Predictive value of preoperative platelet count and D-dimer levels for spinal cord injury following acute type A aortic dissection

Predictive value of preoperative platelet count and D-dimer levels for spinal cord injury following acute type A aortic dissection | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Predictive value of preoperative platelet count and D-dimer levels for spinal cord injury following acute type A aortic dissection Fengbo Pei, jinhua wei, yao yao, hui wu, zujun Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2822183/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Mar, 2024 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 8 You are reading this latest preprint version Abstract Background This study aims to identify the risk factors contributing to spinal cord injury (SCI) following a type A acute aortic dissection (TA-AAD). Methods This retrospective study was conducted at a single center and involved 481 patients who received frozen elephant trunk stent implantation for TA-AAD and underwent total arch replacement with the deep hypothermic circulatory arrest at Fuwai Hospital between September 2016 and April 2020. Results The resulting data of the multivariate logistic regression analysis demonstrated that preoperative platelet count (odds ratio [OR] 0.774) and D-dimer levels (OR 2.247) held potential as independent predictors for postoperative SCI in patients diagnosed with TA-AAD. Conclusion The study results indicated that preoperative platelet count and D-dimer levels are independent risk factors for postoperative SCI in individuals with TA-AAD. This finding holds significance regarding clinical implications for prognosis and therapeutic responses in TA-AAD. spinal cord injury，acute type A aortic dissection，platelet ，D-dimer Background Type A acute aortic dissection (TA-AAD) is a clinically fatal acute and critical condition with a pre-hospital mortality rate of 49%. This condition is considered as one of the most urgent surgical procedures in cardiovascular surgery [ 1 , 2 , 3 , 4 ]. The effects of the dissection can extend to multiple organs in the body, including the spinal cord, where ischemia and postoperative spinal cord injury (SCI) occur as important complications with an incidence of 3.5–20% [ 5 ]. These complications may have negative implications for the prognosis of patients and their quality of life following surgery. However, in recent years, with the widespread use of total arch replacement (TAR) with frozen elephant trunk (FET) technique, the mortality rate of TA-AAD has been gradually decreasing. Nonetheless, SCI remains a serious postoperative complication. Therefore, it may be potentially beneficial to reduce the incidence of SCI by identifying the individuals at high risk for postoperative SCI early in the preoperative period and thus intervening more aggressively in their treatment. Methods Patient population Patients with Stanford TA-AAD admitted to the Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College in Beijing (China) from September 2016 to April 2020 were retrospectively analyzed based on the electronic medical records and laboratory tests. The patients were excluded if the they did not undergo TAR (ascending aorta replacement alone or partial aortic arch replacement), deep hypothermic circulatory arrest (DHCA) (e.g., hybrid total aorta replacement), or chronic type A aortic arch dissection. Study design This retrospectively designed study analyzed patients diagnosed with TA-AAD who underwent TAR with DHCA using the FET technique. The preoperative parameters, intraoperative details, and postoperative outcomes of these individuals were the main focus of the research. This single-center study was approved by the Ethics Committee of the Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (Beijing, China). The provision of informed written consent by each participant or their caregivers was necessary for inclusion. The diagnostic criterion for TA-AAD was the examination using enhanced computed tomography (CT). In addition, the research investigated the incidence of postoperative SCI in individuals with TA-AAD and assessed the risk factors associated with this complication. Surgical procedures Standard anesthetic management and endotracheal intubation were used during surgery. Cardiopulmonary bypass (CPB) was applied in the process of surgery through right axillary artery cannulation. Intraoperatively, DHCA was applied, and the unilateral or bilateral cerebral perfusion was selectively performed. Four-branch prosthetic vessels were used to perform TAR, with the right innominate brachiocephalic trunk, left common carotid artery, and left subclavian artery re-anastomosed to the branches of the prosthetic vessels, respectively. The FET stent was implanted in the descending aorta during the surgery. SCI was diagnosed using the American Spinal Injury Association (ASIA; https://asia-spinalinjury.org/ ) criteria into 5 grades, of which Grade A represented a complete injury. Grade B referred to an incomplete injury, with sensory function present below the nerve plane but without any motor function. Grade C represented an incomplete injury, with more than half of the motor function preserved below the nerve plane and a key muscle strength lower than Level 3. Grade D also referred to an incomplete injury, with more than half of the motor function retained below the nerve plane. The incomplete impairment indicated by Grade D meant that more than half of the motor function was preserved below the nerve plane, and key muscle strength was greater than or equal to Level 3. Grade E was assigned if both motor and sensory function was normal. Whereas, Grade A reflected the most severe SCI, i.e., paraplegia, in ASIA classification, while the spinal cord at Grade E was normal. Statistical analysis The data distribution was examined through the Kolmogorov-Smirnov test. The format of mean ± standard deviation (SD) was utilized for continuous data in case of a normal distribution, whereas the median value and interquartile range were utilized for non-normally distributed data. Counts and percentages were utilized for categorical variables. The Chi-square test or Fisher exact test were used to analyze categorical data, while one-way analysis of variance or Wilcoxon rank sum test was utilized for assessing the comparison of continuous variables. The logistic regression model was employed for the determination of the univariate and multivariate predictors of postoperative SCI. SPSS 26 (SPSS, IBM Corp. Armonk, USA) was employed for the analysis of the data, with p less than 0.05 representing statistical significance. Results Baseline characteristics Overall, 774 individuals with TA-AAD were enrolled through the electronic information system for inpatient physicians. Among them, 293 were excluded as their surgical procedure did not meet the inclusion criteria. Specifically, this included 226 cases of partial aortic arch replacements without DHCA, 45 of hybrid total aortic arch procedures, and 22 of chronic type A aortic arch dissections. Ultimately, 481 TA-AAD cases were screened out with a mean age of 47.2 ± 16.4 years (29-75 years). Of these, 425 were men and 56 were women. The final 39 patients developed SCI postoperatively, with an incidence of 8.1%. Among these, 21 were paraplegic and 18 had incomplete SCI. The preoperative baseline parameters of the two groups are shown in Table 1. Regarding baseline information and preoperative indicators, the two groups lacked any notable statistical variance in age, body mass index (BMI), time from onset to surgery, preoperative complications, preoperative ultrasound, preoperative leukocytes and hemoglobin, and the