血浆D-二聚体联合肌腱蛋白C在老年急性A型主动脉夹层中的临床价值研究

doi:10.3969/j.issn.1006-6233.2025.01.014

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摘要 目的: 探讨血浆D-二聚体和肌腱蛋白C(TNC)在老年急性A型主动脉夹层(ATAAD)中的临床价值。方法: 回顾性分析2021年1月至2024年2月期间147例在新疆维吾尔自治区人民医院治疗的老年ATAAD患者的临床和治疗资料,包括基础疾病史在内的术前指标及TNC、D-二聚体等在内的实验室指标。所有患者在症状出现后24h内接受了紧急手术。根据术后30d内是否出现术后急性肾功能衰竭、严重感染和延长机械通气时间等主要不良事件,将患者分为预后良好组和预后不良组。根据夹层范围,患者分为DeBakey Ⅱ型和Ⅰ型。采用乳胶增强免疫比浊法测定D-二聚体水平,免疫酶联吸附法测定TNC水平。对单变量分析中潜在的预后进行Logistic回归控制,并通过受试者操作特征曲线下面积(ROC-AUC)评估入院时血浆D-二聚体和TNC的预测效能。结果: 老年ATAAD患者术后30d预后不良,占比21.77%(32/147)。预后不良组患者血浆D-二聚体(Z=-3.103,P=0.002)和TNC(Z=-3.849,P<0.001)水平高于预后良好组,D-二聚体联合TNC预测预后不良的ROC-AUC为0.921(95%CI:0.865~0.959)。在控制潜在相关混杂变量后,基础疾病史(OR=5.432,P=0.009)、入院D-二聚体≥112.41μg/mL(OR=1.006,P=0.001)、TNC≥97.12ng/mL(OR=1.038,P<0.001)是多变量Logistic回归分析中预后不良的独立预测因素(P<0.05)。进一步分析D-二聚体和TNC与主动脉夹层形态学特征的关系:首先DeBakey I型夹层患者血浆D-二聚体(Z=-3.323,P=0.001)和TNC水平(Z=-1.965,P=0.049)均高于DeBakey Ⅱ型夹层患者;其次,根据主动脉夹层FL状态,部分血栓形成亚组和无血栓形成亚组血浆D-二聚体和TNC水平也略高于血栓形成亚组(P=0.001)。入院时D-二聚体或TNC水平越高,严重感染风险,延长机械通气的风险以及院内死亡风险越高(P<0.05)。调整年龄和基础疾病史后,D-二聚体水平≥112.41μg/mL+TNC水平≥97.12ng/mL是严重感染(OR=2.09,P=0.005)、延长机械通气(OR=6.40,P=0.028)的独立危险因素。结论: PHR≤1.31是ATAAD患者术后30d内死亡的独立危险因素,并且低PHR还与ATAAD患者术后发生需要透析的AKI有关。

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关键词 ：急性A型主动脉夹层, D-二聚体, 肌腱蛋白C, 主动脉夹层形态学特征

Abstract：Objective: To investigate the clinical value of plasma D-dimer and tenascin C (TNC) in elderly patients with acute type A aortic dissection (ATAAD). Methods: The clinical and therapeutic data of 147 elderly patients with ATAAD treated in Xinjiang Uygur Autonomous Region People's Hospital from January 2021 to February 2024 were retrospectively analyzed,including preoperative indexes including underlying disease history and laboratory indexes including TNC and D-dimer.All patients underwent emergency surgery within 24 hours of the onset of symptoms.According to the occurrence of major adverse events such as postoperative acute renal failure,severe infection,and prolonged mechanical ventilation within 30 days after surgery,patients were divided into good and poor prognosis groups.Patients were classified as DeBakey type II and type I depending on the extent of the dissection.The D-dimer level was determined by latex enhanced immunoturbidimetry and the TNC level was determined by immunoenzyme-linked adsorption.Logistic regression analysis was performed to control for potential prognosis in univariate analysis,and the predictive power of plasma D-dimer and TNC at admission was assessed by area under the receiver Operating characteristic curve (ROC-AUC). Results: The prognosis of aged ATAAD patients was poor 30 days after operation,accounting for 21.77% (32/147).Plasma D-dimer (Z=-3.103,P=0.002) and TNC (Z=-3.849,P<0.001) levels in the poor prognosis group were higher than those in the good prognosis group,and the ROC AUC predicted by D-dimer combined with TNC was 0.921 (95%CI:0.865 ~ 0.959).After controlling for potentially relevant confounding variables,underlying disease history (OR=5.432,P=0.009),admission D-dimer ≥112.41μg/mL (OR=1.006,P=0.001),TNC≥97.12ng/mL (OR=1.038,P<0.001) were independent predictors of poor prognosis in multivariate Logistic regression analysis (P<0.05).The relationship between D-dimer and TNC and the morphological characteristics of aortic dissection was further analyzed.Firstly,plasma D-dimer (Z=-3.323,P=0.001) and TNC levels (Z=-1.965,P=0.049) in patients with DeBakey type I dissection were higher than those in patients with DeBakey type II dissection.Secondly,plasma D-dimer and TNC levels were also slightly higher in partial and non-thrombotic subgroups than in thrombotic subgroups based on FL status of aortic dissection (P=0.001).The higher the level of D-dimer or TNC on admission,the higher the risk of serious infection,the risk of prolonged mechanical ventilation,and the risk of hospital death (P<0.05).After adjusting for age and underlying disease history,D-dimer level≥112.41μg/mL+TNC level≥97.12ng/mL were independent risk factors for severe infection (OR=2.09,P=0.005) and prolonged mechanical ventilation (OR=6.40,P=0.028). Conclusion: PHR≤1.31 is an independent risk factor for death within 30 days after surgery in ATAAD patients,and low PHR is also associated with postoperative AKI requiring dialysis in ATAAD patients.

Key words： Acute type A aortic dissection D-dimer Tenascin C Morphological characteristics of aortic dissection

基金资助:新疆维吾尔自治区自然科学基金,(编号:2020D01C096)

通讯作者: 石晓卉

引用本文:

张晓猛, 热那提·依马木, 石晓卉, 常冬庆, 买尔旦·艾日肯, 杨舒婷. 血浆D-二聚体联合肌腱蛋白C在老年急性A型主动脉夹层中的临床价值研究[J]. 河北医学, 2025, 31(1): 78-84.
ZHANG Xiaomeng, RENATI Yimamu, SHI Xiaohui, et al. Clinical Value of Plasma D-dimer combined with tenascin-C in elderly patients with acute type A aortic dissection. HeBei Med, 2025, 31(1): 78-84.

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http://www.hbyxzzs.cn/CN/10.3969/j.issn.1006-6233.2025.01.014 或 http://www.hbyxzzs.cn/CN/Y2025/V31/I1/78

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