Risk Factors Of Acute Standford Type A Aortic Dissection Involving Three Branches Of The Superior Arch And Early Postoperative Death

Objective:Acute Stanford type A aortic dissection(ATAAD)is one of the most dangerous diseases in cardiac surgery.It is characterized by acute onset,rapid progress,great difficulty in surgery,and high mortality.In addition,the patients with ATAAD have many postoperative complications and poor prognosis.There are two main causes of death in patients,one is hemorrhagic shock caused by preoperative dissection rupture,and the other is serious complications that occur after surgery.The occurrence of complications is mainly related to the involvement of the dissection in the blood supply artery.When an aortic dissection occurs,due to the weakness of the aortic structure,it cannot withstand the impact of high-speed high-pressure blood flow.Under pressure,blood enters the middle layer of the aortic wall through the tear opening of the intima,resulting in separation of the middle layer of the aorta along the long axis.Due to the integrity of the systemic vascular system,the dissection can tear down the descending aorta and even reach the level of the iliac artery.Retrograde torn dissection can affect the aortic valve Coronary artery and other related clinical symptoms occur."The three branch vessels above the arch are the primary branch vessels secondary to the aorta,and the rupture of the dissection is mostly located in the arcuate region from the aortic root to the opening of the subclavian artery.Therefore,when aortic dissection occurs,the three branch vessels are more likely to be involved.As the vessels supplying the upper limbs,neck,and brain are all secondary to the three branch vessels,the involvement of the three branch vessels is an important indication of poor prognosis in aortic dissection.",Therefore,assessing the involvement of three branches of blood vessels is of great significance for assessing the severity of patients’ condition,predicting their prognosis,and improving their perioperative survival rate.Methods:From December 2014 to June 2020,a total of 301 patients,including 218 males and 83 females,with an average age of(50.13±10.39)years,who were diagnosed as ATAAD by imaging examination and underwent urgent surgical treatment within 48 hours of admission to the Provincial Hospital affiliated to Shandong First Medical University,were retrospectively collected.All patients underwent corresponding surgical treatment based on the condition of aorta and branch vessels.According to the preoperative imaging examination and intraoperative direct vision judgment results,the patients with three branches of vascular involvement were counted,and the patients with 0,1,2,and 3 branches of vascular involvement were recorded as Group A,B,C,and D.The basic preoperative data,preoperative examination results,and preoperative ultrasound results of the four groups of patients were collected,including age,gender,past history,personal history,blood routine,liver function biochemistry,blood lipids,coagulation,ascending aorta diameter,left ventricular ejection fraction,cardiac function grading,admission systolic blood pressure,and diastolic blood pressure;Relevant intraoperative indicators,including the location of the dissection rupture,involvement of the coronary artery,the innominate artery,the left common carotid artery,and the left subclavian artery,the surgical method,whether to perform coronary artery bypass grafting at the same time.cardiopulmonary bypass time(CPB),aortic occlusion time,deep hypothermic circulatory arrest time,total surgical time,intraoperative blood loss,infusion of red blood cells,plasma,platelets,and cryoprecipitate;Postoperative complications,hospital deaths,and other indicators were included in statistical analysis.Multivariate logistic regression analysis was conducted on statistically significant indicators to analyze the independent risk factors affecting the three branches of the patient’s arch and leading to hospital death.Results:Among 301 patients,the number of three branch vessels involved in group A was 0,totaling 127;In group B,the number of three branch vessels involved was 1,with a total of 57 patients;The number of three branch blood vessels involved in group C was 2,with a total of 42 patients;The number of three branch blood vessels involved in group D was 3,with a total of 75 patients.Univariate analysis of variance showed that the imaging results,test results,and intraoperative and postoperative conditions of the four groups of patients were statistically significant(P<0.05)in terms of gender,left ventricular hypertrophy,admission systolic blood pressure,BMI,ascending aorta diameter,platelets,albumin,total cholesterol,triglycerides,creatinine,and D-dimer.The results of multivariate logistic regression analysis showed that gender[OR=0.506,95%CI(0.291,0.881)](P<0.05),left ventricular hypertrophy[OR=1.722,95%CI(1.053,2.817)](P<0.05).admission systolic blood pressure[OR=1.01,95%CI(1.001,1.019)](P<0.05),BMI[OR=0.935,95%CI(0.881,0.992)](P<0.05),and platelets[OR=0.997,95%CI(0.994,1.000)](P<0.05)were independent risk factors for the occurrence of three branches of blood vessel involvement above the arch in ATAAD patients.A total of 33 patients died early after surgery,with an early postoperative mortality rate of 10.96%.The univariate analysis results showed that the imaging results,test results,and intraoperative and postoperative conditions of the four groups of patients involved coronary artery,AKI,low cardiac output syndrome,postoperative massive hemorrhage,pleural effusion,pericardial effusion,lung infection,lung injury,delayed chest closure,platelets,neutrophils,AST,ALT,total bilirubin,triglycerides,urea nitrogen,creatinine,K+,CPB time,The aortic occlusion time,circulatory arrest time,intraoperative blood loss,plasma,and total surgical duration were all statistically significant(P<0.05).The results of binary logistic regression analysis showed that AKI[OR=9.955,95%CI(2.578,38.438)],low cardiac output syndrome[OR=155.122,95%CI(1.30218487.591)],and total surgical duration[OR=2.318,95%CI(1.186,4.530)]were independent risk factors for early postoperative death in ATAAD patients,and urea nitrogen[OR=0.79,95%CI(0.666,0.938)]was a protective factor(P<0.05).Conclusion:Gender,left ventricular hypertrophy,admission systolic blood pressure,and platelet count within 24 hours of admission in patients with ATAAD are independent risk factors for the involvement of the three branches of blood vessels above the arch;AKI,low cardiac output syndrome,urea nitrogen,and total surgical duration are independent risk factors for early postoperative death in patients with ATAAD.