumen-compression type),double-double type(double lumen-double lumen type).The primary observation index of this study was the comparison of postoperative renal function and the incidence of clinical adverse events of different types of renal artery involvement.One-way ANOVA test,Kruskal-Wallis H test and paired sample rank sum test were used to compare postoperative renal function between different types of bilateral renal artery involvement.The Chi-square test or Fisher′s exact probability test were used to compare the near and long term adverse events between different types of bilateral renal artery involvement.Kaplan-Meier method was used to compare the all-cause mortality of patients with severe renal functional injury and non-severe renal functional injury before surgery.Results The average age of the patients included in this study was(53±11)years,including 276 males(83.6%)and 54 females(16.4%).There were statistical difference in the level of serum creatinine(preoperative:H=18.686,P=0.005,postoperative:H=18.101,P=0.006)and cystatin C(preoperative:H=17.566,P=0.007,postoperative:H=10.433,P=0.016),pre-and post-operative,between the seven groups of TBAD patients with different renal artery involvement types(P<0.05),and the false-false type group shown the worst kidney function.However,no statistically significant differences were shown when comparing their pre-and post-operative change values(P>0.05).The 30-day follow-up result showed that there were statistically significant differences in the incidence of postoperative acute kidney injury(χ^(2)=15.623,P=0.007),aorta-related adverse events(χ^(2)=15.523,P=0.010),and intraoperative endoleak(χ^(2)=17.935,P=0.004)among the seven groups,and the false-false group was the highest(2/9,5/9 and 5/9,respectively).In terms of long-term follow-up results,there were statistically significant differences in all-cause death(χ^(2)=14.772,P=0.011)and non-aortic death(χ^(2)=15.589,P=0.008)among the seven groups.Kaplan-Meier survival analysis showed that patients with worse pre-operative renal function showed higher long-term all cause death(17.7%vs.4.8%,P=0.009).Conclusions For TBAD patients with renal artery involvement,there were differences in renal function among different types,and TEVAR showed no significant effect on renal function in TBAD patients.The long-term all cause death was higher in patients with worse renal function pre-operative.