Shilane D, Hlatky M A, Winkelmayer W C, Chang T I
Department of Health Research and Policy, Stanford University School of Medicine Palo Alto, CA, USA -
J Cardiovasc Surg (Torino). 2015 Jun;56(3):463-71. Epub 2013 Dec 17.
Patients with end-stage renal disease (ESRD) on maintenance dialysis have a high burden of coronary disease. Prior studies in non-dialysis patients show better outcomes in coronary artery bypass surgery using the internal mammary artery (IMA) compared with the saphenous vein graft (SVG), but less is known about outcomes in ESRD. We sought to compare the effectiveness of multivessel bypass grafting using IMA versus SVG in patients on maintenance dialysis in the United States.
Cohort study using data from the United States Renal Data System to examine IMA versus SVG in patients on maintenance dialysis undergoing multivessel coronary revascularization. We used Cox proportional hazards regression with multivariable adjustment in the full cohort and in a propensity-score matched cohort. The primary outcome was death from any cause; the secondary outcome was a composite of non-fatal myocardial infarction or death.
Overall survival rates were low in this patient population (5-year survival in the matched cohort 25.3%). Use of the IMA compared to SVG was associated with lower risk of death (adjusted hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.84-0.92) and lower risk of the composite outcome (adjusted HR 0.89; CI 0.85-0.93). Results did not materially change in analyses using the propensity-score matched cohort. We found similar results irrespective of patient sex, age, race, or the presence of diabetes, peripheral vascular disease or heart failure.
Although overall survival rates were low, IMA was associated with lower risk of mortality and cardiovascular morbidity compared to SVG in patients on dialysis.
维持性透析的终末期肾病（ESRD）患者冠心病负担较重。既往针对非透析患者的研究表明，与隐静脉移植血管（SVG）相比，使用乳内动脉（IMA）进行冠状动脉搭桥手术的效果更好，但关于ESRD患者的手术效果知之甚少。我们旨在比较在美国接受维持性透析的患者中，使用IMA与SVG进行多支血管搭桥移植的有效性。
采用队列研究，利用美国肾脏数据系统的数据，研究接受多支血管冠状动脉血运重建的维持性透析患者使用IMA与SVG的情况。我们在整个队列以及倾向评分匹配队列中使用Cox比例风险回归并进行多变量调整。主要结局是任何原因导致的死亡；次要结局是由非致命性心肌梗死或死亡组成的复合结局。
该患者群体的总体生存率较低（匹配队列中的5年生存率为25.3%）。与SVG相比，使用IMA与较低的死亡风险（调整后风险比[HR]0.88，95%置信区间[CI]0.84 - 0.92）和较低的复合结局风险（调整后HR 0.89；CI 0.85 - 0.93）相关。在使用倾向评分匹配队列的分析中，结果没有实质性变化。无论患者的性别、年龄、种族，或是否存在糖尿病、外周血管疾病或心力衰竭，我们都发现了相似的结果。
尽管总体生存率较低，但与SVG相比，IMA与透析患者较低的死亡风险和心血管疾病发病率相关。
