背景:冠状动脉手术中动脉血运重建的益处仍存在争议。左胸内动脉(ITA)的额外移植物的增量值主要根据动脉移植物的数量进行评估,可能会限制对其实际影响的检测。我们分析了接受一到三个动脉移植物的患者进行的远端动脉吻合(DAA)数量对晚期死亡率的影响。
方法:回顾性回顾了1989年至2014年进行的3685例原发性孤立性冠状动脉旁路移植术(CABG),平均随访13年。969例患者使用了一次动脉移植物(SITA),两个动脉移植物,ITA或胃上动脉(GEA),1883名患者(BITA:1644;SITAGEA:239),833例患者(BITA+GEA)的三例动脉移植。完全正确,795名患者(22%)接受了一次DAA,1142例患者(31%)二,1337例患者(36%)三,和411名患者(11%)4个或更多。对2104例接受至少2次动脉移植的3血管疾病患者进行了亚组分析。
结果:在本系列中,早期死亡率为1.6%,不受手术技术的影响。晚期死亡率受年龄的影响很大,性别,心力衰竭,左心室射血分数,糖尿病状态,完全血运重建,动脉移植物的数量,DAA的数量,两个ITA,序贯ITA移植,GEA移植。在Cox回归模型的多变量分析中,DAA的数量是唯一有技术意义的晚期生存的独立预后因素(p<0.0001),两者都占主导地位,完全血运重建和动脉移植物的数量。发现DAA数量对生存的影响在1到3之间有区别;在3之后,没有更多的额外影响。在接受至少2次动脉移植的3血管疾病患者中,DAA的数量仍然是晚期生存的显著独立预后因素(p<0.0001).
结论:远端动脉吻合的数量是长期生存的独立预测因素,动脉移植物的数量和血运重建的完整性占优势;数量越高,最好是晚期生存。这有力地支持了动脉移植在CABG中的广泛应用。
BACKGROUND: The benefit of arterial revascularization in coronary surgery remains controversial. The incremental value of additional grafts to the left internal thoracic artery (ITA) has been mainly assessed according to the number of arterial grafts, possibly limiting the detection of its actual impact. We analyzed the influence of the number of distal arterial anastomoses (DAA) performed on late mortality in patients having received from one to three arterial grafts.
METHODS: Retrospective review of 3685 primary isolated coronary artery bypass grafting (CABG) performed from 1989 to 2014 was conducted with a 13-year mean follow-up. One arterial graft (SITA) was used in 969 patients, two arterial grafts, ITA or gastroepiploic artery (GEA), in 1883 patients (BITA: 1644; SITA+GEA: 239), and three arterial grafts in 833 patients (BITA+GEA). Totally, 795 patients (22%) received one DAA, 1142 patients (31%) two, 1337 patients (36%) three, and 411 patients (11%) four or more. A sub-group analysis was done in the 2104 patients with 3-vessel disease who received at least 2 arterial grafts.
RESULTS: In this series the early mortality was 1.6% and it was not influenced by the surgical technique. Late mortality was significantly influenced by age, gender, heart failure, LV ejection fraction, diabetes status, complete revascularization, number of arterial grafts, number of DAA, both ITA, sequential ITA graft, GEA graft. In multivariable analysis with Cox regression model, the number of DAA was the only technical significant independent prognosis factor of late survival (p < 0.0001), predominant over both ITA, complete revascularization and number of arterial grafts. The impact of the number of DAA on survival was found discriminant from 1 to 3; after 3 there was no more additional effect. In 3-vessel disease patients who received at least 2 arterial grafts, the number of DAA remained a significant independent prognosis factor of late survival (p < 0.0001).
CONCLUSIONS: The number of distal arterial anastomoses is an independent predictor of long-term survival, predominant over the number of arterial grafts and the completeness of the revascularization; higher the number, better the late survival. It is a strong support of the extensive use of arterial grafting in CABG.