Imaging anatomic classification of renal artery involvement in patients with Stanford type A aortic dissection and its postoperative acute renal injury
Jiang Wenxiang, Wu Jinlin, Qiu Juntao, Qiu Jiawei, Fan Shuya, Xie-En Zehua, Zhao Rui, Dai Lu, Gao Wei, Cao Fangfang, Yu Cuntao
Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China
Abstract:Objective A study was conducted to observe the CT angiography imaging anatomy of renal artery involvement in Stanford type A aortic dissection and to explore the clinical value of this classification system.Methods Data of 1331 patients with Stanford type A aortic dissection who underwent surgery at Department of Surgery of Fuwai Hospital of Chinese Academy of Medical Science were collected from January 2010 to December 2017. According to the aortic CT plane scan, the anatomical involvement of one side of the renal artery can be divided into the following five cases: type T, true lumen involved; type F false lumen involved; type B, both lumens involved; type C, crushed intimal flap; and type S, sandwich model. According to the actual CT tomographic observation statistics, bilateral renal artery involvement can be classified as TT, TF, TB, BB, BF, CF, and TS types. The incidences of postoperative AKI and CRRT and the early postoperative mortality of patients with bilateral renal artery involvement were analyzed and compared.Results A total of 1331 Stanford type A aortic dissection patients with bilateral renal artery involvement were grouped according to anatomic classification, as follows: 575 patients had TT type; 352 patients had TF type; 198 patients had TB type; 17 patients had BB type; 30 patients had BF type; 84 patients had CF type; and 75 patients had TS type. The incidences of postoperative AKI of the TT, TF, TB, BB, BF, CF, and TS types were 14.61%(84/575), 22.44%(79/352), 36.36%(72/198), 9/17, 40.0%(12/30), 65.48%(55/84), and 36.0%(27/75), respectively. The incidences of postoperative CRRT of the TT, TF, TB, BB, BF, CF, and TS types were 3.48%(20/575), 6.82%(24/352), 12.12%(24/198), 3/17, 10.00%(3/30), 32.14%(27/84), and 9.33%(7/75), respectively. The early mortality of the TT, TF, TB, BB, BF, CF, and TS types were 4.17%(24/575), 4.26% (15/352), 11.11%(22/198), 2/17, 13.33%(4/30), 17.86%(15/84), and 5.33%(4/75), respectively. Statistically significant differences in the incidence of AKI, CRRT use, and early mortality were found among the various subtypes (all P values<0.01). The incidence of CF type was the highest, followed by BB and BF types.Conclusions Statistically differences in the incidence of AKI, CRRT, and early mortality were found among the anatomical types of renal artery involvement in Stanford type A aortic dissection. The incidences of the above three observation indicators were highest in the CF type, followed by the BB and BF types.
Mori Y, Sato N, Kobayashi Y, et al. Acute kidney injury during aortic arch surgery under deep hypothermic circulatory arrest[J]. J Anesth, 2011, 25(6): 799-804. DOI:10.1007/s00540-011-1210-8.
[2]
Wang Z, Ge M, Chen T, et al. Independent risk factors and the long-term outcomes for postoperative continuous renal replacement treatment in patients who underwent emergency surgery for type a acute aortic dissection[J]. J Cardiothorac Surg, 2020, 15(1): 100. DOI:10.1186/s13019-020-01153-8.
[3]
Wu HB, Ma WG, Zhao HL, et al. Risk factors for continuous renal replacement therapy after surgical repair of type A aortic dissection[J]. J Thorac Dis, 2017, 9(4): 1126-1132. DOI:10.21037/jtd.2017.03.128.
[4]
Ko T, Higashitani M, Sato A, et al. Impact of acute kidney injury on early to long-term outcomes in patients who underwent surgery for type A acute aortic dissection[J]. Am J Cardiol, 2015, 116(3): 463-468. DOI:10.1016/j.amjcard.2015.04.043.
[5]
Zhao H, Pan X, Gong Z, et al. Risk factors for acute kidney injury in overweight patients with acute type A aortic dissection: a retrospective study[J]. J Thorac Dis, 2015, 7(8): 1385-1390. DOI:10.3978/j.issn.2072-1439.2015.07.19.
[6]
Kim WH, Lee JH, Kim E, et al. Can we really predict postoperative acute kidney injury after aortic surgery? Diagnostic accuracy of risk scores using gray zone approach[J]. Thorac Cardiovasc Surg, 2016, 64(4): 281-289. DOI:10.1055/s-0034-1396082.
