Karthik Shishir, Musleh Ghassan, Grayson Antony D, Keenan Daniel J M, Pullan D Mark, Dihmis Walid C, Hasan Ragheb, Fabri Brian M
Department of Cardiothoracic Surgery, The Cardiothoracic Centre, Liverpool, United Kingdom.
Ann Thorac Surg. 2004 Apr;77(4):1245-9. doi: 10.1016/j.athoracsur.2003.09.054.
An increasing number of patients with peripheral vascular disease are undergoing coronary artery bypass grafting. Such patients have an increased risk of adverse outcomes. Our aim was to quantify the effect of avoiding cardiopulmonary bypass in this group of patients.
Between April 1997 and March 2002, 3,771 consecutive patients underwent coronary artery bypass grafting performed by five surgeons. Four hundred and twenty-two (11.2%) had peripheral vascular disease and of these, 211 (50%) received off-pump surgery. We used multivariate logistic regression analysis to assess the effect of off-pump surgery on in-hospital mortality and morbidity, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score, which was the probability of receiving off-pump surgery and included core patient characteristics. The C statistic for this model was 0.8.
Off-pump patients were more likely to have preoperative renal dysfunction, previous gastrointestinal surgery, and less extensive disease. The left internal mammary artery was used more in off-pump compared to on-pump cases (90.1% vs 82.9%; p = 0.033). In the univariate analyses, off-pump patients were less likely to have a postoperative stroke (p = 0.007), and had shorter postoperative hospital stays (p < 0.001). However, the incidence of new atrial arrhythmia was higher (p = 0.028). After adjustment for differences in case-mix (propensity score), avoidance of cardiopulmonary bypass was still associated with a significant reduction in postoperative stroke (adjusted odds ratio 0.09 [95% confidence interval 0.02 to 0.50]; p = 0.005), and shorter postoperative hospital stay (p = 0.001).
Off-pump coronary surgery is safe in patients with peripheral vascular disease, with acceptable results. The incidence of postoperative stroke is substantially reduced when avoiding cardiopulmonary bypass in patients with peripheral vascular disease.
越来越多的外周血管疾病患者正在接受冠状动脉旁路移植术。这类患者出现不良结局的风险增加。我们的目的是量化在这组患者中避免体外循环的效果。
在1997年4月至2002年3月期间，连续3771例患者接受了由五位外科医生实施的冠状动脉旁路移植术。其中422例（11.2%）患有外周血管疾病，在这些患者中，211例（50%）接受了非体外循环手术。我们使用多因素逻辑回归分析来评估非体外循环手术对住院死亡率和发病率的影响，同时校正治疗选择偏倚。通过构建倾向评分来控制治疗选择偏倚，倾向评分是接受非体外循环手术的概率，包括患者的核心特征。该模型的C统计量为0.8。
非体外循环手术患者术前更可能存在肾功能不全、既往有胃肠道手术史且疾病范围较小。与体外循环手术相比，非体外循环手术更多地使用左乳内动脉（90.1%对82.9%；p = 0.033）。在单因素分析中，非体外循环手术患者术后发生卒中的可能性较小（p = 0.007），且术后住院时间较短（p < 0.001）。然而，新发房性心律失常的发生率较高（p = 0.028）。在对病例组合差异（倾向评分）进行校正后，避免体外循环仍与术后卒中显著减少相关（校正比值比0.09 [95%置信区间0.02至0.50]；p = 0.005），以及术后住院时间缩短相关（p = 0.001）。
对于外周血管疾病患者，非体外循环冠状动脉手术是安全的，结果可以接受。在外周血管疾病患者中避免体外循环时，术后卒中的发生率会大幅降低。
