基于桡动脉的多动脉冠状动脉旁路移植术的有效性：体型的作用。
Effectiveness of radial artery-based multiarterial coronary artery bypass grafting: Role of body habitus.
机构信息
Department of Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio; Mercy Saint Vincent Medical Center, Toledo, Ohio.
Department of Internal Medicine, Outcomes Research Unit, American University of Beirut, Beirut, Lebanon.
出版信息
J Thorac Cardiovasc Surg. 2018 Jul;156(1):43-51.e2. doi: 10.1016/j.jtcvs.2018.02.085. Epub 2018 Mar 11.
BACKGROUND
The multiarterial grafting survival advantage noted in the overall population undergoing coronary artery bypass grafting is not well defined in the obese. We investigated the early to late survival effects of the radial artery in left internal thoracic artery-based multiarterial bypass grafting (radial artery-multiarterial bypass grafting) versus single arterial bypass grafting (left internal thoracic artery-single arterial bypass grafting) in obese patients.
METHODS
We analyzed 15-year Kaplan-Meier survival in 6102 patients receiving primary, left internal thoracic artery-based coronary artery bypass grafting with 2 or more grafts divided into body mass index groups: nonobese (<30 kg/m) and all-obese, comprised of mildly obese (30-35 kg/m) and morbidly obese (>35 kg/m). Risk-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of radial artery-multiarterial bypass grafting versus left internal thoracic artery-single arterial bypass grafting were derived via Cox regression and applied separately for early (<0.5 years), intermediate (0.5-5 years), and late (5-15 years) follow-up in each body mass index cohort. Propensity score matching between radial artery-multiarterial bypass grafting and left internal thoracic artery-single arterial bypass grafting cohorts within the body mass index groups was performed as a corroborating analysis.
RESULTS
Radial artery-multiarterial bypass grafting was more frequently used in obese patients who were younger (62 ± 10 years; mild/morbid: 45.4%/54.4% radial artery-multiarterial bypass grafting) compared with nonobese patients (66 ± 10 years; 37.4% radial artery-multiarterial bypass grafting). Unadjusted 15-year survival was significantly better for radial artery-multiarterial bypass grafting in all body mass index groups. Multivariate analysis showed a survival benefit of radial artery-multiarterial bypass grafting over the entire 0- to 15-year study period in the all-obese cohort (HR, 0.85; 95% CI, 0.74-0.98) and was more pronounced in the mildly obese (HR, 0.79; 95% CI, 0.66-0.96) versus morbidly obese (HR, 0.88; 95% CI, 0.69-1.13). The radial artery-multiarterial bypass grafting survival benefit was realized between 0.5 and 5 years postoperatively and was comparable for all-obese (HR, 0.69; 95% CI, 0.51-0.94) and nonobese (HR, 0.68; 95% CI, 0.52-0.88) groups. Propensity score matching was confirmatory.
CONCLUSIONS
Radial artery-multiarterial bypass grafting confers a long-term survival advantage in both obese and nonobese patients.
背景
在接受冠状动脉旁路移植术的整体人群中，多动脉吻合的生存优势已得到证实，但在肥胖患者中尚未明确。我们研究了桡动脉在左胸廓内动脉为基础的多动脉旁路移植术（桡动脉-多动脉旁路移植术）与单一动脉旁路移植术（左胸廓内动脉-单一动脉旁路移植术）在肥胖患者中的早期至晚期生存效果。
方法
我们分析了 6102 例接受原发性、以左胸廓内动脉为基础的、有 2 个或更多移植物的冠状动脉旁路移植术患者的 15 年 Kaplan-Meier 生存情况，这些患者被分为体重指数组：非肥胖组（<30kg/m）和所有肥胖组，包括轻度肥胖组（30-35kg/m）和病态肥胖组（>35kg/m）。通过 Cox 回归得出桡动脉-多动脉旁路移植术与左胸廓内动脉-单一动脉旁路移植术的风险调整后的危险比（HR）和 95%置信区间（CI），并分别应用于每个体重指数队列的早期（<0.5 年）、中期（0.5-5 年）和晚期（5-15 年）随访。在体重指数组内，对桡动脉-多动脉旁路移植术和左胸廓内动脉-单一动脉旁路移植术队列进行倾向评分匹配，作为佐证分析。
结果
与非肥胖患者（66±10 岁；桡动脉-多动脉旁路移植术 37.4%）相比，桡动脉-多动脉旁路移植术在肥胖患者中更为常见，这些患者年龄更小（62±10 岁；轻度/病态肥胖：45.4%/54.4%桡动脉-多动脉旁路移植术）。未调整的 15 年生存率在所有体重指数组中，桡动脉-多动脉旁路移植术明显更高。多变量分析显示，在整个 0 至 15 年的研究期间，桡动脉-多动脉旁路移植术在所有肥胖患者队列中具有生存优势（HR，0.85；95%CI，0.74-0.98），在轻度肥胖患者中更为显著（HR，0.79；95%CI，0.66-0.96），而在病态肥胖患者中则不明显（HR，0.88；95%CI，0.69-1.13）。桡动脉-多动脉旁路移植术的生存获益在术后 0.5 年至 5 年之间实现，且在肥胖和非肥胖患者中相似（肥胖患者 HR，0.69；95%CI，0.51-0.94；非肥胖患者 HR，0.68；95%CI，0.52-0.88）。倾向评分匹配是验证性的。
结论
桡动脉-多动脉旁路移植术在肥胖和非肥胖患者中均具有长期生存优势。
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