Zacharias Anoar, Schwann Thomas A, Riordan Christopher J, Durham Samuel J, Shah Aamir S, Habib Robert H
Yvonne Viens, SGM, Research Institute, Saint Vincent Mercy Medical Center, Toledo, Ohio 43608, USA.
Ann Thorac Surg. 2009 Jan;87(1):19-26.e2. doi: 10.1016/j.athoracsur.2008.09.050.
Use of one or more arterial grafts to revascularize two-vessel and three-vessel coronary artery disease has been shown to improve coronary artery bypass graft surgery (CABG) survival. Yet, the presumed long-term survival benefits of all-arterial CABG have not been quantified.
We compared propensity-adjusted 12-year survival in two contemporaneous multivessel primary CABG cohorts with all patients receiving 2 or more grafts: (1) all-arterial cohort (n = 612; 297 three-vessel disease [49%]); and (2) single internal thoracic artery (ITA) plus saphenous vein (SV) cohort (n = 4,131; 3,187 three-vessel disease [77%]).
Early (30-day) deaths were similar for the all-arterial and ITA/SV cohorts (8 [1.30%] versus 69 [1.67%]) whereas late mortality was substantially greater for the ITA/SV cohort (85 [13.9%] versus 1,216 [29.4%]; p < 0.0001). The risk-adjusted 12-year survival was significantly better for all-arterial (with a risk ratio [RR] = 0.60; 95% confidence interval [CI]: 0.48 to 0.75; p < 0.001), but this benefit was true only for three-vessel disease (RR = 0.58; 95% CI: 0.43 to 0.78; p < 0.001) and not for two-vessel disease (RR = 0.97; 95% CI: 0.66 to 1.43; p = 0.89). The all-arterial survival benefit was also true for varying risk subcohorts: no diabetes mellitus (RR = 0.50; 95% CI: 0.37 to 0.69), diabetes mellitus (RR = 0.77; 95% CI: 0.56 to 1.07), ejection fraction 40% or greater (RR = 0.60; 95% CI: 0.45 to 0.78), and ejection fraction less than 40% (RR = 0.62; 95% CI: 0.40 to 0.98). Lastly, the multivariate analysis indicated a strong long-term effect of completeness of revascularization, particularly for all-arterial patients, so that compared with patients with two grafts, survival was significantly better when three grafts (RR = 0.54; 95% CI: 0.33 to 0.87) or four grafts (RR = 0.40; 95% CI: 0.21 to 0.76) were completed.
All-arterial revascularization is associated with significantly better 12-year survival compared with the standard single ITA with saphenous vein CABG operation, in particular for triple-vessel disease patients. The completeness of revascularization of the underlying coronary disease is critical for maximizing the long-term benefits of arterial-only grafting.
使用一根或多根动脉移植物对双支和三支冠状动脉疾病进行血运重建已被证明可提高冠状动脉旁路移植术（CABG）的生存率。然而，全动脉CABG假定的长期生存益处尚未得到量化。
我们比较了两个同期多支血管原发性CABG队列中倾向调整后的12年生存率，所有患者均接受了2根或更多移植物：（1）全动脉队列（n = 612；297例三支血管疾病[49%]）；以及（2）单根胸廓内动脉（ITA）加隐静脉（SV）队列（n = 4131；3187例三支血管疾病[77%]）。
全动脉队列和ITA/SV队列的早期（30天）死亡率相似（8例[1.30%]对69例[1.67%]），而ITA/SV队列的晚期死亡率则显著更高（85例[13.9%]对1216例[29.4%]；p < 0.0001）。全动脉组的风险调整后12年生存率显著更好（风险比[RR] = 0.60；95%置信区间[CI]：0.48至0.75；p < 0.001），但这种益处仅适用于三支血管疾病（RR = 0.58；95%CI：0.43至0.78；p < 0.001），不适用于双支血管疾病（RR = 0.97；95%CI：0.66至1.43；p = 0.89）。全动脉生存益处对于不同风险亚组也成立：无糖尿病（RR = 0.50；95%CI：0.37至0.69）、糖尿病（RR = 0.77；95%CI：0.56至1.07）、射血分数40%或更高（RR = 0.60；95%CI：0.45至0.78）以及射血分数低于40%（RR = 0.62；95%CI：0.40至0.98）。最后，多变量分析表明血运重建完整性具有强大的长期影响，特别是对于全动脉患者，因此与接受2根移植物的患者相比，完成3根移植物（RR = 0.54；95%CI：0.33至0.87）或4根移植物（RR = 0.40；95%CI：0.21至0.76）时生存率显著更好。
与标准的单根ITA加隐静脉CABG手术相比，全动脉血运重建与显著更好的12年生存率相关，特别是对于三支血管疾病患者。基础冠状动脉疾病血运重建的完整性对于最大化仅使用动脉移植物的长期益处至关重要。
