Analysis of Factors Affecting Limb Function Recovery Following Surgery for Acute Type A Aortic Dissection Complicated by Lower Extremity Malperfusion: A Retrospective Study
DOI:
https://doi.org/10.59958/hsf.8253Keywords:
acute type A aortic dissection, lower extremity malperfusion, limb function recovery, influencing factorsAbstract
Background: This study aims to analyze the clinical characteristics and factors influencing postoperative limb function recovery in patients with acute type A aortic dissection (ATAAD) complicated by lower extremity malperfusion (LEM). The objective is to accurately assess preoperative conditions, identify and manage risk factors, improve surgical techniques, and offer insights to enhance the recovery rate of LEM following surgery. Methods: This retrospective study included 131 patients with ATAAD complicated by LEM, admitted to the Department of Cardiothoracic Surgery at Nanjing Drum Tower Hospital between January 2013 and June 2019. Based on the resolution of lower extremity malperfusion postoperatively, patients were divided into a recovery group (n = 80) and a non-recovery group (n = 51). The preoperative limb status and general condition of both groups were evaluated, and factors influencing limb function recovery were analyzed using univariate and multivariate logistic regression. Results: Univariate analysis revealed statistically significant differences between the recovery and non-recovery groups for various variables. These included ischemic symptoms (odds ratio [OR] = 3.841, 95% confidence interval [CI] 1.850–8.197, p < 0.001), paresthesia (OR = 2.197, 95% CI 1.080–4.538, p = 0.031), decreased muscle strength (OR = 2.594, 95% CI 1.203–5.688, p = 0.016), decreased skin temperature (OR = 2.475, 95% CI 1.205–5.162, p = 0.014), non-detectable limb blood pressure (OR = 2.667, 95% CI 1.270–5.692, p = 0.010), prolonged cardiopulmonary bypass time (OR = 1.008, 95% CI 1.003–1.014, p = 0.002), prolonged aortic occlusion time (OR = 1.008, 95% CI 1.001–1.014, p = 0.018), and the requirement for continuous renal replacement therapy (CRRT) (OR = 8.095, 95% CI 3.620–19.165, p < 0.001). There were no significant differences between the groups in terms of gender, age, body mass index (BMI), absence of limb numbness or pain, skin pallor or mottling, absence of femoral or dorsalis pedis pulses, or non-detectable lower limb blood pressure (p > 0.05). Multivariate logistic regression identified ischemic symptoms (OR = 4.519, 95% CI 1.910–11.320, p = 0.001), non-measurable blood pressure (OR = 2.720, 95% CI 1.093–6.996, p = 0.033), and prolonged cardiopulmonary bypass time (OR = 1.018, 95% CI 1.006–1.034, p = 0.011) as independent early predictors of failure to recover limb function in patients with ATAAD. Conclusion: In ATAAD patients presenting with lower extremity ischemia at admission, healthcare providers should maintain heightened vigilance for postoperative ischemia, especially in cases with bilateral limb ischemia and non-measurable blood pressure. Early identification of these risk factors may contribute to enhancing postoperative outcomes.
References
Okita Y, Miyata H, Motomura N, Takamoto S, Japan Cardiovascular Surgery Database Organization. A study of brain protection during total arch replacement comparing antegrade cerebral perfusion versus hypothermic circulatory arrest, with or without retrograde cerebral perfusion: analysis based on the Japan Adult Cardiovascular Surgery Database. The Journal of Thoracic and Cardiovascular Surgery. 2015; 149: S65–S73. https://doi.org/10.1016/j.jtcvs.2014.08.070.
Tolenaar JL, Froehlich W, Jonker FHW, Upchurch GR, Jr, Rampoldi V, Tsai TT, et al. Predicting in-hospital mortality in acute type B aortic dissection: evidence from International Registry of Acute Aortic Dissection. Circulation. 2014; 130: S45–S50. https://doi.org/10.1161/CIRCULATIONAHA.113.007117.
Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. European Heart Journal. 2018; 39: 739d–749d. https://doi.org/10.1093/eurheartj/ehx319.
Malaisrie SC, Szeto WY, Halas M, Girardi LN, Coselli JS, Sundt TM, 3rd, et al. 2021 The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection. The Journal of Thoracic and Cardiovascular Surgery. 2021; 162: 735–758.e2. https://doi.org/10.1016/j.jtcvs.2021.04.053.
Isselbacher EM, Preventza O, Hamilton Black J, 3rd, Augoustides JG, Beck AW, Bolen MA, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022; 146: e334–e482. https://doi.org/10.1161/CIR.0000000000001106.
Zindovic I, Gudbjartsson T, Ahlsson A, Fuglsang S, Gunn J, Hansson EC, et al. Malperfusion in acute type A aortic dissection: An update from the Nordic Consortium for Acute Type A Aortic Dissection. The Journal of Thoracic and Cardiovascular Surgery. 2019; 157: 1324–1333.e6. https://doi.org/10.1016/j.jtcvs.2018.10.134.
Narayan P, Rogers CA, Benedetto U, Caputo M, Angelini GD, Bryan AJ. Malperfusion rather than merely timing of operative repair determines early and late outcome in type A aortic dissection. The Journal of Thoracic and Cardiovascular Surgery. 2017; 154: 81–86. https://doi.org/10.1016/j.jtcvs.2017.03.041.
