Trehan N, Mishra M, Kasliwal R R, Mishra A
Escorts Heart Institute and Research Centre, New Delhi, India.
Ann Thorac Surg. 2000 Nov;70(5):1558-64. doi: 10.1016/s0003-4975(00)01926-3.
Mobile atheromas of the thoracic aorta have been identified as a major cause of stroke after coronary artery bypass grafting (CABG). This prospective study was undertaken to identify mobile atheromas and to determine the incidence of immediate postoperative embolic events after suitable surgical modifications. Late clinical events attributable to embolization were also studied.
Between January 1993 and July 1997, 3,660 patients scheduled for CABG underwent intraoperative transesophageal echocardiography to identify aortic atheromatous disease. The disease was graded as follows: grade I, plaques extending less than 5 mm into the aortic lumen; grade II, plaques extending more than 5 mm into the aortic lumen; and grade III, plaques with a mobile element. Only patients with grade III atheromas were included in the study. Various surgical modifications were done depending on the location of the lesion, eg, aortic arch atherectomy, CABG combined with transmyocardial laser revascularization, off-pump CABG by median sternotomy, and minimally invasive direct coronary artery bypass. Measured outcomes were death, stroke, and other vascular events, both early (within 1 week) and late (1 to 5 years) after operation.
Of the 3,660 patients, 104 (2.84%) had mobile atheromas. The perioperative stroke rate was 0.96%, and the incidence of other vascular events was 1.92% at 1 week. There was no embolic event in the group of 88 patients who underwent off-pump CABG. Of the study group, 98.07% are in regular follow-up. At 5 years, 1 patient had had a nonfatal stroke, and 2 patients had died of causes unrelated to atheromatous disease.
The stroke rate was very low in patients with mobile aortic atheromas who underwent CABG after modification in surgical technique, especially off-pump CABG. A follow-up of 5 years showed that patients with mobile atheromas have a very low incidence of spontaneous embolization.
胸主动脉的移动性动脉粥样硬化斑块已被确认为冠状动脉旁路移植术（CABG）后中风的主要原因。本前瞻性研究旨在识别移动性动脉粥样硬化斑块，并确定在进行适当的手术改良后术后即刻栓塞事件的发生率。还研究了栓塞所致的晚期临床事件。
1993年1月至1997年7月期间，3660例计划行CABG的患者接受术中经食管超声心动图检查以识别主动脉粥样硬化疾病。疾病分级如下：I级，斑块向主动脉腔内延伸小于5mm；II级，斑块向主动脉腔内延伸大于5mm；III级，带有可移动成分的斑块。仅III级动脉粥样硬化患者纳入研究。根据病变位置进行各种手术改良，例如主动脉弓斑块切除术、CABG联合经心肌激光血运重建术、经正中胸骨切开非体外循环CABG以及微创直接冠状动脉旁路移植术。测量的结果指标为术后早期（1周内）和晚期（1至5年）的死亡、中风及其他血管事件。
3660例患者中，104例（2.84%）有移动性动脉粥样硬化斑块。围手术期中风发生率为0.96%，1周时其他血管事件发生率为1.92%。88例接受非体外循环CABG的患者组中未发生栓塞事件。研究组中98.07%的患者进行了定期随访。5年时，1例患者发生非致命性中风，2例患者死于与动脉粥样硬化疾病无关的原因。
手术技术改良后行CABG的移动性主动脉粥样硬化斑块患者中风发生率非常低，尤其是非体外循环CABG。5年随访显示，移动性动脉粥样硬化斑块患者自发栓塞发生率非常低。