number of intercostal vessels involved. However, they varied significantly in terms of gender, preoperative platelets, preoperative D-dimer, and Adamkiewicz artery involvement. Table 1 Preoperative baseline characteristics of patients with TA-AAD Baseline characteristics Normal group (n = 442) SCI group (n = 39) P Demographic information Age 46.9 ± 17.2 50.7 ± 17.9 0.084 Gender (male) 396 (89.5%) 29 (74.3%) 0.009 BMI 24.9 ± 3.2 26.7 ± 4.1 0.612 Onset to surgery time (h) 45[21,124] 42[19,140] 0.194 Medical history Hypertension 407 (92.0%) 36 (92.3%) 0.795 Diabetes 11 (2.4%) 2 (5.1%) 0.645 Cerebrovascular disease 21 (4.7%) 3 (7.6%) 0.670 Smoking history 224 (50.6%) 23 (58.9%) 0.408 COPD 2 (0.4%) 0 > 0.999 Preoperative situation Lactic acid (mmol/L) 1.9 ± 0.7 2.1 ± 0.9 0.091 PaO 2 /FiO 2 265 ± 82 249 ± 76 0.163 D-dimer (μg/mL) 1.1[0.4,2.9] 2.7[0.8,3.4] 0.004 Leukocytes (10^9/L) 12.7 ± 2.4 11.6 ± 3.5 0.071 Hemoglobin (g/L) 134 ± 21 131 ± 25 0.647 Platelets (10^9/L) 179 ± 28 144 ± 21 < 0.001 Blood creatinine (μmol/L) 87.5 ± 29.4 90.6 ± 30.4 0.117 Troponin I 0.02[0.00,0.06] 0.02[0.00,0.08] 0.911 Aortic root diameter (mm) 42.1 ± 8.4 42.9 ± 10.2 0.379 Ascending aorta diameter (mm) 45.8 ± 7.6 46.7 ± 8.1 0.317 Left ventricular ejection fraction (%) 62.5 ± 6.4 63.8 ± 5.8 0.453 Adamkiewicz artery involvement 89 (20.1%) 16 (41.0%) 0.004 Number of intercostal vessels involved 3 [0.6] 4 [0,7] 0.847 Note: TA-AAD, type A acute aortic dissection; SCI, spinal cord injury; BMI, body mass index; COPD, chronic obstructive pulmonary disease; The intraoperative conditions of the groups are presented in Table 2. No statistical variance was indicated between the groups concerning surgery duration, intraoperative CPB duration, aortic block duration, and DHCA duration, and intraoperative nasopharyngeal temperature. However, intraoperative blood loss and cerebrospinal fluid pressure exhibited considerably higher values in the SCI group in contrast to the control group. Table 2 Intraoperative characteristics of patients with TA-AAD Features Normal group (n = 442) SCI group (n = 39) P Surgery duration (h) 8.7 ± 1.9 9.2 ± 2.2 0.068 CPB duration (min) 174 ± 52 180 ± 57 0.059 Aortic block duration (min) 139 ± 46 144 ± 57 0.228 DHCA duration (min) 21 ± 4.7 22 ± 5.4 0.314 Nasopharyngeal temperature (℃) 24.7 ± 2.9 24.2 ± 4.5 0.773 Intraoperative blood loss (mL) 1071 ± 446 1453 ± 579 0.035 Intraoperative cerebrospinal fluid pressure (mmHg) 14.7 ± 5.4 19.5 ± 7.6 0.015 Note: TA-AAD, type A acute aortic dissection; SCI, spinal cord injury; CPB, cardiopulmonary bypass; DHCA, deep hypothermic circulatory arrest. Postoperative conditions in both groups are shown in Table 3, with in-hospital mortality slightly increased in the SCI group than in the normal group (12.8% vs. 2.9%). Postoperative outcomes such as intensive care unit (ICU) stay, renal replacement, low cardiac output and gastrointestinal complications were notably increased in the SCI group in contrast to the normal group. Table 3 Postoperative outcomes of both groups Outcomes Normal group (n = 442) Paraplegic group (n = 39) P In-hospital death in 30 days 13 (2.9%) 5 (12.8%) 0.007 ICU stay (days) 5 [3,11] 9 [6.17] 0.001 Postoperative renal replacement therapy 26 (5.8%) 11 (28.2%) <0.001 Re-thoracotomy 4 (0.9%) 0 0.746 Postoperative low cardiac output 5 (1.1%) 6 (15.3%) <0.001 Postoperative gastrointestinal complications 14 (3.1%) 5 (12.8%) 0.011 Note: ICU, intensive care unit. In the univariate logistic regression analysis, preoperative, intraoperative, and postoperative factors were analyzed, and multivariate logistic regression analysis was undertaken on parameters with P < 0.1. Using the backward-stepwise regression method, factors with P ≥ 0.1 were removed from the regression model in each step. After correction for confounding factors, the results are shown in Table 4. Preoperative platelet count (odds ratio [OR] = 0.774, 95% confidence interval [CI] 0.416-0.895, P = 0.007) and D-dimer levels (OR = 2.247, 95% CI 1.756-4.226, P = 0.016) were determined as independent risk factors for SCI after TA-AAD. Other factors left in the multivariate logistic regression model were gender (OR = 3.117, P = 0.004), intraoperative cerebrospinal fluid pressure (OR = 1.816, P = 0.029), and postoperative low cardiac output (OR = 2.149, P = 0.017). Table 4. Risk factors in multivariate logistic regression analysis of postoperative paraplegia in patients with TA-AAD Factor OR 95% CI P Gender 3.117 1.592 - 8.063 0.004 Preoperative platelet count 0.774 0.416 - 0.895 0.007 Preoperative D-dimer levels 2.247 1.756 - 4.226 0.016 Intraoperative cerebrospinal fluid pressure 1.816 1.469 - 3.274 0.029 Postoperative low cardiac output 2.149 1.736 - 5.075 0.017 Note: TA-AAD, type A acute aortic dissection; OR, odds ratio; CI, confidence interval Discussion The present research revealed that the decline in preoperative platelet and the elevation in D-dimer levels held promise as independent risk factors for postoperative SCI. Despite advances in surgical techniques, TA-AAD continues to present significant surgical challenges. However, as TAR using the FET technique gains increasing popularity, the rate of mortality and re-thoracotomy for TA-AAD is gradually decreasing. SCI and paraplegia are serious complications that affect the prognosis of patients, not only increasing their mortality but also affecting their quality of life in the long term. The incidence reported in the literature related to SCI varies widely, with incidence rates ranging from 3.5–20% [ 5 ]. Prior research has primarily focused on intraoperative surgical procedures and intraoperative spinal cord protection strategies, such as the reconstruction of the intercostal vessels and Adamkiewicz artery. Some studies suggest that the intraoperative circulatory arrest with a core body temperature ≥ 28°C and a duration > 40 min as well as the inadequate cerebral protection may function as risk factors for postoperative SCI. It remains a matter of debate whether FET technique leads to inadequate spinal cord blood supply and thus increases the risk of SCI. Chakos et al. [ 6 ] have reported an increased incidence of SCI with the FET technique compared to conventional aortic arch repair (CAR) using a soft elephant trunk (FET: 3.8% vs. CAR: 1.4%, P < 0.01). However, this finding was not supported by the study of Ling et al. [ 7 ]. They argued that the FET stent did not elevate the risk of postoperative paraplegia, and that the "cutoff" sign after descending aortic surgery may be an important cause of early postoperative paraplegia. Some studies have proposed that excessive coverage of the intercostal artery by the FET stent with its distal anchorage area below Th10 may act as a risk factor for SCI [ 8 – 9 ]. However, other studies could not substantiate this concept [ 10 ]. According to the study of Hori et al. [ 11 ], higher creatinine levels and significant perfusion of the spinal cord by the false lumen may be risk factors contributing to postoperative SCI. The spinal circulation is a longitudinal, continuous, and flexible system [ 12 , 13 ], so the input of any single segmental artery along its length is not critical. The spinal cord circulation is fragile in the first few days after extensive segmental artery embolization and disruption of the balance of the spinal cord blood supply due to hypovolemia, hyperthermia, and high venous pressure should be avoided. Once the anterior spinal artery proliferates and new vessels are generated and converted into large arteries, the spinal cord blood supply will return to normal. Therefore, rapid thrombosis of the preoperative false lumen leading to reduced spinal arterial blood supply may be a pivotal risk factor for postoperative