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Risk Factors for Hypoxemia after Surgery for Acute Aortic Dissection

Objective To determine risk factors associated with postoperative hypoxemia after surgery for acute aortic dissection. Methods We retrospectively analyzed clinical data of 116 patients with acute aortic dissection who underwent endovascular stent-graft exclusion or open surgery in Qingdao Municipal Hospital from February 2007 to February　2012. All the 116 patients were diagnosed as acute aortic dissection by CT angiography （CTA），including 60 patients with Stanford type A aortic dissection and 56 patients with Stanford type B aortic dissection. According to whether they had postoperative hypoxemia，all the 116 patients with acute aortic dissection were divided into hypoxemia group［arterial　partial pressure of oxygen （PaO2） /fraction of inspired oxygen （FiO2） ＜200 mm Hg］：33 patients including 28 males and 5 females with their age of 52.7±11.4 years； and non-hypoxemia group（PaO2/FiO2≥200 mm Hg）：83 patients including　66 males and 17 females with their age of 55.0±13.8 years. Perioperative clinical data were analyzed and compared　between the two groups. Multivariate logistic regression was performed to identify risk factors of postoperative hypoxemia after surgery for acute aortic dissection. Results The incidence of postoperative hypoxemia after surgery for acute aortic dissection was 28.4% （33/116）. Perioperative death occurred in 13 patients（11.2%，including 8 patients in the hypoxemia group and 5 patients in the non-hypoxemia group）. Univariate analysis showed that preoperatively the percentages of　patients with body mass index（BMI） ＞ 25 kg/m2，smoking history，duration from onset to operation ＜24 h，preoperative　PaO2/FiO2≤300 mm Hg，and patients undergoing open surgery in the hypoxemia group were significantly higher than those　in the non-hypoxemia group（P＜0.05）. Deep hypothermic circulatory arrest（DHCA） ratio，blood transfusion in 24 hours　postoperatively，mechanical ventilation time，length of ICU stay and hospital stay in the hypoxemia group were significantly　higher or longer than those in the non-hypoxemia group（P＜0.05）. Logistic multivariate regression identified BMI＞25 kg/m2（RR=98.861，P=0.006），DHCA（RR=22.487，P=0.007），preoperative PaO2/FiO2≤300 mm Hg（RR=9.080，P=0.037） and blood transfusion＞6 U in 24 hours postoperatively（RR=32.813，P=0.003） as independent　predictors of postoperative hypoxemia for open-surgery patients，while BMI＞25 kg/m2 （RR=24.984，P=0.036） and preoperative PaO2/FiO2 ratio≤300 mm Hg （RR=21.145，P=0.042） as independent predictors of hypoxemia for endovascular stent-graft exclusion patients. Conclusion Postoperative hypoxemia is a common complication after surgery for acute aortic dissection. Early interventions for obesity and preoperative hypoxemia，and reducing perioperative blood transfusion may decrease the incidence of postoperative hypoxemia after surgery for acute aortic dissection.

Surgical Treatment for Acute Aortic Dissection with Involvement of Aortic Root

Abstract:　Objective　To evaluate surgical strategies for the treatment of acute Stanford type A aortic dissection with involvement of the aortic root.　Methods　From January 2005 to December 2010, 62 consecutive patients underwent emergency surgical intervention for acute Stanford type A aortic dissection with involvement of the aortic root in Renji Hospital Affiliated to Medical School of Shanghai Jiaotong University. According to different methods for the management of proximal aortic dissection, these patients were divided into 3 groups: group A, aortic valve commissural suspension＋supracommissural replacement of the ascending aorta （SCR）,including 28 patients （20 males and 8 females，mean age 45.2±15.6 years）; group B, partial sinus remodeling+ascending aortic replacement, including 10 patients （7 males and 3 females，mean age 44.6±14.9 years）；group C, Bentall procedure,including 24 patients （17 males and 7 females，mean age 46.2±15.6 years）. Clinical outcomes were compared among the three groups.　Results　Six patients died peri-operatively and in-hospital mortality was 9.67% （6/62）. Fifty-four patients were followed up, and the mean follow-up time was 27.3±15.7 months. During follow up, 2 patients died, one for lung cancer and the other for unknown reason. One patient in group A underwent CT scan 6 months after surgery which showed aortic root pseudo-aneurysm. Cardiopulmonary bypass time and aortic cross-clamping time of group C were significantly longer than those of group A and group B （274±97 min vs. 194±65 min, 210±77 min, t=22.482, 30.419, P=0.002， 0.122；150±56 min vs. 97±33 min, 105±46 min, t=12.630, 17.089, P=0.000，0.034）. There was no statistical difference in mortality （t=1.352，P=0.516）, incidence of postoperative reexploration for bleeding, acute renal failure and neurological complication （t=0.855, 0.342, 2.281; P=0.652, 0.863, 0.320） among the three groups.　Conclusion　For patients with acute aortic dissection involving the aortic root, aortic valve commissural suspension+SCR，partial sinus remodeling＋ascending aortic replacement and Bentall procedure may be considered the surgical treatment of choice with respective advantages and disadvantages. Satisfactory clinical outcomes can be achieveed if surgical indications and procedures are properly employed.

