冠状动脉内膜剥脱联合旁路移植治疗弥漫性冠状动脉狭窄病变的近中期效果

目的探讨冠状动脉内膜剥脱术(CE)联合冠状动脉旁路移植术(CABG)治疗弥漫性冠状动脉狭窄病变的近中期效果。方法回顾性分析2010年1月至2019年1月在南京市第一医院心胸血管外科接受CE+CABG的248例弥漫性冠状动脉狭窄病变患者的临床资料。男性201例,女性47例;年龄(65.6±8.5)岁(范围:43~79岁)。体外循环手术156例,非体外循环手术92例。共对269根病变血管完成CE,包括前降支108根,右冠状动脉140根,钝缘支21根。共完成旁路移植872支,包括左胸廓内动脉248支,桡动脉48支,大隐静脉576支,每例患者移植(3.5±0.8)支(范围:2~6支)。CE后平均血流量为(26±8)ml/min(范围:13~59 ml/min),血流指数为3.1±0.8(范围:2.0~6.7)。采用t检验或χ²检验比较体外循环和非体外循环患者的手术结果及术后通畅率。结果全组围手术期病死率为1.2%(3/248),2例死于肾功能衰竭,1例死于术后顽固性低心排血量。9例发生围手术期心肌梗死。随访(41.8±21.4)个月(范围:1~68个月)。旁路血管术后1年通畅率为78.4%(182/232),3年通畅率为69.8%(162/232)。左冠状动脉系统通畅率明显高于右冠状动脉系统(1年:87.4%比73.1%,χ²=6.533,P=0.011;3年:78.2%比64.8%,χ²=4.588,P=0.032)。体外循环组和非体外循环组旁路血管通畅率无差异(1年:80.0%比76.9%,χ²=0.277,P=0.599;3年:71.5%比67.9%,χ²=0.300,P=0.584)。结论CE+CABG治疗弥漫性冠状动脉狭窄病变可以获得较满意的完全再血管化,有较好的早、中期效果和旁路血管通畅率。体外循环和非体外循环手术具有相似的早中期结果。

The early and midterm results of coronary endarterectomy combined with coronary artery bypass grafting for diffuse coronary artery stenosis

Objective To examine the early and mid-term results of coronary endarterectomy(CE)combined with coronary artery bypass grafting(CABG)in the treatment of diffuse coronary artery stenosis.Methods The clinical data and follow-up results of 248 patients who underwent CE+CABG surgery from January 2010 to January 2019 at Department of Cardiovascular Surgery,Nanjing Hospital Affiliated to Nanjing Medical University was analyzed retrospectively.There were 201 males and 47 females,aged(65.6±8.5)years(range:43 to 79 years).The on-pump group included 156 patients and the off-pump group included 92 patients.CABG was performed after CE.CE was performed on 248 patients who represented 269 target coronary lesions,of which 108 were located on the left anterior descending artery and sub-branches,140 were located on the right coronary artery and sub-branches,and 21 were located on the left circumflex artery and obtuse marginal artery.A total of 872 bypass grafts were performed,including 248 left internal thoracic arteries,48 radial arteries,and 576 great saphenous veins,with(3.5±0.8)grafts(range:2 to 6 grafts)per patient.The grafts had satisfactory bridge blood flow after CE,with the graft flow rates of(26±8)ml/min(range:13 to 59 ml/min)and the pulsatility index value of 3.1±0.8(range:2.0 to 6.7).The t test andχ²test was used to compare the surgical results and graft patency rate between patients in on-pump and off-pump group,respectively.Results The number of graft vessels of on-pump group and off-pump group was 3.6±0.9 and 3.2±0.7,respectively(t=1.637,P=0.085).There were 3 deaths during the perioperative period,with a mortality rate of 1.2%.Two people died of renal failure,and one case was due to postoperative refractory low cardiac output.Perioperative myocardial infarction occurred in 9 cases.The follow-up time was(41.8±21.4)months(range:1 to 68 months).The all graft patency rate was 78.4%(812/232)in 1 year and 69.8%(162/232)in 3 years postoperatively.The left coronary graft patency rate was significantly higher than the right coronary graft patency rate(1-year:87.4%vs.73.1%,χ²=6.533,P=0.011,3-year:78.2%vs.64.8%,χ²=4.588,P=0.032).There was no significant difference in graft patency rates between the on-pump group and off-pump group(1-year:80.0%vs.76.9%,χ²=0.277,P=0.599,3-year:71.5%vs.67.9%,χ²=0.300,P=0.584).Conclusions CE+CABG is a safe and feasible technique for patients with diffuse coronary artery disease to get more satisfied complete revascularization,with good early and medium-term results and graft patency rates.The outcomes of on-pump or off-pump CE+CABG are similar.