SCI. Notably, preoperative platelet count decline and preoperative D-dimer level elevation were risk factors for postoperative SCI in this study. The mechanism may be related to the massive platelet depletion due to preoperative pseudoluminal thrombosis of the dissection. The persistent decline in platelets often suggests exacerbation of dissection in patients. A study by Liu et al. [ 14 ] has suggested that postoperative platelet count decline in aortic dissection was associated with 3-year mortality. The D-dimer level is an indicator of coagulation in the body. It has been established that D-dimer is a by-product of cross-linked fibrin degradation in humans. It is significant in the anticoagulation system of the body and performs a critical role in maintaining the permeability of the vascular walls and normal blood flow. Furthermore, D-dimer plays a crucial role in both coagulation and fibrinolysis, and is commonly used as a serum marker to reflect these processes in patients. As reported previously, D-dimer reflects the fibrinolytic process of coagulation and its level is linked to the size of the thrombus formed and the contact area of thrombus with blood [ 15 ]. Wang et al. [ 16 ] also demonstrated that D-dimer levels were considerably elevated in individuals with type A aortic dissection after massive thrombosis of the false lumen than in type B dissection, and that individuals who died had obviously higher D-dimer levels than surviving patients. Limitations This research is limited in some aspects. The data were retrieved from a single center with a relatively small size for this retrospective study, which may have introduced selection bias. Additionally, the impact of factors such as the personal experience of surgeons and the treatment philosophy of different medical institutions on the results were not taken into consideration. Hence, prospective studies are still needed to validate these results. Conclusion This research indicates that preoperative platelet count decrease and D-dimer level increase are two independent risk factors for postoperative SCI in TAAAD patients undergoing TAR using the FET technique. Therefore, these patients should be actively managed with appropriate preventive measures to reduce the risk of developing postoperative SCI. Declarations Conflicts of interest statement: The authors have no conflicts of interest to declare. Source of Funding: This work has no source of funding. Ethical Approval The study was approved by the ethics committee of research setting Hospital (Ethical approval number: 2021-1557). Written informed consent from all patients for this study was waived. Competing interests Consent was obtained from the patients or their relatives Authors' contributions Conception and design: Fengbo Pei, Jinhua Wei, Zujun Chen; Provision of study materials or patients: Fengbo Pei, Jinhua Wei, Collection and assembly of data: Fengbo Pei, Jinhua Wei, Yao Yao1, Hui Wu, Data analysis and interpretation: Fengbo Pei, Jinhua Wei, Manuscript writing: Fengbo Pei, Jinhua Wei, Zujun Chen Final approval of manuscript: All authors. Competing interests The authors declare that they have no competing interests Availability of data and materials Additional data are available by request through emailing Chen Zujun References Gudbjartsson T, Ahlsson A, Geirsson A, et al. Acute type A aortic dissection—A review. Scand Cardiovasc J, 2020, 54(1): 1-13. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA, 2000, 283(7): 897-903. Howard DP, Banerjee A, Fairhead JF, et al. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation, 2013, 127(20): 2031-2037. Reutersberg B, Salvermoser M, Trenner M, et al. Hospital Incidence and In-Hospital Mortality of Surgically and Interventionally Treated Aortic Dissections: Secondary Data Analysis of the Nationwide German Diagnosis-Related Group Statistics From 2006 to 2014. J Am Heart Assoc, 2019, 8(8): e011402. Ogino H. Acute type A aortic dissection: the role of frozen elephant trunk. Ann Cardiothorac Surg, 2020, 9(3): 233-235. Chakos A, Jbara D, Yan TD, et al. Long-term survival and related outcomes for hybrid versus traditional arch repair-a meta-analysis. Ann Cardiothorac Surg, 2018, 7(3): 319-327. Ling Tan,Jun Xiao,Xinmin Zhou, et al. Untreated distal intimal tears may be associated with paraplegia after total arch replacement and frozen elephant trunk treatment of acute Stanford type A aortic dissection. [J].J Thorac Cardiovasc Surg,2019,158(2):343-350.e1 Leontyev S, Tsagakis K, Pacini D, et al. Impact of clinical factors and surgical techniques on early outcome of patients treated with frozen elephant trunk technique by using EVITA open stent-graft: results of a multicentre study. Eur J Cardiothorac Surg, 2016, 49(2): 660-666. Flores J, Kunihara T, Shiiya N, et al. Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury. J Thorac Cardiovasc Surg, 2006, 131(2): 336-342. Pacini D, Tsagakis K, Jakob H, et al. The frozen elephant trunk for the treatment of chronic dissection of the thoracic aorta: a multicenter experience. Ann Thorac Surg, 2011, 92(5): 1663-1670. Hori D, Kusadokoro S, Adachi K, et al. Risk factors for spinal cord injury in patients undergoing frozen elephant trunk technique for acute aortic dissection. Gen Thorac Cardiovasc Surg, 2020, 68(4): 328-334 Griepp EB, Di Luozzo G, Schray D, et al. The anatomy of the spinal cord collateral circulation. Ann Cardiothorac Surg, 2012, 1(3): 350-357. Etz CD, Kari FA, Mueller CS, et al. The collateral network concept: a reassessment of the anatomy of spinal cord perfusion. J Thorac Cardiovasc Surg, 2011, 141(4): 1020-1028. Liu, G., Wang, H., Luo, Q. et al. Low postoperative blood platelet count may be a risk factor for 3-year mortality in patients with acute type A aortic dissection. J Cardiothorac Surg 16, 274 (2021). Huang B, Yang Y, Lu H, et al. Impact of D-dimer levels on admission on inhospital and long-term outcome in patients with type A acute aortic dissection. Am J Cardiol. 2015;115(11):1595–600. Wang, D., Chen, J., Sun, J. et al. The diagnostic and prognostic value of D-dimer in different types of aortic dissection. J Cardiothorac Surg 17, 194 (2022) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Mar, 2024 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Major revision 30 Sep, 2023 Reviews received at journal 23 May, 2023 Reviewers agreed at journal 15 May, 2023 Reviewers agreed at journal 15 May, 2023 Reviewers invited by journal 15 May, 2023 Submission checks completed at journal 27 Apr, 2023 Editor assigned by journal 27 Apr, 2023 First submitted to journal 15 Apr, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2822183","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":195523512,"identity":"4e7b0c74-c432-4110-8318-60985b3b00af","order_by":0,"name":"Fengbo Pei","email":"","orcid":"","institution":"Fuwai Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fengbo","middleName":"","lastName":"Pei","suffix":""},{"id":195523513,"identity":"503360a1-7738-493a-8ecb-273bb28e5b41","order_by":1,"name":"jinhua wei","email":"","orcid":"","institution":"Fuwai Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"jinhua","middleName":"","lastName":"wei","suffix":""},{"id":195523514,"identity":"7c92f91a-9d54-4433-97dc-3437fb0ce540","order_by":2,"name":"yao yao","email":"","orcid":"","institution":"Fuwai Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"yao","middleName":"","lastName":"yao","suffix":""},{"id":195523515,"identity":"51dcf80a-4819-48f7-b850-d9cbb4507084","order_by":3,"name":"hui