Garofalo Mariano, Nardi Paolo, Borioni Raoul, Del Giudice Costantino, Pellegrino Antonio, Chiariello Luigi
Università degli Studi Tor Vergata, Roma.
Ital Heart J Suppl. 2005 Jun;6(6):369-74.
Complications due to undetectable coronary artery disease are the major causes of morbidity and mortality in the surgical treatment of abdominal aortic aneurysm (AAA). The aim of our study was to evaluate the importance of significant coronary artery disease identification and the impact of coronary revascularization on early and late outcomes after surgical repair of AAA.
Between January 1994 and July 2004, 210 patients (204 males and 6 females, mean age 68 +/- 12 years) were candidates to elective surgical repair of AAA. Coronary angiography was performed in 122 patients (58%) in presence of angina symptoms, previous myocardial infarction, echocardiographic or scinti-scan evidence of myocardial ischemia. Coronary revascularization was performed in 83 patients (39.5%). The population was divided into two groups: coronary artery bypass graft/coronary angioplasty (CABG/PTCA) + AAA group (83 patients submitted to CABG surgery [n = 61], or PTCA [n = 22], for significant coronary artery disease before surgical repair of AAA), AAA group (127 patients without significant coronary artery disease, operated for AAA). Follow-up (90% complete) had a mean duration of 42 +/- 23 months.
CABG/PTCA + AAA group compared to AAA group presented major symptoms of angina (p = 0.001), higher incidence of previous myocardial infarction (67 vs 10%, p < 0.0001), lower mean value of left ventricular ejection fraction (50 vs 54%, p = 0.01). Operative mortality was 0.95%, and was not related to any cardiac morbidity: operative mortality was observed in the AAA group (2 patients died of anossic cerebral damage and respiratory failure) and was absent in the CABG/PTCA + AAA group (p = 0.8). The overall 8-year survival in the AAA group and in the CABG/PTCA + AAA group was 80 +/- 11 vs 95 +/- 2.8%, respectively (p = 0.7). Freedom from cardiac late death and freedom from cardiac events (recurrence of angina, myocardial infarction, congestive heart failure) were high in both groups (93 +/- 6.4 vs 97 +/- 2.3%, p = 0.6; and 91 +/- 6.6 vs 89 +/- 6.7%, p = 0.5, respectively). In the CABG/PTCA + AAA group symptoms for angina (p = 0.0002) and dyspnea (p < 0.0001) significantly improved during the follow-up.
Significant coronary artery disease was not negligible (39.5%) in patients candidates to surgical repair of AAA. Identification and correction of coronary artery disease prior to AAA surgery is the most important strategy to reduce the risk of vascular procedure. The beneficial impact of coronary revascularization on early and late outcomes is evident, in terms of satisfactory survival and freedom from cardiac adverse events. Therefore, coronary angiography is strongly suggested to optimize early and long-term results.
隐匿性冠状动脉疾病导致的并发症是腹主动脉瘤（AAA）手术治疗中发病和死亡的主要原因。我们研究的目的是评估识别显著冠状动脉疾病的重要性以及冠状动脉血运重建对AAA手术修复后早期和晚期结局的影响。
1994年1月至2004年7月期间，210例患者（204例男性和6例女性，平均年龄68±12岁）成为AAA择期手术修复的候选者。122例（58%）有胸痛症状、既往心肌梗死、超声心动图或心肌缺血闪烁扫描证据的患者接受了冠状动脉造影。83例（39.5%）患者进行了冠状动脉血运重建。将研究人群分为两组：冠状动脉旁路移植术/冠状动脉成形术（CABG/PTCA）+AAA组（83例患者在AAA手术修复前因显著冠状动脉疾病接受了CABG手术[n = 61]或PTCA[n = 22]），AAA组（127例无显著冠状动脉疾病的患者接受了AAA手术）。随访（90%完整）的平均持续时间为42±23个月。
与AAA组相比，CABG/PTCA+AAA组有更严重的胸痛症状（p = 0.001），既往心肌梗死的发生率更高（67%对10%，p < 0.0001），左心室射血分数的平均值更低（50%对54%，p = 0.01）。手术死亡率为0.95%，与任何心脏并发症均无关：AAA组观察到手术死亡（2例死于缺氧性脑损伤和呼吸衰竭），CABG/PTCA+AAA组无手术死亡（p = 0.8）。AAA组和CABG/PTCA+AAA组的总体8年生存率分别为80±11%和95±2.8%（p = 0.7）。两组的心脏晚期死亡自由度和心脏事件（心绞痛复发、心肌梗死、充血性心力衰竭）自由度均较高（分别为93±6.4%对97±2.3%，p = 0.6；以及91±6.6%对89±6.7%）。在CABG/PTCA+AAA组中，随访期间胸痛症状（p = 0.0002）和呼吸困难（p < 0.0001）显著改善。
对于AAA手术修复的候选患者，显著冠状动脉疾病不容忽视（39.5%）。在AAA手术前识别并纠正冠状动脉疾病是降低血管手术风险的最重要策略。就令人满意的生存率和无心脏不良事件而言，冠状动脉血运重建对早期和晚期结局的有益影响是明显的。因此，强烈建议进行冠状动脉造影以优化早期和长期结果。
