Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
J Thorac Cardiovasc Surg. 2013 Oct;146(4):894-900.e3. doi: 10.1016/j.jtcvs.2013.04.030. Epub 2013 Jun 29.
Restoring dual blood supply to transplanted lungs by bronchial artery revascularization (BAR) remains controversial. We compared outcomes after lung transplantation performed with and without BAR.
From December 2007 to July 2010, 283 patients underwent transplantation; 187 were 18 years or older, without previous or concomitant cardiac surgery. Of these patients, 27 underwent BAR in a pilot study to test success, safety, effectiveness, and teachability. A propensity score was generated to match BAR patients and 54 routine non-BAR patients. Follow-up was 1.3 ± 0.68 years.
BAR was angiographically successful in 26 (96%) of 27 patients. BAR and non-BAR patients had similar skin-to-skin time (P = .07) and postoperative hospital stays (P = .2), but more reoperations for bleeding (P = .002). Tracheostomy was performed in 9 (33%) of 27 BAR and 10 (19%) of 54 non-BAR patients (P = .2, log-rank). One BAR (3.7%) and 4 non-BAR (7.4%) patients required extracorporeal membrane oxygenation (P = .7). Airway ischemia was observed in 1 BAR (3.7%) versus 12 non-BAR (22%) patients (P = .03); anastomotic intervention was required in no BAR versus 8 non-BAR (15%) patients (P = .04). Hospital mortality was 1 of 27 versus 2 of 54 (P = .9). BAR patients had lower early biopsy tissue rejection grades (P = .008) and fewer pulmonary (P < .04) and bloodstream (P < .02) infections. Forced 1-second expiratory volume was similar (P > .2); 3 BAR versus 9 non-BAR patients developed bronchiolitis obliterans syndrome (BOS) (P = .14, log-rank). During follow-up, 4 BAR and 8 non-BAR patients died (P = .6, log-rank).
BAR is safe, with comparable early outcomes. Benefits of BAR include reduced airway ischemia and complications, lower biopsy tissue grades, fewer infections, and delay of BOS. A multicenter study is needed to establish these benefits.
通过支气管动脉血重建（BAR）恢复移植肺的双重血液供应仍然存在争议。我们比较了行和不行支气管动脉血重建的肺移植术后的结果。
2007 年 12 月至 2010 年 7 月，283 例患者接受了移植；187 例患者年龄在 18 岁或以上，无既往或同时心脏手术。其中 27 例在一项试验研究中进行了支气管动脉血重建，以测试其成功率、安全性、有效性和可教性。生成了一个倾向评分来匹配支气管动脉血重建患者和 54 例常规非支气管动脉血重建患者。随访时间为 1.3±0.68 年。
27 例患者中 26 例（96%）支气管动脉血重建成功。支气管动脉血重建组和非支气管动脉血重建组患者的皮肤至皮肤时间（P=0.07）和术后住院时间（P=0.2）相似，但支气管动脉血重建组因出血而需要再次手术的患者更多（P=0.002）。27 例支气管动脉血重建患者中有 9 例（33%）和 54 例非支气管动脉血重建患者中有 10 例（19%）行气管切开术（P=0.2，对数秩）。1 例支气管动脉血重建（3.7%）和 4 例非支气管动脉血重建（7.4%）患者需要体外膜肺氧合（P=0.7）。1 例支气管动脉血重建（3.7%）患者出现气道缺血，12 例非支气管动脉血重建（22%）患者出现气道缺血（P=0.03）；支气管动脉血重建组无一例患者需要吻合口干预，而非支气管动脉血重建组有 8 例（15%）患者需要吻合口干预（P=0.04）。支气管动脉血重建组 1 例（3.7%）患者和非支气管动脉血重建组 2 例（4.4%）患者需要体外心肺复苏（P=0.9）。支气管动脉血重建组患者早期活检组织排斥分级较低（P=0.008），肺部（P<0.04）和血流（P<0.02）感染较少。用力呼气一秒量（FEV1）相似（P>0.2）；支气管动脉血重建组有 3 例（11%）和非支气管动脉血重建组有 9 例（17%）发生闭塞性细支气管炎综合征（BOS）（P=0.14，对数秩）。在随访期间，支气管动脉血重建组有 4 例（15%）患者和非支气管动脉血重建组有 8 例（15%）患者死亡（P=0.6，对数秩）。
支气管动脉血重建是安全的，具有相似的早期结果。支气管动脉血重建的益处包括减少气道缺血和并发症、降低活检组织分级、减少感染和延迟发生闭塞性细支气管炎综合征。需要进行多中心研究来确定这些益处。