wu","email":"","orcid":"","institution":"Fuwai Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"hui","middleName":"","lastName":"wu","suffix":""},{"id":195523516,"identity":"6a88099f-8239-4593-b2d8-2164f93e0353","order_by":4,"name":"zujun Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYDACCTDJBsSMDxg+ACk+BgZmYrUwGzDOAPLZiNTCANbCzEOMFv7Zzcce/mzjS9zOwMwmbVNxuI6NvfmwAUONTTROS+4cSzeQbGNL3NkA1JJz5rAEG8+x5ASGY2m5DTi0GEjkmEkYArVsuP/+2O3cNqAWiRzjA4wNh/Foyf8mkQjScoCZ7bYlcVpy2CQOwrQwQrUk4NMicSPNTLLhHJsxUAv7z54z6ZJtQL8YJODxC/+M5GeSP8qOyQK1MBv8qLDm5weGmMSHGhucWqDgGBo/Ab9yEKghrGQUjIJRMApGLgAA7K9RWJaAzRcAAAAASUVORK5CYII=","orcid":"","institution":"Fuwai Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"zujun","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2023-04-16 03:14:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2822183/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2822183/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-024-02597-y","type":"published","date":"2024-03-13T15:01:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":52907228,"identity":"79b14daa-7952-40ad-8a38-970f34941a35","added_by":"auto","created_at":"2024-03-18 15:11:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":305881,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2822183/v1/942ba400-c2a2-4d62-82c4-850204b97eb2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Predictive value of preoperative platelet count and D-dimer levels for spinal cord injury following acute type A aortic dissection","fulltext":[{"header":"Background","content":"\u003cp\u003eType A acute aortic dissection (TA-AAD) is a clinically fatal acute and critical condition with a pre-hospital mortality rate of 49%. This condition is considered as one of the most urgent surgical procedures in cardiovascular surgery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The effects of the dissection can extend to multiple organs in the body, including the spinal cord, where ischemia and postoperative spinal cord injury (SCI) occur as important complications with an incidence of 3.5\u0026ndash;20% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These complications may have negative implications for the prognosis of patients and their quality of life following surgery. However, in recent years, with the widespread use of total arch replacement (TAR) with frozen elephant trunk (FET) technique, the mortality rate of TA-AAD has been gradually decreasing. Nonetheless, SCI remains a serious postoperative complication. Therefore, it may be potentially beneficial to reduce the incidence of SCI by identifying the individuals at high risk for postoperative SCI early in the preoperative period and thus intervening more aggressively in their treatment.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient population\u003c/h2\u003e \u003cp\u003ePatients with Stanford TA-AAD admitted to the Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College in Beijing (China) from September 2016 to April 2020 were retrospectively analyzed based on the electronic medical records and laboratory tests. The patients were excluded if the they did not undergo TAR (ascending aorta replacement alone or partial aortic arch replacement), deep hypothermic circulatory arrest (DHCA) (e.g., hybrid total aorta replacement), or chronic type A aortic arch dissection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis retrospectively designed study analyzed patients diagnosed with TA-AAD who underwent TAR with DHCA using the FET technique. The preoperative parameters, intraoperative details, and postoperative outcomes of these individuals were the main focus of the research. This single-center study was approved by the Ethics Committee of the Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (Beijing, China). The provision of informed written consent by each participant or their caregivers was necessary for inclusion. The diagnostic criterion for TA-AAD was the examination using enhanced computed tomography (CT). In addition, the research investigated the incidence of postoperative SCI in individuals with TA-AAD and assessed the risk factors associated with this complication.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedures\u003c/h2\u003e \u003cp\u003eStandard anesthetic management and endotracheal intubation were used during surgery. Cardiopulmonary bypass (CPB) was applied in the process of surgery through right axillary artery cannulation. Intraoperatively, DHCA was applied, and the unilateral or bilateral cerebral perfusion was selectively performed. Four-branch prosthetic vessels were used to perform TAR, with the right innominate brachiocephalic trunk, left common carotid artery, and left subclavian artery re-anastomosed to the branches of the prosthetic vessels, respectively. The FET stent was implanted in the descending aorta during the surgery.\u003c/p\u003e \u003cp\u003eSCI was diagnosed using the American Spinal Injury Association (ASIA; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://asia-spinalinjury.org/\u003c/span\u003e\u003cspan address=\"https://asia-spinalinjury.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) criteria into 5 grades, of which Grade A represented a complete injury. Grade B referred to an incomplete injury, with sensory function present below the nerve plane but without any motor function. Grade C represented an incomplete injury, with more than half of the motor function preserved below the nerve plane and a key muscle strength lower than Level 3. Grade D also referred to an incomplete injury, with more than half of the motor function retained below the nerve plane. The incomplete impairment indicated by Grade D meant that more than half of the motor function was preserved below the nerve plane, and key muscle strength was greater than or equal to Level 3. Grade E was assigned if both motor and sensory function was normal. Whereas, Grade A reflected the most severe SCI, i.e., paraplegia, in ASIA classification, while the spinal cord at Grade E was normal.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data distribution was examined through the Kolmogorov-Smirnov test. The format of mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) was utilized for continuous data in case of a normal distribution, whereas the median value and interquartile range were utilized for non-normally distributed data. Counts and percentages were utilized for categorical variables. The Chi-square test or Fisher exact test were used to analyze categorical data, while one-way analysis of variance or Wilcoxon rank sum test was utilized for assessing the comparison of continuous variables. The logistic regression model was employed for the determination of the univariate and multivariate predictors of postoperative SCI. SPSS 26 (SPSS, IBM Corp. Armonk, USA) was employed for the analysis of the data, with \u003cem\u003ep\u003c/em\u003e less than 0.05 representing statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, 774 individuals with TA-AAD were enrolled through the electronic information system for inpatient physicians. Among them, 293 were excluded as their surgical procedure did not meet the inclusion criteria. Specifically, this included 226 cases of partial aortic arch replacements without DHCA, 45 of hybrid total aortic arch procedures, and 22 of chronic type A aortic arch dissections. Ultimately, 481 TA-AAD cases were screened out with a mean age of 47.2 \u0026plusmn; 16.4 years (29-75 years). Of these, 425 were men and 56 were women. The final 39 patients developed SCI postoperatively, with an incidence of 8.1%. Among these, 21 were paraplegic and 18 had incomplete SCI. The preoperative baseline parameters of the two groups are shown in Table 1. Regarding baseline information and preoperative indicators, the two groups lacked any notable statistical variance in age, body mass index (BMI), time from onset to surgery, preoperative complications, preoperative ultrasound, preoperative leukocytes and hemoglobin, and the number of intercostal vessels involved. However, they varied significantly in terms of gender, preoperative platelets, preoperative D-dimer, and Adamkiewicz artery involvement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 Preoperative baseline characteristics of patients with TA-AAD\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"657\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eBaseline characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003eNormal group (n = 442)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003eSCI group (n = 39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eDemographic information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e46.9 \u0026plusmn; 17.