Subramanian Sreekumar, Sabik Joseph F, Houghtaling Penny L, Nowicki Edward R, Blackstone Eugene H, Lytle Bruce W
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
Ann Thorac Surg. 2009 May;87(5):1392-8; discussion 1400. doi: 10.1016/j.athoracsur.2009.02.032.
It is unknown whether coronary reintervention confers a survival advantage when a previously placed left internal thoracic artery graft to the left anterior descending coronary artery (LAD) is patent. We compared survival after medical therapy, percutaneous intervention, and reoperative coronary artery bypass grafting in such patients who developed non-LAD territory jeopardy.
From 1971 to 2000, 4,640 patients with prior coronary artery bypass grafting that included left internal thoracic artery to LAD grafting were found on angiography during active follow-up to have a patent left internal thoracic artery to LAD graft, but at least 50% stenosis of non-LAD territories or grafts to them. Two survival analyses were performed: (1) intent-to-treat, which included patients undergoing reoperative coronary artery bypass grafting (n = 731) or percutaneous intervention (n = 994) within 6 weeks of angiography or medical management (n = 2,782), and (2) competing risk/crossover, in which patients were classified as medically managed until crossover to coronary artery bypass grafting or percutaneous intervention.
In the intent-to-treat analysis, propensity-adjusted early (<1 year) survival was similar for all patients, but late survival was slightly better after percutaneous intervention than with medical management (p < or = 0.05). In the competing risk/crossover analysis, adjusted survival was best for medically treated patients early; however, late survival was similar among all three groups.
Patients with patent left internal thoracic artery to LAD grafts who develop non-LAD territory jeopardy derive no survival benefit from reintervention, consistent with previous observations that for coronary reintervention to improve survival, the LAD territory must be jeopardized. Reintervention in patients with a patent left internal thoracic artery to LAD graft may be warranted to relieve symptoms, without expecting a survival benefit.
对于先前植入的左乳内动脉至左前降支冠状动脉（LAD）的移植血管通畅时，冠状动脉再次干预是否能带来生存获益尚不清楚。我们比较了此类出现非LAD区域危险的患者接受药物治疗、经皮介入治疗和再次冠状动脉搭桥手术后的生存率。
1971年至2000年期间，在积极随访的血管造影检查中发现，4640例曾接受冠状动脉搭桥手术（包括左乳内动脉至LAD移植）的患者，其左乳内动脉至LAD的移植血管通畅，但非LAD区域或其移植血管至少有50%的狭窄。进行了两项生存分析：（1）意向性治疗分析，包括在血管造影后6周内接受再次冠状动脉搭桥手术（n = 731）或经皮介入治疗（n = 994）或药物治疗（n = 2782）的患者；（2）竞争风险/交叉分析，其中患者在转为冠状动脉搭桥手术或经皮介入治疗之前被归类为接受药物治疗。
在意向性治疗分析中，所有患者经倾向调整后的早期（<1年）生存率相似，但经皮介入治疗后的晚期生存率略高于药物治疗（p≤0.05）。在竞争风险/交叉分析中，早期接受药物治疗的患者调整后的生存率最佳；然而，晚期三组患者的生存率相似。
左乳内动脉至LAD移植血管通畅且出现非LAD区域危险的患者，再次干预并不能带来生存获益，这与之前的观察结果一致，即冠状动脉再次干预要改善生存，LAD区域必须受到威胁。对于左乳内动脉至LAD移植血管通畅的患者，再次干预可能有助于缓解症状，但不应期望能带来生存获益。
