全弓置换联合象鼻支架术治疗急性A型主动脉夹层的术后并发症研究

第一部分

全弓置换联合冰冻象鼻支架术治疗急性A型主动脉夹层的临床回顾分析

目的：总结我院接受全弓置换联合冰冻象鼻支架术(TAR + FET)治疗急性A型主动脉夹层(ATAAD)患者的流行病学特征、临床表现和住院结局。

方法：回顾性分析自2013年1月至2018年12月在我院住院行TAR + FET术的ATAAD患者670人。收集并分析患者的一般情况、临床资料和住院转归等信息。

结果：所有患者中，女性有144人(21.5%)。所有患者的平均年龄为46.9±10.2岁。男性患者比女性更年轻(岁)(45.6±9.5 vs. 51.7±11.1, P<0.001)，体重指数更高(kg/m²)(26.9±4.5 vs. 25.1±3.3, P<0.001)。高血压是最常见的既往史，总体发生率为83.7%。胸痛是最常见的入院症状(83.9%)，冬季为发病高峰期(30.4%)，尤其是1月份(11.0%)。主动脉夹层主要受累分支为无名动脉(57.8%)，左肾动脉受累比右肾动脉多(45.1% vs. 28.5%)。总体住院死亡率为4.3%，女性患者围术期心肌梗死的发生率高于男性(6.3% vs. 2.5%, P=0.033)。

结论：接受TAR + FET手术的ATAAD患者中，男性更常见，他们更年轻，体重指数更高。高血压史最普遍。胸痛为最常见症状，冬季为发病高峰期。无名动脉最容易受累及，左肾动脉受累比右肾动脉多。女性患者围术期心肌梗死的发生率高于男性。

第二部分

术后重度急性肾损伤：全弓置换联合冰冻象鼻支架术治疗急性A型主动脉夹层

目的：本研究旨在探讨急性A型主动脉夹层(ATAAD)患者接受全弓置换联合冰冻象鼻支架术(TAR + FET)后发生重度急性肾损伤(AKI)的发病率和危险因素，并评估重度AKI对患者住院结局和远期生存率的影响。

方法：本项回顾性研究纳入了670例接受TAR + FET手术的ATAAD患者。基于术后是否发生重度AKI，将患者分为两组，比较两组的一般情况、临床资料和住院结果。运用多因素Logistic回归法确定重度AKI的独立危险因素。采用Kaplan-Meier法进行生存分析，并通过Log-rank检验进行差异分析。

结果：在670名患者中，80例（11.9%）术后发生重度AKI，其中67例（10.0%）需进行床旁血滤治疗。重度AKI组的住院死亡率显著高于非重度AKI组(13.8% vs. 3.1%, P<0.001)，呼吸机时间(小时)(149.8±172.6 vs. 42.7±81.9, P<0.001)及重症监护时间(天)(13.9±8.2 vs. 4.4±4.7, P<0.001)均显著增加，远期生存率显著下降(P=0.005)。多因素分析结果显示，年龄(OR=1.029；95% CI：1.002-1.056；P=0.032)、下肢症状(OR=4.384；95% CI：2.240-8.582；P<0.001)、冠状动脉受累(OR=2.478；95% CI：1.432-4.288；P=0.001)、血肌酐(OR=1.008；95% CI：1.003-1.013；P=0.001)以及体外循环时间(OR=1.011；95% CI：1.006-1.015；P<0.001)是重度AKI的独立危险因素。

结论：在接受TAR + FET手术的ATAAD患者中，重度AKI的发生率较高，且与更高的住院死亡率相关。此外，出现重度AKI的患者远期生存率显著降低。年龄、下肢症状、冠状动脉受累、血肌酐和体外循环时间是重度AKI的独立危险因素。

第三部分

全弓置换联合冰冻象鼻支架术治疗急性A型主动脉夹层的主要不良结局

目的：本研究旨在评估全弓置换联合冰冻象鼻支架术(TAR + FET)治疗急性A型主动脉夹层(ATAAD)的主要不良结局(MAO)的发生率和危险因素，以及MAO对远期生存率的影响。