腔内隔绝术、联合血管旁路移植术治疗主动脉夹层动脉瘤

摘要: 　目的　总结腔内隔绝术、联合血管旁路移植术治疗主动脉夹层动脉瘤的临床经验, 以提高其治疗效果。方法　自2002 年9 月至2006 年12 月, 共完成腔内隔绝术或联合血管旁路移植术8 例。对4 例近端支架固定区lt; 15mm的患者于腔内隔绝术前行椎动脉2左颈总动脉端侧吻合术1 例, 应用8mm 人工血管行左锁骨下动脉2左颈总动脉旁路移植术2 例, 左锁骨下动脉2左颈总动脉2右颈总动脉旁路移植术1 例, 手术后8～ 10d, 行腔内隔绝手术。4 例破口距左锁骨下动脉开口gt; 15mm 的患者直接行腔内隔绝手术。　结果　行血管旁路移植的4 例患者术后恢复良好, 术后8～ 10d行腔内隔绝手术, 8 例患者腔内隔绝手术操作顺利, 隔绝术后3～ 8d 出院, 无住院死亡。出院前增强CT 扫描无内漏发生。随访4 例, 随访时间2～ 48 个月, 其中1 例患者长期胸痛, 经对症处理胸痛缓解; 4 例患者夹层内血栓机化良好, 无内漏出现或夹层剥离的现象发生。　结论　腔内隔绝手术是一种创伤小、恢复快、疗效好的治疗方法, 腔内隔绝术联合血管旁路移植术治疗主动脉夹层动脉瘤, 扩大了腔内隔绝术的手术适应证。

A型主动脉夹层动脉瘤的外科治疗

目的 总结1996年1月至2002年8月收治的34例A型主动脉夹层动脉瘤的外科治疗经验. 方法 应用Bentall手术19例,升主动脉人工血管置换术7例,升主动脉人工血管置换加主动脉瓣成形术(Trusler’s法)5例,分别行升主动脉人工血管置换及主动脉瓣置换术(Wheat术)2例,升主动脉、主动脉弓人工血管置换术1例. 结果 手术死亡6例,死亡率17.6%.其中慢性主动脉夹层动脉瘤死亡3例,急性夹层动脉瘤死亡3例.随访20例,随访率71.4%.随访时间2～46个月,平均24.7个月,1例术后3个月猝死(原因不明),1例术后6个月死于心内膜炎.18例存活患者情况良好. 结论 应根据夹层动脉瘤的部位及范围采用不同的手术方式,保留主动脉瓣的升主动脉人工血管置换术治疗该病效果较好,准确可靠的吻合技术、保留瘤壁的完整性,将使手术更为安全.

深低温停循环重力脑逆行灌注在主动脉瘤手术中的脑保护作用

目的 探讨深低温停循环重力脑逆行性灌注技术在主动脉夹层动脉瘤手术中对脑和脊髓的保护作用。方法 建立体外循环后，开始降温。肛温17℃时，患者深度头低位(deep trendelenburg position)。控制股静脉回流, 股动脉流量降至1.5 L/min，升高和维持中心静脉压在20～23 cmH2O（1kPa=10.2 cmH2O)，即可完成脑逆行性灌注。结果 本组2例患者停循环脑逆行性灌注时间分别为50分钟和116分钟，术后未发生神经系统并发症。结论 深低温停循环重力脑逆行性灌注技术操作简单,能够充分暴露术野，对脑和脊髓有很好的保护作用。