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e50.7 \u0026plusmn; 17.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eGender (male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e396 (89.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e29 (74.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e24.9 \u0026plusmn; 3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e26.7 \u0026plusmn; 4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.612\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eOnset to surgery time (h)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e45[21,124]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e42[19,140]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.194\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eMedical history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e407 (92.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e36 (92.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.795\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e11 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e2 (5.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.645\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eCerebrovascular disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e21 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e3 (7.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.670\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eSmoking history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e224 (50.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e23 (58.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.408\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eCOPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e2 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e\u0026gt; 0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003ePreoperative situation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eLactic acid (mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e1.9 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e2.1 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.091\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003ePaO\u003csub\u003e2\u003c/sub\u003e/FiO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e265 \u0026plusmn; 82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e249 \u0026plusmn; 76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.163\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eD-dimer (\u0026mu;g/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e1.1[0.4,2.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e2.7[0.8,3.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eLeukocytes (10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e12.7 \u0026plusmn; 2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e11.6 \u0026plusmn; 3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eHemoglobin (g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e134 \u0026plusmn; 21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e131 \u0026plusmn; 25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.647\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003ePlatelets (10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e179 \u0026plusmn; 28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e144 \u0026plusmn; 21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eBlood creatinine (\u0026mu;mol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e87.5 \u0026plusmn; 29.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e90.6 \u0026plusmn; 30.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.117\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eTroponin I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e0.02[0.00,0.06]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e0.02[0.00,0.08]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.911\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eAortic root diameter (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e42.1 \u0026plusmn; 8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e42.9 \u0026plusmn; 10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.379\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eAscending aorta diameter (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e45.8 \u0026plusmn; 7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e46.7 \u0026plusmn; 8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.317\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eLeft ventricular ejection fraction (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e62.5 \u0026plusmn; 6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e63.8 \u0026plusmn; 5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.453\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eAdamkiewicz\u0026nbsp;artery involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e89 (20.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e16 (41.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.203957382039576%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of intercostal vessels involved\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570776255707763%\"\u003e\n \u003cp\u003e3 [0.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.070015220700153%\"\u003e\n \u003cp\u003e4 [0,7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.155251141552512%\"\u003e\n \u003cp\u003e0.847\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: TA-AAD,\u0026nbsp;type A acute aortic dissection;\u0026nbsp;SCI,\u0026nbsp;spinal cord injury;\u0026nbsp;BMI,\u0026nbsp;body mass index; COPD,\u0026nbsp;chronic obstructive pulmonary disease;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The intraoperative conditions of the groups are presented in Table 2. No statistical variance was indicated between the groups concerning surgery duration, intraoperative CPB duration, aortic block duration, and DHCA duration, and intraoperative nasopharyngeal temperature. However, intraoperative blood loss and cerebrospinal fluid pressure exhibited considerably higher values in the SCI group in contrast to the control group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 Intraoperative characteristics of patients with TA-AAD\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"657\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.76864535768645%\"\u003e\n \u003cp\u003eFeatures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.245053272450534%\"\u003e\n \u003cp\u003eNormal group (n = 442)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.91780821917808%\"\u003e\n \u003cp\u003eSCI group (n = 39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.068493150684931%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.76864535768645%\"\u003e\n \u003cp\u003eSurgery duration (h)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.245053272450534%\"\u003e\n \u003cp\u003e8.7 \u0026plusmn; 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.91780821917808%\"\u003e\n \u003cp\u003e9.2 \u0026plusmn; 2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.068493150684931%\"\u003e\n \u003cp\u003e0.068\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.76864535768645%\"\u003e\n \u003cp\u003eCPB duration (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.245053272450534%\"\u003e\n \u003cp\u003e174 \u0026plusmn; 52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.91780821917808%\"\u003e\n \u003cp\u003e180 \u0026plusmn; 57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.068493150684931%\"\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.76864535768645%\"\u003e\n \u003cp\u003eAortic block duration (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.245053272450534%\"\u003e\n \u003cp\u003e139 \u0026plusmn; 46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.91780821917808%\"\u003e\n \u003cp\u003e144 \u0026plusmn; 57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.068493150684931%\"\u003e\n \u003cp\u003e0.228\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.76864535768645%\"\u003e\n \u003cp\u003eDHCA duration (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.245053272450534%\"\u003e\n \u003cp\u003e21 \u0026plusmn; 4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.91780821917808%\"\u003e\n \u003cp\u003e22 \u0026plusmn; 5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.068493150684931%\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.76864535768645%\"\u003e\n \u003cp\u003eNasopharyngeal temperature (℃)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.245053272450534%\"\u003e\n \u003cp\u003e24.7 \u0026plusmn; 2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.91780821917808%\"\u003e\n \u003cp\u003e24.2 \u0026plusmn; 4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.068493150684931%\"\u003e\n \u003cp\u003e0.773\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.76864535768645%\"\u003e\n \u003cp\u003eIntraoperative blood loss (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.245053272450534%\"\u003e\n \u003cp\u003e1071 \u0026plusmn; 446\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.91780821917808%\"\u003e\n \u003cp\u003e1453 \u0026plusmn; 579\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.068493150684931%\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.76864535768645%\"\u003e\n \u003cp\u003eIntraoperative cerebrospinal fluid pressure (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.245053272450534%\"\u003e\n \u003cp\u003e14.7 \u0026plusmn; 5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.91780821917808%\"\u003e\n \u003cp\u003e19.5 \u0026plusmn; 7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.068493150684931%\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNote: TA-AAD, type A acute aortic dissection; SCI, spinal cord injury; CPB, cardiopulmonary bypass; DHCA, deep hypothermic circulatory arrest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePostoperative conditions in both groups are shown in Table 3, with in-hospital mortality slightly increased in the SCI group than in the normal group (12.8% \u003cem\u003evs.\u0026nbsp;\u003c/em\u003e2.9%). Postoperative\u0026nbsp;outcomes such as\u0026nbsp;intensive care unit (ICU) stay, renal replacement, low cardiac output and gastrointestinal complications were notably increased in the SCI group in\u0026nbsp;contrast to\u0026nbsp;the normal group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 Postoperative outcomes of both groups\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"657\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.78723404255319%\"\u003e\n \u003cp\u003eOutcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.051671732522795%\"\u003e\n \u003cp\u003eNormal group (n = 442)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.11550151975684%\"\u003e\n \u003cp\u003eParaplegic group (n = 39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.045592705167174%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.78723404255319%\"\u003e\n \u003cp\u003eIn-hospital death in 30 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.051671732522795%\"\u003e\n \u003cp\u003e13 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.11550151975684%\"\u003e\n \u003cp\u003e5 (12.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.045592705167174%\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.78723404255319%\"\u003e\n \u003cp\u003eICU stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.051671732522795%\"\u003e\n \u003cp\u003e5 [3,11]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.11550151975684%\"\u003e\n \u003cp\u003e9 [6.17]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.045592705167174%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.78723404255319%\"\u003e\n \u003cp\u003ePostoperative renal replacement therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.051671732522795%\"\u003e\n \u003cp\u003e26 (5.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.11550151975684%\"\u003e\n \u003cp\u003e11 (28.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.045592705167174%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.78723404255319%\"\u003e\n \u003cp\u003eRe-thoracotomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.051671732522795%\"\u003e\n \u003cp\u003e4 (0.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.11550151975684%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.045592705167174%\"\u003e\n \u003cp\u003e0.746\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.78723404255319%\"\u003e\n \u003cp\u003ePostoperative low cardiac output\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.051671732522795%\"\u003e\n \u003cp\u003e5 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.11550151975684%\"\u003e\n \u003cp\u003e6 (15.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.045592705167174%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.78723404255319%\"\u003e\n \u003cp\u003ePostoperative gastrointestinal complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.051671732522795%\"\u003e\n \u003cp\u003e14 (3.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.11550151975684%\"\u003e\n \u003cp\u003e5 (12.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.045592705167174%\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: ICU, intensive care unit.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the univariate logistic regression analysis, preoperative, intraoperative, and postoperative factors were analyzed, and multivariate logistic regression analysis was undertaken on parameters with \u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.1. Using the backward-stepwise regression method, factors with \u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026ge; 0.1 were removed from the regression model in each step. After correction for confounding factors, the results are shown in Table 4. Preoperative platelet count (odds ratio [OR] = 0.774, 95% confidence interval [CI] 0.416-0.895, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.007) and D-dimer levels (OR = 2.247, 95% CI 1.756-4.226, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.016) were determined as independent risk factors for SCI after TA-AAD. Other factors left in the multivariate logistic regression model were gender (OR = 3.117, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.004), intraoperative cerebrospinal fluid pressure (OR = 1.816, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.029), and postoperative low cardiac output (OR = 2.149, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.017).