Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
Ann Thorac Surg. 2022 Aug;114(2):458-466. doi: 10.1016/j.athoracsur.2021.09.015. Epub 2021 Oct 20.
Although coronary artery bypass grafting using bilateral internal thoracic arteries (ITA) maximizes long-term survival, knowledge of the effect of different right ITA (RITA) inflow configurations on graft patency is limited. We have compared RITA occlusion among these configurations and identified its risk factors while adjusting for outflow coronary target location.
From January 1972 to January 2016, of 7092 patients undergoing bilateral ITA grafting at a single center, 1331 received one ITA to the left anterior descending coronary artery and had one or more evaluable postoperative coronary angiograms: 835 (63%) in situ, 496 free RITA grafts (311 [63%] originating from aorta; 98 [20%] left ITA [LITA], 76 [15%] saphenous vein graft, 11 [2%] radial graft). RITA occlusion reported on 1983 angiograms performed a median of 5.8 years later was estimated using nonlinear mixed-effects longitudinal modeling.
RITA patency was 90% at 1 year, 87% at 5 years, and 86% at 10 and 15 years. At 15 years, in situ RITA patency was 91% and free RITA patency from aorta was 91%, LITA 89%, and saphenous vein graft 77%. After adjusting for coronary target location and degree of stenosis, occlusion was similar in free RITAs from aorta (P = .15), LITA (P = .4), saphenous vein grafts (P = .13), and in situ RITAs. However, RITAs grafted to the left anterior descending coronary artery had fewer occlusions (P < .001), with patency similar to LITAs.
Among patients with bilateral ITA grafting requiring interval coronary angiography, long-term RITA patency was high and independent of its inflow configuration. Therefore, priority should be a RITA configuration optimizing its reach to important coronary targets, including the left anterior descending coronary artery.
尽管使用双侧内乳动脉（ITA）进行冠状动脉旁路移植术可以最大限度地提高长期生存率，但对于不同右内乳动脉（RITA）流入构型对移植物通畅性的影响知之甚少。我们比较了这些构型中的 RITA 闭塞情况，并在调整流出冠状动脉靶位的位置后确定了其危险因素。
1972 年 1 月至 2016 年 1 月，在一家中心接受双侧 ITA 移植术的 7092 例患者中，有 1331 例接受了一条 ITA 移植至左前降支，且有一条或多条可评估的术后冠状动脉造影：835 例（63%）原位，496 例游离 RITA 移植物（311 例[63%]起源于主动脉；98 例[20%]左 ITA [LITA]，76 例[15%]大隐静脉移植物，11 例[2%]桡动脉移植物）。1983 次造影中的 RITA 闭塞情况在中位数为 5.8 年后使用非线性混合效应纵向模型进行估计。
RITA 的通畅率在 1 年时为 90%，在 5 年时为 87%，在 10 年和 15 年时为 86%。15 年时，原位 RITA 通畅率为 91%，游离 RITA 通畅率来自主动脉为 91%，LITA 为 89%，大隐静脉移植物为 77%。在调整了冠状动脉靶位和狭窄程度后，游离 RITA 来自主动脉（P=0.15）、LITA（P=0.4）、大隐静脉移植物（P=0.13）和原位 RITA 的闭塞情况相似。然而，移植至左前降支的 RITA 闭塞较少（P<.001），通畅率与 LITA 相似。
在需要间隔冠状动脉造影的双侧 ITA 移植患者中，RITA 的长期通畅率较高且不受其流入构型的影响。因此，应优先考虑 RITA 构型，以优化其到达包括左前降支在内的重要冠状动脉靶位的能力。