主动脉弓部夹层动脉瘤手术治疗

目的 总结通过人工血管旁路术延长锚定距离后，腔内隔绝术（endovascular graft exclusion，EVGE）治疗主动脉弓部夹层动脉瘤的疗效。 方法 2005 年9 月－ 2007 年9 月，采用血管旁路术后二期行EVGE 治疗主动脉弓部夹层动脉瘤10 例。男9 例，女1 例；年龄33 ～ 55 岁，平均38 岁。合并高血压病8 例，尿毒症1 例。DSA 示近端破口位于左颈总动脉与左锁骨下动脉之间4 例；破口距左锁骨下动脉开口lt; 1.5 cm 且左椎动脉为优势动脉6 例，合并无名动脉瘤1 例，升主动脉及主动脉弓部壁内血肿1 例。 结果 除1 例患者由于真腔闭塞未能行EVGE 治疗外，9 例均顺利完成EVGE 治疗。术后即刻造影示Ⅰ型内漏、Ⅱ型内漏（左锁骨下动脉未结扎所致）各1 例，分别于治疗后1、3 个月经计算机X 线断层扫描血管造影术证实内漏消失。8 例破口封堵良好，1 例并发降主动脉周围血肿而失访。8 例获随访，随访时间12 ～ 36 个月，降主动脉假腔内血栓形成。 结论 人工血管旁路术延长锚定距离，不仅可扩大EVGE 的适应证，还能降低Ⅰ型内漏。

诊断主动脉夹层动脉瘤的影像学比较

【摘要】　目的　讨论彩色多普勒超声、多层螺旋CT（multislice spiral CT，MSCT）及MRI对主动脉夹层动脉瘤（aortic disection，AD）的诊断价值，评价3种检查方式的优势与不足，为临床选择检查提供依据。　方法　回顾性分析2008年1月—2010年6月期间，32例经手术证实为AD患者的彩色多普勒超声、MSCT及MRI检查资料，并与术中所见及病理分型进行对比分析。　结果　术前彩色多普勒超声检出率为78.1%（25/32），诊断准确率为84%（21/25），MSCT及MRI检出率及诊断准确率均为100%。　结论　3种检查方法对AD术前均有较高的诊断价值，彩色多普勒超声术前诊断准确率及检出率低于MSCT及MRI，应存患者病情允许情况下，MSCT及MRI为首选检查方法，若病情危重则以床旁彩色多普勒超声为最佳检查方法，3种检查在临床应用上各有优势与不足，具体选择应视患者病情而定。

主动脉夹层动脉瘤支架置入术中血钾浓度异常增高二例

腔内隔绝术抢救Stanford B型主动脉夹层动脉瘤破裂一例

Predictive Risk Factors for Prolonged Stay in the Intensive Care Unit after Surgery for Acute Aortic Dissection Type A

Objective To identify the predictors of prolonged stay in the intensive care unit (ICU) in patients undergoing surgery for acute aortic dissection type A. Methods We retrospectively analyzed the clinical data of 80 patients who underwent surgery for acute aortic dissection type A in Qingdao Municipal Hospital from December 2009 through December 2013. The mean age of the patients was 48.9±12.5 years, including 54 males (67.5%) and 26 females (32.5%). The patients were divided into two groups based on their stay time in the ICU. Prolonged length of ICU stay was defined as 5 days or longer time in the ICU postoperatively. There were 67 patients with length of ICU stay shorter than 5 days, 13 patients with length of ICU stay 5 days or longer time. Univariate and multivariate analysis (logistic regression) were used to identify the predictive risk factors. Results The length of ICU stay was 63.2±17.4 hours and 206.9±25.4 hours separately. Overall in-hospital mortality was 3.0% and 15.4% respectively in the two groups. In univariate analyses, there were statistically significant differences with respect to the age, the European system for cardiac operative risk evaluation (EuroSCORE), the preoperative D-dimmer level, total cardiopulmonary bypass (CPB) time, deep hypothermic circulatory arrest (DHCA), inotropes and occurrence of postoperative stroke, acute renal failure and acute respiratory failure, ICU stay duration and hospital stay duration between the patients with length of ICU stay shorter than 5 days and longer than 5 days. Multivariate logistic analysis showed that CPB time, occurrence of postoperative stroke, acute renal failure, or acute respiratory failure were independent predictors for prolonged ICU stay. Conclusion The incidence of prolonged ICU stay is high after surgery for acute aortic dissection type A. It can be predicted by CPB time, occurrence of postoperative stroke, acute renal failure, and acute respiratory failure were independent predictors for prolonged ICU stay. For patients with these risk factors, more perioperative care strategies are needed in order to shorten the ICU stay time.