方法：本研究回顾性分析了接受TAR + FET手术治疗的ATAAD患者的临床资料，并使用多因素logistic回归分析了MAO的危险因素。采用Kaplan-Meier法进行生存分析，以评估患者的远期生存情况。

结果：总体住院死亡率为4.3%，MAO组的死亡率为17.2%。MAO患者的重症监护时间(天)(11.1±9.4 vs 3.6±2.3，P<0.001)和呼吸机时间(小时)(131.4±180.4 vs 29.9±26.2，P<0.001)均显著增加。生存分析表明，与非MAO患者相比，MAO患者的远期生存率显著降低(P=0.002)。多因素分析发现年龄(OR)=1.025，95%置信区间(95%CI)：1.005-1.045，P=0.014)、下肢症状(OR=2.562，95%CI：1.407-4.666，P=0.002)、冠状动脉受累(OR=2.027，95%CI：1.312-3.130，P=0.001)、左肾动脉受累(OR=1.998，95%CI：1.359-2.938，P<0.001)、体外循环时间(OR=1.011，95%CI：1.007-1.015，P<0.001)和白细胞计数(OR=1.045，95%CI：1.007-1.083，P=0.019)是MAO的独立危险因素。

结论：TAR + FET手术是ATAAD患者的安全、有效的治疗选择，但需仔细的患者选择与管理，以降低术后MAO发生率并改善患者预后。MAO对远期死亡率有显著影响。

Study on postoperative complications of total arch replacement combined with elephant trunk technique for the treatment of acute type A aortic dissection

Part 1

Clinical Retrospective Analysis of Total Arch Replacement Combined with Frozen Elephant Trunk Surgery for Acute Type A Aortic Dissection

Objective: To summarize the epidemiological characteristics, clinical presentation, and in-hospital outcomes of patients with acute type A aortic dissection (ATAAD) who underwent total arch replacement combined with frozen elephant trunk (TAR + FET) procedure in our hospital.

Methods: This retrospective analysis included 670 ATAAD patients who underwent the TAR + FET procedure during hospitalization from January 2013 to December 2018. Data on demographics, clinical information, and hospital outcomes were collected and analyzed.

Results: Among all patients, there were 144 females (21.5%). The average age of all patients was 46.9±10.2 years. Male patients were younger (45.6±9.5 vs. 51.7±11.1, P<0.001) and had a higher BMI (kg/m²) (26.9±4.5 vs. 25.1±3.3, P<0.001) compared to females. Hypertension was the most common comorbidity with a prevalence of 83.7%. Chest pain was the most frequent presenting symptom (83.9%), with a peak incidence in winter (30.4%), especially in January (11.0%). The brachiocephalic artery was the commonest branch of the aorta to be involved (57.8%), and the left renal artery was more frequently involved than the right (45.1% vs. 28.5%). The overall in-hospital mortality rate was 4.3%, with female patients having a higher rate of perioperative myocardial infarction than males (6.3% vs. 2.5%, P=0.033).

Conclusion: In patients with ATAAD who have undergone TAR + FET surgery, males are more prevalent, and they are younger with a higher body mass index. Hypertension is the most common history. Chest pain is the most common symptom, with a peak incidence in winter. The brachiocephalic artery is most likely to be involved, with the left renal artery more commonly involved than the right. Female patients have a higher rate of perioperative myocardial infarction compared to males.

Part2

Postoperative Severe Acute Kidney Injury: Treatment of Acute Type A Aortic Dissection with Total Arch Replacement and Frozen Elephant Trunk Technique 

Objective: This study aims to explore the incidence and risk factors of severe acute kidney injury (AKI) in patients with acute type A aortic dissection (ATAAD) who undergo total arch replacement combined with frozen elephant trunk (TAR + FET) surgery, and to assess the impact of severe AKI on patients' in-hospital outcomes and long-term survival.

