Risk factors of delayed surgery for acute type A aortic dissection in out-of-hospital referrals
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摘要: 目的 探讨院外转诊急性A型主动脉夹层(ATAAD)患者手术延迟的危险因素，并探讨解决手术延迟的方法。 方法 回顾性分析2019年4月—2023年5月外院转诊的378例ATAAD患者的临床资料。根据发病至手术时间是否大于12 h，将患者分为延迟组(110例)和及时组(268例)。比较两组患者病史资料、发病及就诊信息，采用logistic回归分析筛选手术延迟的独立危险因素，并采用受试者工作特征曲线(ROC)对危险因素的预测效能进行判断。 结果 及时组和延时组患者年龄、发病症状、发病地点、发病时间、发病至三甲医院时间、转诊单车程时间、转诊模式相比较均差异有统计学意义(均P＜0.05)。Logistic回归分析显示，发病地点为农村(OR=4.66，95%CI：1.99~10.90，P＜0.001)、发病到三甲医院时间>6 h(OR=8.65，95%CI：3.80~19.69，P＜0.001)、转诊单车程时间>2 h(OR=11.65，95%CI：4.64~29.23，P＜0.001)、年龄>60岁(OR=4.88，95%CI：2.01~11.83，P＜0.001)、常规逐级转诊(OR=11.35，95%CI：4.53~28.45，P＜0.001)是ATAAD患者手术延迟的独立危险因素。ROC分析显示，各危险因素联合预测手术延时的AUC为0.926(95%CI：0.893~0.958，P＜0.05)，预测灵敏度为89.5%，特异度为78.4%。 结论 ATAAD患者年龄>60岁、发病地点为农村、发病至三甲医院时间>6 h、转诊单车程时间>2 h、常规逐级转诊是手术延迟的独立危险因素。
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关键词:
- A型主动脉夹层，急性 /
- 手术延迟 /
- 危险因素 /
- 转诊模式
Abstract: Objective To analyze the risk factors for surgical delay in patients with acute type A aortic dissection (ATAAD) referred out of hospital and to identify strategies to minimize surgical delays. Methods Clinical data of 378 cases with ATAAD who were referred to other hospitals from April 2019 to May 2023 were retrospectively analyzed. All patients were divided into the delayed group (n=110) and the timely group (n=268) according to whether the time from onset to operation was longer than 12 h. The preoperative data and referral information of the two groups were compared. Logistic regression analysis was used to identified risk factors for surgical delay, and receiver operating characteristic (ROC) curves were used to evaluate the predictive values of risk factors. Results Patients' age, onset symptoms, onset location, onset time, onset time to Grade-Ⅲ hospital, referral travel time, and referral mode between the two groups were statistically significant(all P < 0.05). Logistic regression analysis showed that the location of onset in rural areas(OR=4.66, 95%CI: 1.99-10.90, P < 0.001), time>6 hours from onset to Grade-Ⅲ hospital(OR=8.65, 95%CI: 3.80-19.69, P < 0.001), single driving time>2 hours for referral(OR=11.65, 95%CI: 4.64-29.23, P < 0.001), age of onset>60 years old(OR=4.88, 95%CI: 2.01-11.83, P < 0.001), and routine progressive referral(OR=11.35, 95%CI: 4.53-28.45, P < 0.001) were independent risk factors for surgical delay in ATAAD patients. ROC analysis showed that the area under the curves of joint risk factors for predicting surgical delay was 0.926(95%CI: 0.893-0.958, P < 0.05), the sensitivity was 89.5%, the specificity was 78.4%. Conclusion Patients' age of onset>60 years old, location of onset in rural areas, time>6 hours from onset to Grade Ⅲ hospital, single driving time>2 hours for referral, and routine progressive referral are independent risk factors for delayed ATAAD surgery.-
Key words:
- type A aortic dissection, acute /
- surgical delay /
- risk factor /
- referral model
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图 1 危险因素预测手术延时的ROC曲线
Figure 1. ROC curves for predicting surgical delay by risk factors
表 1 一般临床资料
Table 1. Clinical data
例(%), X±S 项目 及时组(268例) 延时组(110例) t/χ2 P 男/女/例 233/35 93/17 0.377 0.539 年龄/岁 47.1±11.9 55.2±9.2 6.396 ＜0.001 发病地点为农村 96(35.8) 77(70.0) 35.342 ＜0.001 发病时间 周末白天 36(13.4) 17(15.5) 1.259 0.209 晚9点到早6点发病 78(29.1) 49(44.5) 5.179 0.023 社会因素 10(3.7) 8(7.2) 2.157 0.142 中专及以上 84(31.3) 26(23.6) 2.245 0.134 BMI/(kg/m2) 27.1±2.8 26.6±3.2 1.511 0.132 高血压病史 220(82.1) 94(85.5) 0.628 0.428 高血脂病史 158(58.9) 69(62.7) 0.463 0.496 糖尿病病史 30(11.2) 12(10.9) 0.006 0.936 冠心病病史 25(9.3) 17(11.8) 0.535 0.465 吸烟史 163(60.8) 70(63.6) 0.261 0.609 饮酒史 168(62.7) 74(67.3) 1.141 0.285 发病时撕裂样疼痛 214(79.9) 76(69.1) 5.056 0.025 
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表 2 院前情况
Table 2. Pre-hospital data
例(%), X±S 项目 及时组(268例) 延时组(110例) t/χ2 P 转诊模式 59.641 ＜0.001 常规逐级转诊 75(27.9) 78(70.9) 点对点转诊 193(72.1) 32(29.1) 发病到三甲医院就诊时间/h 5.2±3.6 8.2±4.5 6.824 ＜0.001 转诊单车程时间/h 1.8±0.9 2.2±1.3 3.423 ＜0.001
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表 3 多因素logistic回归分析结果
Table 3. Multiple logistic regression analysis results
危险因素 β SE Wals OR(95%CI) P 发病地点为农村 1.54 0.43 3.55 4.66(1.99~10.90) ＜0.001 发病到三甲医院时间>6 h 2.16 0.42 5.14 8.65(3.80~19.69) ＜0.001 转诊单车程时间>2 h 2.46 0.47 5.23 11.65(4.64~29.23) ＜0.001 年龄>60岁 1.58 0.45 3.51 4.88(2.01~11.83) ＜0.001 常规逐级转诊 2.43 0.47 5.18 11.35(4.53~28.45) ＜0.001
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表 4 ROC曲线分析结果
Table 4. ROC analysis results
危险因素 SE AUC(95%CI) P 常规逐级转诊 0.031 0.707(0.645~0.768) ＜0.001 发病到三甲医院时间>6 h 0.029 0.769(0.711~0.827) ＜0.001 发病地点为农村 0.031 0.675(0.614~0.737) ＜0.001 年龄>60岁 0.032 0.646(0.582~0.709) 0.010 转诊单车程时间>2 h 0.030 0.716(0.656~0.776) ＜0.001 联合 0.016 0.926(0.893~0.958) ＜0.001
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