Soylu Erdinc, Harling Leanne, Ashrafian Hutan, Casula Roberto, Kokotsakis John, Athanasiou Thanos
Department of Surgery and Cancer, Imperial College London, London, UK.
Department of Surgery and Cancer, Imperial College London, London, UK
Interact Cardiovasc Thorac Surg. 2014 Sep;19(3):462-73. doi: 10.1093/icvts/ivu157. Epub 2014 Jun 3.
Coronary endarterectomy (CE) may provide a useful adjunct to coronary artery bypass grafting (CABG) in patients with extensive, diffuse coronary atheroma. However, concerns regarding its morbidity and mortality have created uncertainty as to the role of CE in the current era. The aim of this study was therefore to quantitatively summarize the short- and long-term outcomes of CE. Twenty observational studies were identified by systematic literature search, incorporating 54 440 patients (7366 CABG + CE; 47 074 CABG only), which were analysed using random-effects modelling. Heterogeneity, subgroup analysis, quality scoring and risk of bias were assessed. Primary end-points were 30-day mortality and perioperative and postoperative myocardial infarction (MI). Secondary end-points were postoperative morbidity, intensive care unit (ITU) stay, hospital stay and long-term graft patency. Adjunctive CE significantly increased 30-day mortality [odds ratios (OR) = 1.69, 95% confidence interval (CI) [1.49-1.92], P <0.00001], perioperative (OR = 2.10, 95% CI [1.82-2.43], P <0.00001) and postoperative MI (OR = 3.34, 95% CI [1.74-6.41], P = 0.0003) when compared with CABG alone. Furthermore, postoperative ventricular arrhythmias, pulmonary complications, renal failure and inotrope use were significantly greater in patients undergoing adjunct CE. CE also increased ITU and hospital stay and reduced angiographic patency at the last follow-up (OR = 0.57, 95% CI [0.36-0.88]). Increased 30-day morbidity and mortality continues to raise concerns over the safety of adjunct CE. Furthermore, the procedure can be associated with worse long-term graft patency. To better determine whether CE should remain a viable adjunct to CABG, novel studies must focus on collecting prospective data with homogeneous inclusion criteria for CE as well as isolating outcomes for different coronary vessels and standardizing postoperative anticoagulation.
对于患有广泛弥漫性冠状动脉粥样硬化的患者，冠状动脉内膜切除术（CE）可能是冠状动脉旁路移植术（CABG）的一种有用辅助手段。然而，对其发病率和死亡率的担忧使得CE在当前时代的作用存在不确定性。因此，本研究的目的是定量总结CE的短期和长期结果。通过系统的文献检索确定了20项观察性研究，纳入了54440例患者（7366例行CABG + CE；47074例仅行CABG），并使用随机效应模型进行分析。评估了异质性、亚组分析、质量评分和偏倚风险。主要终点为30天死亡率、围手术期和术后心肌梗死（MI）。次要终点为术后发病率、重症监护病房（ITU）住院时间、住院时间和长期移植物通畅率。与单纯CABG相比，辅助性CE显著增加了30天死亡率[比值比（OR）= 1.69，95%置信区间（CI）[1.49 - 1.92]，P <0.00001]、围手术期（OR = 2.10，95% CI [1.82 - 2.43]，P <0.00001）和术后MI（OR = 3.34，95% CI [1.74 - 6.41]，P = 0.0003）。此外，接受辅助性CE的患者术后室性心律失常、肺部并发症、肾衰竭和使用血管活性药物的情况也显著更多。CE还增加了ITU和住院时间，并降低了最后一次随访时的血管造影通畅率（OR = 0.57，95% CI [0.36 - 0.88]）。30天发病率和死亡率的增加继续引发对辅助性CE安全性的担忧。此外，该手术可能与更差的长期移植物通畅率相关。为了更好地确定CE是否应继续作为CABG的可行辅助手段，新的研究必须专注于收集具有统一纳入标准的前瞻性数据，以及分离不同冠状动脉血管的结果并规范术后抗凝。
