Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, NY.
Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, NY.
J Thorac Cardiovasc Surg. 2014 Jan;147(1):163-8. doi: 10.1016/j.jtcvs.2013.09.008. Epub 2013 Oct 28.
Current guidelines have recommended against coronary revascularization before noncardiac surgery in patients with asymptomatic coronary artery disease. However, myocardial infarction after thoracic aneurysm (TA) repair dramatically increases the morbidity and mortality. Revascularization with coronary artery bypass grafting before TA repair minimizes the incidence of perioperative ischemia. However, the recovery can be prolonged, and a percentage of patients will either never return for aneurysm repair or will develop a rupture during convalescence. Percutaneous coronary intervention (PCI) before TA repair might be preferable. Previous studies examining PCI before major vascular surgery included few patients with TAs. We examined the outcomes of patients undergoing PCI before TA repair.
From 1997 to 2012, 592 patients underwent TA repair. Patients presenting for elective repair underwent cardiac catheterization before surgery. Those with significant single- or double-vessel coronary artery disease underwent PCI. The perioperative outcomes were examined and compared with those of patients undergoing TA repair without revascularization.
A total of 44 patients (7.4%) underwent PCI with bare metal stents before surgery. No PCI-related complications occurred. Dual antiplatelet therapy was administered for 4 to 6 weeks. No instances of aneurysm rupture occurred in the interval between PCI and surgery. The incidence of stent thrombosis, myocardial infarction, and mortality for those undergoing PCI was 0. No bleeding complications occurred.
PCI is safe and efficacious in patients undergoing TA repair. Aneurysm rupture did not occur in the interval before surgery. Antiplatelet therapy did not increase the risk of bleeding complications. Stent thrombosis was not seen. We recommend PCI those with significant single- or double-vessel coronary artery disease before elective TA repair.
目前的指南建议在无症状性冠状动脉疾病患者中非心脏手术前避免进行冠状动脉血运重建。然而，胸主动脉瘤（TA）修复后的心肌梗死显著增加了发病率和死亡率。在修复 TA 之前进行冠状动脉旁路移植术（CABG）血运重建可最大限度地减少围手术期缺血的发生。然而，恢复可能会延长，一部分患者将永远不会返回进行动脉瘤修复，或者在康复期间会发生破裂。在修复 TA 之前进行经皮冠状动脉介入治疗（PCI）可能更为可取。以前研究过在大血管手术前进行 PCI 的研究中，TA 患者较少。我们检查了在修复 TA 之前进行 PCI 的患者的结局。
从 1997 年到 2012 年，592 例患者接受了 TA 修复。择期修复的患者在手术前行心脏导管检查。有明显单支或双支冠状动脉疾病的患者进行 PCI。检查并比较了接受血运重建与未接受血运重建的 TA 修复患者的围手术期结局。
共有 44 例患者（7.4%）在手术前行 PCI 置入裸金属支架。无 PCI 相关并发症发生。给予双联抗血小板治疗 4-6 周。在 PCI 和手术之间，未发生动脉瘤破裂。行 PCI 的患者发生支架血栓形成、心肌梗死和死亡率为 0%。未发生出血并发症。
在接受 TA 修复的患者中，PCI 是安全有效的。在手术前的间隔期间未发生动脉瘤破裂。抗血小板治疗并未增加出血并发症的风险。未观察到支架血栓形成。我们建议对有明显单支或双支冠状动脉疾病的患者在择期 TA 修复前进行 PCI。
