Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia; ; University of Melbourne, Melbourne, Victoria, Australia.
Ann Cardiothorac Surg. 2013 Jul;2(4):499-506. doi: 10.3978/j.issn.2225-319X.2013.07.02.
Graft patency determines prognosis in coronary artery bypass grafting (CABG). Numerous reports over the past 20 years have documented superior patencies and prognosis when multiple arterial grafts are used, yet less than 10% of CABG have multiple arterial grafts. Several conduits have been proposed, with varying degrees of success. Saphenous vein grafts (SVG) begin to fail with intimal hypertrophy and then atheroma after 5 years, with patency rates of 50% to 60% at 10 years, and <30% at 15 years. In contrast, left internal thoracic artery (LITA) patency is >95% at 10 years and >90% at 20 years. The radial artery is extremely versatile and can reach all territories, but is muscular and vulnerable to spasm and competitive flow. Similarly, the right gastroepiploic artery is also muscular, and is best suited to the posterior descending coronary artery, especially in reoperations and is also affected by competitive flow. In addition, bilateral internal thoracic artery grafting (BITA) grafts and total arterial revascularization (TACR) can be performed with identical perioperative mortality (1%) and perioperative morbidity to LITA + SVG. Importantly, survival is superior-85% to 90% at 10 years versus 75% to 80% respectively. BITA/TACR patients also suffer fewer late cardiac events and reoperations, with superior results for older patients, those requiring urgent surgery, diabetics, patients with renal dysfunction and in reoperations. Contraindications to BITA include obesity, insulin dependent diabetics, and severe chronic obstructive airways disease. As such, arterial grafts have better patencies and clinical results. BITA/TACR is often underutilized, but can be achieved in the majority of patients. Opportunities exist to enhance BITA/TACR use in CABG to the potential benefit of our patients.
移植通畅性决定了冠状动脉旁路移植术（CABG）的预后。在过去的 20 年中，有大量报告记录了使用多支动脉移植物时更好的通畅性和预后，但只有不到 10%的 CABG 使用了多支动脉移植物。已经提出了几种导管，成功率不同。大隐静脉移植物（SVG）在 5 年后开始出现内膜增生和动脉粥样硬化，10 年时通畅率为 50%至 60%，15 年时<30%。相比之下，左内乳动脉（LITA）的通畅率在 10 年时>95%，在 20 年时>90%。桡动脉非常灵活，可以到达所有区域，但它是肌肉性的，容易痉挛和发生竞争血流。同样，胃网膜右动脉也是肌肉性的，最适合后降支冠状动脉，尤其是在再次手术中，也受到竞争血流的影响。此外，双侧内乳动脉移植（BITA）和全动脉血运重建（TACR）可以在与 LITA+SVG 相同的围手术期死亡率（1%）和围手术期发病率下进行。重要的是，10 年生存率分别为 85%至 90%，优于 75%至 80%。BITA/TACR 患者的晚期心脏事件和再次手术也较少，对老年患者、需要紧急手术的患者、糖尿病患者、肾功能障碍患者和再次手术患者的效果更好。BITA 的禁忌症包括肥胖、依赖胰岛素的糖尿病患者和严重的慢性阻塞性气道疾病。因此，动脉移植物具有更好的通畅性和临床效果。BITA/TACR 未得到充分利用，但可在大多数患者中实现。有机会增加 CABG 中 BITA/TACR 的使用，为我们的患者带来潜在的益处。