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Risk factors in multivariate logistic regression analysis of postoperative paraplegia in patients with TA-AAD\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"657\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.81430745814308%\"\u003e\n \u003cp\u003eFactor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.590563165905632%\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.80821917808219%\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.81430745814308%\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.590563165905632%\"\u003e\n \u003cp\u003e3.117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.80821917808219%\"\u003e\n \u003cp\u003e1.592 - 8.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.7869101978691%\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.81430745814308%\"\u003e\n \u003cp\u003ePreoperative platelet count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.590563165905632%\"\u003e\n \u003cp\u003e0.774\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.80821917808219%\"\u003e\n \u003cp\u003e0.416 - 0.895\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.7869101978691%\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.81430745814308%\"\u003e\n \u003cp\u003ePreoperative D-dimer levels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.590563165905632%\"\u003e\n \u003cp\u003e2.247\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.80821917808219%\"\u003e\n \u003cp\u003e1.756 - 4.226\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.7869101978691%\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.81430745814308%\"\u003e\n \u003cp\u003eIntraoperative cerebrospinal fluid pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.590563165905632%\"\u003e\n \u003cp\u003e1.816\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.80821917808219%\"\u003e\n \u003cp\u003e1.469 - 3.274\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.7869101978691%\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.81430745814308%\"\u003e\n \u003cp\u003ePostoperative low cardiac output\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.590563165905632%\"\u003e\n \u003cp\u003e2.149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.80821917808219%\"\u003e\n \u003cp\u003e1.736 - 5.075\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.7869101978691%\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: TA-AAD, type A acute aortic dissection; OR, odds ratio; CI, confidence interval\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present research revealed that the decline in preoperative platelet and the elevation in D-dimer levels held promise as independent risk factors for postoperative SCI. Despite advances in surgical techniques, TA-AAD continues to present significant surgical challenges. However, as TAR using the FET technique gains increasing popularity, the rate of mortality and re-thoracotomy for TA-AAD is gradually decreasing. SCI and paraplegia are serious complications that affect the prognosis of patients, not only increasing their mortality but also affecting their quality of life in the long term. The incidence reported in the literature related to SCI varies widely, with incidence rates ranging from 3.5\u0026ndash;20% [ 5 ].\u003c/p\u003e \u003cp\u003ePrior research has primarily focused on intraoperative surgical procedures and intraoperative spinal cord protection strategies, such as the reconstruction of the intercostal vessels and Adamkiewicz artery. Some studies suggest that the intraoperative circulatory arrest with a core body temperature\u0026thinsp;\u0026ge;\u0026thinsp;28\u0026deg;C and a duration\u0026thinsp;\u0026gt;\u0026thinsp;40 min as well as the inadequate cerebral protection may function as risk factors for postoperative SCI. It remains a matter of debate whether FET technique leads to inadequate spinal cord blood supply and thus increases the risk of SCI. Chakos \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] have reported an increased incidence of SCI with the FET technique compared to conventional aortic arch repair (CAR) using a soft elephant trunk (FET: 3.8% \u003cem\u003evs.\u003c/em\u003e CAR: 1.4%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). However, this finding was not supported by the study of Ling \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. They argued that the FET stent did not elevate the risk of postoperative paraplegia, and that the \"cutoff\" sign after descending aortic surgery may be an important cause of early postoperative paraplegia. Some studies have proposed that excessive coverage of the intercostal artery by the FET stent with its distal anchorage area below Th10 may act as a risk factor for SCI [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, other studies could not substantiate this concept [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. According to the study of Hori \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], higher creatinine levels and significant perfusion of the spinal cord by the false lumen may be risk factors contributing to postoperative SCI.\u003c/p\u003e \u003cp\u003eThe spinal circulation is a longitudinal, continuous, and flexible system [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], so the input of any single segmental artery along its length is not critical. The spinal cord circulation is fragile in the first few days after extensive segmental artery embolization and disruption of the balance of the spinal cord blood supply due to hypovolemia, hyperthermia, and high venous pressure should be avoided. Once the anterior spinal artery proliferates and new vessels are generated and converted into large arteries, the spinal cord blood supply will return to normal. Therefore, rapid thrombosis of the preoperative false lumen leading to reduced spinal arterial blood supply may be a pivotal risk factor for postoperative SCI.\u003c/p\u003e \u003cp\u003eNotably, preoperative platelet count decline and preoperative D-dimer level elevation were risk factors for postoperative SCI in this study. The mechanism may be related to the massive platelet depletion due to preoperative pseudoluminal thrombosis of the dissection. The persistent decline in platelets often suggests exacerbation of dissection in patients. A study by Liu \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] has suggested that postoperative platelet count decline in aortic dissection was associated with 3-year mortality.\u003c/p\u003e \u003cp\u003eThe D-dimer level is an indicator of coagulation in the body. It has been established that D-dimer is a by-product of cross-linked fibrin degradation in humans. It is significant in the anticoagulation system of the body and performs a critical role in maintaining the permeability of the vascular walls and normal blood flow. Furthermore, D-dimer plays a crucial role in both coagulation and fibrinolysis, and is commonly used as a serum marker to reflect these processes in patients. As reported previously, D-dimer reflects the fibrinolytic process of coagulation and its level is linked to the size of the thrombus formed and the contact area of thrombus with blood [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Wang \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] also demonstrated that D-dimer levels were considerably elevated in individuals with type A aortic dissection after massive thrombosis of the false lumen than in type B dissection, and that individuals who died had obviously higher D-dimer levels than surviving patients.