[7]
Nadim MK, Forni LG, Bihorac A, et al. Cardiac and vascular surgery-associated acute kidney injury: the 20th international consensus conference of the ADQI (acute disease quality initiative) group[J]. J Am Heart Assoc, 2018, 7(11): e008834. DOI:10.1161/JAHA.118.008834.
[8]
Yagdi T, Atay Y, Engin C, et al. Impact of organ malperfusion on mortality and morbidity in acute type A aortic dissections[J]. J Card Surg, 2006, 21(4): 363-369. DOI:10.1111/j.1540-8191.2006.00246.x.
[9]
Toda R, Moriyama Y, Masuda H, et al. Organ malperfusion in acute aortic dissection[J]. Jpn J Thorac Cardiovasc Surg, 2000, 48(9): 545-550. DOI:10.1007/BF03218198.
[10]
Miller DC, Mitchell RS, Oyer PE, et al. Independent determinants of operative mortality for patients with aortic dissections[J]. Circulation, 1984, 70(3 Pt 2): I153-164.
[11]
Fann JI, Smith JA, Miller DC, et al. Surgical management of aortic dissection during a 30-year period[J]. Circulation, 1995, 92(9 Suppl): II113-121. DOI:10.1161/01.cir.92.9.113.
[12]
Chan WH, Huang YC, Weng HH, et al. Analysis of intimal extent and predictors of renal atrophy in patients with aortic dissection[J]. Acta Radiol, 2012, 53(7): 732-741. DOI:10.1258/ar.2012.110614.
[13]
Iwakoshi S, Dake MD, Irie Y, et al. Management of renal arteries in conjunction with thoracic endovascular aortic repair for complicated stanford type B aortic dissection: the Japanese multicenter study (J-predictive study)[J]. Radiology, 2020, 294(2): 455-463. DOI:10.1148/radiol.2019190598.
[14]
Williams DM, Lee DY, Hamilton BH, et al. The dissected aorta: part III. Anatomy and radiologic diagnosis of branch-vessel compromise[J]. Radiology, 1997, 203(1): 37-44. DOI:10.1148/radiology.203.1.9122414.
[15]
Gaxotte V, Cocheteux B, Haulon S, et al. Relationship of intimal flap position to endovascular treatment of malperfusion syndromes in aortic dissection[J]. J Endovasc Ther, 2003, 10(4): 719-727. DOI:10.1177/152660280301000406.
[16]
Nagamine H, Ueno Y, Ueda H, et al. A new classification system for branch artery perfusion patterns in acute aortic dissection for examining the effects of central aortic repair[J]. Eur J Cardiothorac Surg, 2013, 44(1): 146-153. DOI:10.1093/ejcts/ezs631.
[17]
Gross SC, Barr I, Eyler WR, et al. Computed tomography in dissection of the thoracic aorta[J]. Radiology, 1980, 136(1): 135-139. DOI:10.1148/radiology.136.1.7384487.
[18]
Urban BA, Ratner LE, Fishman EK. Three-dimensional volume-rendered CT angiography of the renal arteries and veins: normal anatomy, variants, and clinical applications[J]. Radiographics, 2001, 21(2): 373-386, questionnaire 549-555. DOI:10.1148/radiographics.21.2.g01mr19373.
[19]
Bossard G, Bourgoin P, Corbeau JJ, et al. Early detection of postoperative acute kidney injury by Doppler renal resistive index in cardiac surgery with cardiopulmonary bypass[J]. Br J Anaesth, 2011, 107(6): 891-898. DOI:10.1093/bja/aer289.
[20]
葛翼鹏, 里程楠, 钟永亮, 等. 急性Stanford A型主动脉夹层肾动脉受累分型与肾功能关系的临床研究[J]. 中国胸心血管外科临床杂志, 2019, 26(9): 870-873. DOI:10.7507/1007-4848.201901013.Ge YP, Li CN, Zhong YL, et al. Clinical study on relationship between renal artery involvement and renal function in acute Stanford A aortic dissection[J].Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2019, 26(9): 870-873. DOI:10.7507/1007-4848.201901013.
[21]
Khayat M, Cooper KJ, Khaja MS, et al. Endovascular management of acute aortic dissection[J]. Cardiovasc Diagn Ther, 2018, 8(Suppl 1): S97-97S107. DOI:10.21037/cdt.2017.10.07.
[22]
Haase M, Bellomo R, Devarajan P, et al. Novel biomarkers early predict the severity of acute kidney injury after cardiac surgery in adults[J]. Ann Thorac Surg, 2009, 88(1): 124-130. DOI:10.1016/j.athoracsur.2009.04.023.