Kapetanakis Emmanouil I, Stamou Sotiris C, Dullum Mercedes K C, Hill Peter C, Haile Elizabeth, Boyce Steven W, Bafi Ammar S, Petro Kathleen R, Corso Paul J
Department of Surgery, Section of Cardiac Surgery, Washington Hospital Center, Washington, DC 20010-2975, USA.
Ann Thorac Surg. 2004 Nov;78(5):1564-71. doi: 10.1016/j.athoracsur.2004.05.019.
Cerebral embolization of atherosclerotic plaque debris caused by aortic manipulation during conventional coronary artery bypass grafting (CABG) is a major mechanism of postoperative cerebrovascular accidents (CVA). Off-pump CABG (OPCABG) reduces stroke rates by minimizing aortic manipulation. Consequently, the effect of different levels of aortic manipulation on neurologic outcomes after CABG surgery was examined.
From January 1998 to June 2002, 7,272 patients underwent isolated CABG surgery through three levels of aortic manipulation: full plus tangential (side-biting) aortic clamp application (on-pump surgery; n = 4,269), only tangential aortic clamp application (OPCABG surgery; n = 2,527) or an "aortic no-touch" technique (OPCABG surgery; n = 476). A risk-adjusted logistic regression analysis was performed to establish the likelihood of postoperative stroke with each technique. Preoperative risk factors for stroke from the literature, and those found significant in a univariable model were used.
A significant association for postoperative stroke correspondingly increasing with the extent of aortic manipulation was demonstrated by the univariable analysis (CVA incidence respectively increasing from 0.8% to 1.6% to a maximum of 2.2%, p < 0.01). In the logistic regression model, patients who had a full and a tangential aortic clamp applied were 1.8 times more likely to have a stroke versus those without any aortic manipulation (95% confidence interval: 1.15 to 2.74, p < 0.01) and 1.7 times more likely to develop a postoperative stroke than those with only a tangential aortic clamp applied (95% confidence interval: 1.11 to 2.48, p < 0.01).
Aortic manipulation during CABG is a contributing mechanism for postoperative stroke. The incidence of postoperative stroke increases with increased levels of aortic manipulation.
在传统冠状动脉旁路移植术（CABG）期间，主动脉操作导致动脉粥样硬化斑块碎片的脑栓塞是术后脑血管意外（CVA）的主要机制。非体外循环CABG（OPCABG）通过尽量减少主动脉操作来降低中风发生率。因此，研究了不同程度的主动脉操作对CABG手术后神经学结局的影响。
从1998年1月至2002年6月，7272例患者通过三种程度的主动脉操作接受了单纯CABG手术：完全加切线（侧咬）主动脉钳夹应用（体外循环手术；n = 4269）、仅切线主动脉钳夹应用（OPCABG手术；n = 2527）或“主动脉免接触”技术（OPCABG手术；n = 476）。进行风险调整的逻辑回归分析以确定每种技术术后中风的可能性。使用文献中报道的术前中风风险因素以及在单变量模型中发现有显著意义的因素。
单变量分析显示术后中风与主动脉操作程度相应增加之间存在显著关联（CVA发生率分别从0.8%增至1.6%，最高达2.2%，p < 0.01）。在逻辑回归模型中，应用完全和切线主动脉钳夹的患者发生中风的可能性是未进行任何主动脉操作患者的1.8倍（95%置信区间：1.15至2.74，p < 0.01），且比仅应用切线主动脉钳夹的患者发生术后中风的可能性高1.7倍（95%置信区间：1.11至2.48，p < 0.01）。
CABG期间的主动脉操作是术后中风的一个促成机制。术后中风的发生率随着主动脉操作程度的增加而升高。
