Department of Internal Medicine and Outcomes Research Unit-Clinical Research Institute, American University of Beirut, Beirut, Lebanon;
Ann Cardiothorac Surg. 2013 Jul;2(4):453-7. doi: 10.3978/j.issn.2225-319X.2013.06.05.
Use of multiple arterial grafts for surgical coronary revascularization remains limited in scope worldwide, and is disproportionately low in two growing segments of coronary artery disease patients-women and the elderly. While a prevailing practice, this trend is not supported by objective data. This report discusses two recent reports that support the liberal use of the radial artery (RA) as a second arterial conduit, in the elderly and irrespective of sex, instead of the conventional operation based on a single internal thoracic artery (ITA) with additional vein grafts.
From 1996 to 2007, 6,384 patients underwent primary, non-salvage emergency coronary artery bypass grafting with at least 2 complete grafts (including one ITA graft) were included in the present analysis. Those with bilateral ITA, ITA-only grafts, or concomitant valve/aortic surgery were excluded. 2,605 patients aged 70 or greater were further included in a subsequent analysis. Patients were further matched on propensity score models based on ITA/RA versus ITA/saphenous vein (SV) grafts.
69% of all included patients were male. Propensity models yielded 1,416 ITA/RA and ITA/SV matched pairs in men and 567 pairs in women. Operative mortality was similar for both graft combinations in men and women, while late mortality was significantly lower for ITA/RA subcohorts in both sexes. Matched Kaplan-Meier cumulative mortality was significantly better for ITA/RA irrespective of sex (men: risk reduction (RR) =0.65, P<0.001; women: RR=0.75, P=0.045). In patients aged 70 years or older, operative death was essentially identical for ITA/RA vs. ITA/SV (2.31% vs. 2.31%; P=0.880). Patients undergoing ITA/RA grafting had significantly better unadjusted 12-year survival. In 480 elderly matched pairs, cumulative mortality at 1, 5, and 10 years was significantly better for the ITA/RA cohort.
The discussed data showed a clinically significant improvement in intermediate (1-5 years) and late (>5 years) survival with multiple arterial grafts in female and male patients and in the elderly. The latter was true for both the septuagenarian and octogenarian subgroups. Importantly, the choice of the RA as the second arterial conduit seems to be associated with low associated perioperative risks, and avoids the potential for sternal healing complications due to bilateral ITA dissection in certain patients.
在全球范围内，外科冠状动脉血运重建术使用多支动脉移植物的范围仍然有限，在女性和老年人这两个不断增长的冠心病患者群体中，使用量尤其低。尽管这是一种流行的做法，但这种趋势并没有客观数据支持。本报告讨论了最近的两份报告，这两份报告支持在老年患者中，无论性别如何，将桡动脉（RA）作为第二支动脉移植物自由使用，而不是基于单一内乳动脉（ITA）和额外的静脉移植物的传统手术。
从 1996 年到 2007 年，共有 6384 名患者接受了原发性、非抢救性紧急冠状动脉旁路移植术，至少有 2 个完整的移植物（包括 1 个 ITA 移植物）被纳入本分析。排除双侧 ITA、仅 ITA 移植物或同时行瓣膜/主动脉手术的患者。随后，在后续分析中进一步纳入了 2605 名年龄在 70 岁或以上的患者。根据 ITA/RA 与 ITA/隐静脉（SV）移植物，基于倾向评分模型对患者进行进一步匹配。
所有纳入患者中，69%为男性。倾向模型在男性中产生了 1416 对 ITA/RA 和 ITA/SV 匹配对，在女性中产生了 567 对。两种移植物组合的手术死亡率在男性和女性中相似，而在两性中，ITA/RA 亚组的晚期死亡率显著降低。在两性中，ITA/RA 亚组的匹配 Kaplan-Meier 累积死亡率显著更好（男性：风险降低（RR）=0.65，P<0.001；女性：RR=0.75，P=0.045）。在 70 岁或以上的患者中，ITA/RA 与 ITA/SV 的手术死亡率基本相同（2.31%比 2.31%；P=0.880）。接受 ITA/RA 移植的患者 12 年生存率显著提高。在 480 对年龄匹配的患者中，ITA/RA 组的 1 年、5 年和 10 年累积死亡率显著更好。
讨论的数据显示，女性和男性患者以及老年患者中，多支动脉移植物在中期（1-5 年）和晚期（>5 年）生存方面有明显的改善。对于 70 岁以上的患者和 80 岁以上的患者都是如此。重要的是，桡动脉作为第二支动脉移植物的选择似乎与围手术期的低风险相关，并且可以避免由于某些患者双侧 ITA 解剖导致胸骨愈合并发症的潜在风险。
