Dourado Luciana Oliveira Cascaes, Bittencourt Marcio Sommer, Pereira Alexandre Costa, Poppi Nilson Tavares, Dallan Luis Alberto Oliveira, Krieger José Eduardo, Cesar Luiz Antonio Machado, Gowdak Luís Henrique Wolff
Cardiopneumology department, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.
Division of Internal Medicine, Center for Clinical and Epidemiological Research, University Hospital, University of São Paulo, São Paulo, Brazil.
Thorac Cardiovasc Surg. 2018 Sep;66(6):477-482. doi: 10.1055/s-0037-1601306. Epub 2017 Mar 29.
Proper treatment of patients with diffuse, severe coronary artery disease (CAD) is a challenge due to its complexity. Thus, data on the outcomes after coronary artery bypass graft (CABG) in this population is scarce. In this study, we aimed to determine the impact of CABG on the clinical and functional status, as well as graft patency in those individuals.
Patients with severe and diffuse CAD who underwent incomplete CABG due to complex anatomy or extensive distal coronary involvement were evaluated preoperatively and 1 year after surgery. Postoperative coronary angiography was performed to evaluate graft patency. Graft occlusion was defined as the complete absence of opacification of the target vessel. Stratified analysis of graft occlusion was performed by graft type and territories, defined as left anterior descending artery (LAD), the left circumflex branch, and the right coronary artery territories; the latter two, grouped, were further classified as non-LAD territory.
A total of 57 patients were included, in whom 131 grafts were placed. There was a significant improvement in Canadian Cardiovascular Society angina symptom severity ( = -6.1; < 0.001) and maximum oxygen uptake ( < 0.001), with a corresponding decrease in the use of long-acting nitrates ( < 0.001). The overall graft occlusion rate was 19.1%, with no significant difference between LAD and non-LAD territories ( = 0.08). However, a significantly lower occlusion rate was noted for the internal mammary artery (IMA) grafts when compared with saphenous vein grafts ( = 0.01), though this difference was only significant in the LAD territory ( = 0.04). Overall, the use of venous graft was the only predictor occlusion at 1 year (odds ratio: 4.03; = 0.016).
In patients with diffuse CAD, incomplete CABG surgery resulted in a significant clinical improvement, with acceptable graft occlusion rates at 1 year, particularly for IMA grafts to the LAD territory.
由于弥漫性严重冠状动脉疾病（CAD）病情复杂，对其患者进行恰当治疗颇具挑战。因此，关于该人群冠状动脉旁路移植术（CABG）后结局的数据较为匮乏。在本研究中，我们旨在确定CABG对这些个体的临床及功能状态以及移植血管通畅情况的影响。
对因解剖结构复杂或冠状动脉远端广泛受累而接受不完全CABG的严重弥漫性CAD患者在术前及术后1年进行评估。术后进行冠状动脉造影以评估移植血管通畅情况。移植血管闭塞定义为目标血管完全不显影。按移植血管类型及区域进行移植血管闭塞的分层分析，区域定义为左前降支动脉（LAD）、左旋支及右冠状动脉区域；后两者合并后进一步分类为非LAD区域。
共纳入57例患者，置入了131条移植血管。加拿大心血管学会心绞痛症状严重程度（= -6.1；<0.001）及最大摄氧量（<0.001）有显著改善，长效硝酸盐类药物使用相应减少（<0.001）。总体移植血管闭塞率为19.1%，LAD区域与非LAD区域之间无显著差异（= 0.08）。然而，与大隐静脉移植血管相比，乳内动脉（IMA）移植血管的闭塞率显著更低（= 0.01），不过这种差异仅在LAD区域显著（= 0.04）。总体而言，静脉移植血管的使用是1年时移植血管闭塞的唯一预测因素（比值比：4.03；= 0.016）。
在弥漫性CAD患者中，不完全CABG手术带来了显著的临床改善，1年时移植血管闭塞率可接受，尤其是LAD区域的IMA移植血管。