Kawahito K, Kimura N, Yamaguchi A, Aizawa K. Malperfusion in type A aortic dissection: results of emergency central aortic repair. General Thoracic and Cardiovascular Surgery. 2019; 67: 594–601. https://doi.org/10.1007/s11748-019-01072-z.
Berretta P, Trimarchi S, Patel HJ, Gleason TG, Eagle KA, Di Eusanio M. Malperfusion syndromes in type A aortic dissection: what we have learned from IRAD. Journal of Visualized Surgery. 2018; 4: 65. https://doi.org/10.21037/jovs.2018.03.13.
Beck CJ, Germano E, Artis AS, Kirksey L, Smolock CJ, Lyden SP, et al. Outcomes and role of peripheral revascularization in type A aortic dissection presenting with acute lower extremity ischemia. Journal of Vascular Surgery. 2022; 75: 495–503.e5. https://doi.org/10.1016/j.jvs.2021.08.050.
Fujita W, Daitoku K, Taniguchi S, Fukuda I. Endovascular stent placement for acute type-B aortic dissection with malperfusion–an intentional surgical delay and a possible 'bridging therapy'. Interactive Cardiovascular and Thoracic Surgery. 2009; 8: 266–268. https://doi.org/10.1510/icvts.2008.191361.
Di Eusanio M, Trimarchi S, Patel HJ, Hutchison S, Suzuki T, Peterson MD, et al. Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection. The Journal of Thoracic and Cardiovascular Surgery. 2013; 145: 385–390.e1. https://doi.org/10.1016/j.jtcvs.2012.01.042.
Kamman AV, Yang B, Kim KM, Williams DM, Michael Deeb G, Patel HJ. Visceral Malperfusion in Aortic Dissection: The Michigan Experience. Seminars in Thoracic and Cardiovascular Surgery. 2017; 29: 173–178. https://doi.org/10.1053/j.semtcvs.2016.10.002.
Howe KL, Harlock J, Parry D. Management of Lower Extremity Ischaemia During Type A Dissection Repair. EJVES Short Reports. 2018; 39: 44–46. https://doi.org/10.1016/j.ejvssr.2018.05.011.
White RA, Miller DC, Criado FJ, Dake MD, Diethrich EB, Greenberg RK, et al. Report on the results of thoracic endovascular aortic repair for acute, complicated, type B aortic dissection at 30 days and 1 year from a multidisciplinary subcommittee of the Society for Vascular Surgery Outcomes Committee. Journal of Vascular Surgery. 2011; 53: 1082–1090. https://doi.org/10.1016/j.jvs.2010.11.124.
Xue Y, Zhou Q, Pan J, Cao H, Fan F, Zhu X, et al. “Double Jacket Wrapping” Root Reconstruction for Acute Type A Aortic Dissection. The Annals of Thoracic Surgery. 2020; 110: 1060–1062. https://doi.org/10.1016/j.athoracsur.2020.03.081.
Zhou Q, Xue Y, Cao H, Pan J, Wang Q, Fan F, et al. Novel arch fenestrated stent graft for acute Stanford Type A aortic dissection with open antegrade implantation. Interactive Cardiovascular and Thoracic Surgery. 2018; 26: 369–375. https://doi.org/10.1093/icvts/ivx335.
Zhou Y, Fan R, Jiang H, Liu R, Huang F, Chen X. A novel nomogram model to predict in-hospital mortality in patients with acute type A aortic dissection after surgery. Journal of Cardiothoracic Surgery. 2024; 19: 362. https://doi.org/10.1186/s13019-024-02921-6.
Yuan H, Sun Z, Zhang Y, Wu W, Liu M, Yang Y, et al. Clinical Analysis of Risk Factors for Mortality in Type A Acute Aortic Dissection: A Single Study From China. Frontiers in Cardiovascular Medicine. 2021; 8: 728568. https://doi.org/10.3389/fcvm.2021.728568.
Charlton-Ouw KM, Sandhu HK, Leake SS, Jeffress K, Miller CC, Rd, Durham CA, et al. Need for Limb Revascularization in Patients with Acute Aortic Dissection is Associated with Mesenteric Ischemia. Annals of Vascular Surgery. 2016; 36: 112–120. https://doi.org/10.1016/j.avsg.2016.03.012.
Yang B, Rosati CM, Norton EL, Kim KM, Khaja MS, Dasika N, et al. Endovascular Fenestration/Stenting First Followed by Delayed Open Aortic Repair for Acute Type A Aortic Dissection With Malperfusion Syndrome. Circulation. 2018; 138: 2091–2103. https://doi.org/10.1161/CIRCULATIONAHA.118.036328.
Blaisdell FW. The pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review. Cardiovascular Surgery (London, England). 2002; 10: 620–630. https://doi.org/10.1016/s0967-2109(02)00070-4.
Yassin MMI, Harkin DW, Barros D'Sa AAB, Halliday MI, Rowlands BJ. Lower limb ischemia-reperfusion injury triggers a systemic inflammatory response and multiple organ dysfunction. World Journal of Surgery. 2002; 26: 115–121. https://doi.org/10.1007/s00268-001-0169-2.
Gargotta HR. Type A Aortic Dissection Complicated by Renal and Lower Extremity Malperfusion. Advanced Emergency Nursing Journal. 2019; 41: 23–32. https://doi.org/10.1097/TME.0000000000000220.
Okita Y, Okada K. Treatment strategies for malperfusion syndrome secondary to acute aortic dissection. Journal of Cardiac Surgery. 2021; 36: 1745–1752. https://doi.org/10.1111/jocs.14983.
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