游离内乳动脉旁路移植与原位内乳动脉旁路移植在疗效和移植物失败率方面的比较（来自 PREVENT IV 试验）。
Comparison of Outcomes and Frequency of Graft Failure With Use of Free Versus In Situ Internal Mammary Artery Bypass Conduits (from the PREVENT IV Trial).
机构信息
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina.
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina; WakeMed Clinical Research Institute, Raleigh, North Carolina.
出版信息
Am J Cardiol. 2019 Feb 15;123(4):571-575. doi: 10.1016/j.amjcard.2018.11.029. Epub 2018 Nov 24.
Although in situ internal mammary artery (is-IMA) grafting remains the most frequent conduit in coronary artery bypass grafting (CABG), circumstances may necessitate free grafting of the IMA (f-IMA), though differences in outcomes have not been fully characterized. The purpose of this study was to compare clinical and angiographic outcomes of is-IMA versus f-IMA coronary bypass grafts in patients who underwent elective CABG surgery. In 1,829 patients in the angiographic cohort of PREVENT IV, 1,572 (85.9%) had at least 1 IMA graft; of these, 34 (2.2%) patients had at least 1 f-IMA graft and 1,538 (97.8%) had at least 1 is-IMA graft without additional f-IMA grafts. Characteristics of patients, procedure, and grafts/targets were compared between cohorts. Primary endpoints included death, myocardial infarction, and revascularization, as well as incidence of graft failure (stenosis >75%) on angiography at 12-18 months postoperatively. Patients receiving is-IMA grafts were more often of white race and higher weight. Aortic cross-clamp time was shorter in the f-IMA cohort (39.5 vs 57.0 min, p = 0.04), but duration of bypass was similar (93.5 vs 100.0 minutes, p = 0.793). Of the in situ grafts, 97.3% were via the left internal mammary artery (LIMA), 86.6% were of good quality, and the left anterior descending (LAD) was bypassed in 88.2%. This compares with free grafts, which were via the LIMA in 68.0%, of good quality in 96.1%, and bypassed the LAD in 58.8% and first obtuse marginal (OM1) in 23.5%. Rates of death, myocardial infarction, and revascularization were similar between groups. The rate of graft failure was higher in f-IMA grafts (23.3%) compared with is-IMA grafts (8.5%; p < 0.01). Although clinical outcomes were similar with use of free versus in situ IMA grafts, higher rates of graft failure were encountered with use of the f-IMA graft. In conclusion, in situ grafts should be the preferred conduit for patients who undergo CABG surgery.
尽管原位内乳动脉（is-IMA）移植仍然是冠状动脉旁路移植术（CABG）中最常用的移植物，但在某些情况下可能需要游离内乳动脉（f-IMA）移植，尽管其结果差异尚未完全明确。本研究旨在比较接受择期 CABG 手术的患者中，IMA 原位与游离移植的临床和血管造影结果。在 PREVENT IV 的血管造影队列的 1829 例患者中，有 1572 例（85.9%）至少有 1 支 IMA 移植物；其中，34 例（2.2%）患者至少有 1 支游离 IMA 移植物，1538 例（97.8%）至少有 1 支 IMA 原位移植物，无额外的游离 IMA 移植物。比较两组患者的特征、手术和移植物/靶血管。主要终点包括死亡、心肌梗死和血运重建，以及术后 12-18 个月血管造影时的移植物失败（狭窄>75%）发生率。接受 IMA 移植物的患者更多为白种人和较高体重。游离 IMA 组的主动脉夹闭时间较短（39.5 分钟 vs 57.0 分钟，p = 0.04），但体外循环时间相似（93.5 分钟 vs 100.0 分钟，p = 0.793）。原位移植物中，97.3%为左内乳动脉（LIMA），86.6%为优质，88.2%旁路吻合左前降支（LAD）。相比之下，游离移植物中，68.0%通过 LIMA，96.1%为优质，58.8%旁路吻合 LAD，23.5%旁路吻合第一钝缘支（OM1）。两组之间的死亡率、心肌梗死和血运重建发生率相似。游离 IMA 移植物的移植物失败率（23.3%）高于原位 IMA 移植物（8.5%；p < 0.01）。尽管使用游离与原位 IMA 移植物的临床结果相似，但游离 IMA 移植物的移植物失败发生率较高。总之，在接受 CABG 手术的患者中，原位移植物应作为首选移植物。
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