Methods: This retrospective study included 670 ATAAD patients who underwent TAR + FET. Patients were divided into two groups based on the occurrence of severe AKI postoperatively, and their general conditions, clinical data, and in-hospital outcomes were compared. Multivariate logistic regression was used to identify independent risk factors for severe AKI. Survival analysis was performed using the Kaplan-Meier method, and differences were analyzed using the log-rank test.

Results: Among 670 patients, 80 (11.9%) developed severe AKI postoperatively, with 67 (10.0%) requiring bedside continuous renal replacement therapy. The in-hospital mortality rate of the severe AKI group was significantly higher than that of the non-severe AKI group (13.8% vs. 3.1%, P<0.001), with significantly increased ventilator time (hours) (149.8±172.6 vs. 42.7±81.9, P<0.001) and intensive care time (days) (13.9±8.2 vs. 4.4±4.7, P<0.001), and a significant decrease in long-term survival rate (P=0.005). Multifactorial analysis showed that age (OR=1.029; 95% CI: 1.002-1.056; P=0.032), lower limb symptoms (OR=4.384; 95% CI: 2.240-8.582; P<0.001), coronary artery involvement (OR=2.478; 95% CI: 1.432-4.288; P=0.001),  serum creatinine (OR=1.008; 95% CI: 1.003-1.013; P=0.001), and  cardiopulmonary bypass time (OR=1.011; 95% CI: 1.006-1.015; P<0.001) were independent risk factors for severe AKI.

Conclusion: In patients suffering from ATAAD who are undergoing TAR + FET surgery, there is a notably higher incidence of severe AKI, which correlates with an increased rate of mortality during hospitalization. Furthermore, patients who develop severe AKI exhibit a significantly lower rate of long-term survival. Age, lower limb symptoms, coronary artery involvement, serum creatinine, and cardiopulmonary bypass time are independent risk factors for severe AKI.

Part3

Major Adverse Outcomes Following Total Arch Replacement with Frozen Elephant Trunk Technique in Patients with Acute Type A Aortic Dissection

Objective: This study aims to evaluate the incidence and risk factors of major adverse outcomes (MAO) in patients with acute type A aortic dissection (ATAAD) following total arch replacement combined with frozen elephant trunk (TAR + FET) technique , as well as the impact of MAO on long-term survival outcomes.

Methods: We conducted a retrospective analysis of clinical data from ATAAD patients following TAR + FET technique. Multifactorial logistic regression analysis is used to identify risk factors for MAO, while Kaplan-Meier survival analysis is applied to estimate long-term survival.

Results: The overall in-hospital mortality rate was 4.3%, while the mortality rate in the MAO group was 17.2%. Patients with MAO experienced significantly increased ICU stay (days) (11.1±9.4 vs 3.6±2.3, P<0.001) and ventilator time (hours) (131.4±180.4 vs 29.9±26.2, P<0.001). Survival analysis indicated that, compared with non-MAO patients, the long-term survival rate of MAO patients was significantly reduced (P=0.002). Multivariate analysis revealed that age (OR=1.025; 95% CI: 1.005-1.045; P=0.014), lower limbs symptoms(OR=2.562; 95%CI：1.407-4.666; P=0.002), coronary artery involvement (OR=2.027; 95%CI：1.312-3.130; P=0.001), left renal artery involvement (OR=1.998; 95%CI：1.359-2.938; P<0.001), cardiopulmonary bypass time (OR=1.011; 95%CI：1.007-1.015; P<0.001), and white blood cell count (OR=1.045; 95%CI：1.007-1.083; P=0.019) were independent risk factors for MAO.

Conclusion: TAR + FET technique is a safe and effective treatment option for patients with ATAAD, but careful selection and management of patients are required to reduce the incidence of postoperative MAO and to improve patient outcomes. MAO significantly impacts long-term mortality.