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis research is limited in some aspects. The data were retrieved from a single center with a relatively small size for this retrospective study, which may have introduced selection bias. Additionally, the impact of factors such as the personal experience of surgeons and the treatment philosophy of different medical institutions on the results were not taken into consideration. Hence, prospective studies are still needed to validate these results.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis research indicates that preoperative platelet count decrease and D-dimer level increase are two independent risk factors for postoperative SCI in TAAAD patients undergoing TAR using the FET technique. Therefore, these patients should be actively managed with appropriate preventive measures to reduce the risk of developing postoperative SCI.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of interest statement:\u003c/strong\u003e The authors have no conflicts of interest to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of Funding:\u003c/strong\u003e This work has no source of funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was approved by the ethics committee of research setting Hospital (Ethical approval number: 2021-1557). Written informed consent from all patients for this study was waived.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent was obtained from the patients or their relatives\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConception and design: Fengbo Pei, Jinhua Wei, \u0026nbsp;Zujun Chen;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProvision of study materials or patients: Fengbo Pei, Jinhua Wei,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCollection and assembly of data: Fengbo Pei, Jinhua Wei, Yao Yao1, Hui Wu,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData analysis and interpretation: Fengbo Pei, Jinhua Wei,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eManuscript writing: Fengbo Pei, Jinhua Wei, \u0026nbsp;Zujun Chen\u003c/p\u003e\n\u003cp\u003eFinal approval of manuscript: All authors. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditional data are available by request through emailing Chen Zujun\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGudbjartsson T, Ahlsson A, Geirsson A, et al. Acute type A aortic dissection\u0026mdash;A review. Scand Cardiovasc J, 2020, 54(1): 1-13.\u003c/li\u003e\n\u003cli\u003eHagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA, 2000, 283(7): 897-903.\u003c/li\u003e\n\u003cli\u003eHoward DP, Banerjee A, Fairhead JF, et al. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation, 2013, 127(20): 2031-2037.\u003c/li\u003e\n\u003cli\u003eReutersberg B, Salvermoser M, Trenner M, et al. Hospital Incidence and In-Hospital Mortality of Surgically and Interventionally Treated Aortic Dissections: Secondary Data Analysis of the Nationwide German Diagnosis-Related Group Statistics From 2006 to 2014. J Am Heart Assoc, 2019, 8(8): e011402.\u003c/li\u003e\n\u003cli\u003eOgino H. Acute type A aortic dissection: the role of frozen elephant trunk. 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Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury. J Thorac Cardiovasc Surg, 2006, 131(2): 336-342.\u003c/li\u003e\n\u003cli\u003ePacini D, Tsagakis K, Jakob H, et al. The frozen elephant trunk for the treatment of chronic dissection of the thoracic aorta: a multicenter experience. Ann Thorac Surg, 2011, 92(5): 1663-1670.\u003c/li\u003e\n\u003cli\u003eHori D, Kusadokoro S, Adachi K, et al. Risk factors for spinal cord injury in patients undergoing frozen elephant trunk technique for acute aortic dissection. Gen Thorac Cardiovasc Surg, 2020, 68(4): 328-334\u003c/li\u003e\n\u003cli\u003eGriepp EB, Di Luozzo G, Schray D, et al. The anatomy of the spinal cord collateral circulation. Ann Cardiothorac Surg, 2012, 1(3): 350-357.\u003c/li\u003e\n\u003cli\u003eEtz CD, Kari FA, Mueller CS, et al. The collateral network concept: a reassessment of the anatomy of spinal cord perfusion. J Thorac Cardiovasc Surg, 2011, 141(4): 1020-1028.\u003c/li\u003e\n\u003cli\u003eLiu, G., Wang, H., Luo, Q. et al. Low postoperative blood platelet count may be a risk factor for 3-year mortality in patients with acute type A aortic dissection. J Cardiothorac Surg 16, 274 (2021). \u003c/li\u003e\n\u003cli\u003eHuang B, Yang Y, Lu H, et al. Impact of D-dimer levels on admission on inhospital and long-term outcome in patients with type A acute aortic dissection. Am J Cardiol. 2015;115(11):1595\u0026ndash;600.\u003c/li\u003e\n\u003cli\u003eWang, D., Chen, J., Sun, J. et al. The diagnostic and prognostic value of D-dimer in different types of aortic dissection. J Cardiothorac Surg 17, 194 (2022)\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"spinal cord injury，acute type A aortic dissection，platelet ，D-dimer","lastPublishedDoi":"10.21203/rs.3.rs-2822183/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2822183/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study aims to identify the risk factors contributing to spinal cord injury (SCI) following a type A acute aortic dissection (TA-AAD).\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis retrospective study was conducted at a single center and involved 481 patients who received frozen elephant trunk stent implantation for TA-AAD and underwent total arch replacement with the deep hypothermic circulatory arrest at Fuwai Hospital between September 2016 and April 2020.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe resulting data of the multivariate logistic regression analysis demonstrated that preoperative platelet count (odds ratio [OR] 0.774) and D-dimer levels (OR 2.247) held potential as independent predictors for postoperative SCI in patients diagnosed with TA-AAD.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe study results indicated that preoperative platelet count and D-dimer levels are independent risk factors for postoperative SCI in individuals with TA-AAD. This finding holds significance regarding clinical implications for prognosis and therapeutic responses in TA-AAD.\u003c/p\u003e","manuscriptTitle":"Predictive value of preoperative platelet count and D-dimer levels for spinal cord injury following acute type A aortic dissection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-05-02 11:02:05","doi":"10.21203/rs.3.rs-2822183/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-09-30T05:50:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-05-23T12:23:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"45af204f-cdc9-493e-aca6-8eca5ff3e83c","date":"2023-05-15T10:38:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"ec3e8766-c4de-40ee-898d-09f7189d836c","date":"2023-05-15T10:29:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-05-15T09:23:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-04-27T05:19:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-04-27T05:19:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2023-04-16T03:04:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"01806d5d-b1ed-49b3-bae6-0d420aebff55","owner":[],"postedDate":"May 2nd, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-03-18T15:04:44+00:00","versionOfRecord":{"articleIdentity":"rs-2822183","link":"https://doi.org/10.1186/s13019-024-02597-y","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2024-03-13 15:01:08","publishedOnDateReadable":"March 13th, 2024"},"versionCreatedAt":"2023-05-02 11:02:05","video":"","vorDoi":"10.1186/s13019-024-02597-y","vorDoiUrl":"https://doi.org/10.1186/s13019-024-02597-y","workflowStages":[]},"version":"v1","identity":"rs-2822183","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2822183","identity":"rs-2822183","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}