Chang Hyoung Woo, Han Hyun Jeong, Park Kay-Hyun
Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea.
J Thorac Dis. 2022 Jun;14(6):1909-1921. doi: 10.21037/jtd-21-1731.
Bilateral internal thoracic artery Y-composite grafting with sequential anastomoses is a well-established strategy for multi-arterial coronary artery bypass grafting. This study investigated the factors affecting long-term patency of bilateral internal thoracic artery Y-composite grafts and their influence on survival.
Patients who underwent coronary artery bypass grafting using bilateral internal thoracic artery Y-composite grafts due to triple-vessel disease were included. In total, 415 cases (2003-2020) with at least 1 postoperative coronary computed tomography or angiography examination were enrolled. Through a retrospective review of medical records and computed tomography, risk factors for graft events (string sign or occlusion) were analysed, and the influence of string sign or occlusion in the initial postoperative computed tomography on long-term survival was evaluated.
Patients' mean age was 66±9 years and 324 were male (78%). The mean number of anastomoses from bilateral internal thoracic artery grafts was 4.0±0.9. The mean follow-up duration was 8.0±4.0 years (interquartile range: 4.8-11.5 years). Beating-heart surgery negatively affected the patency of grafts to the left circumflex and right coronary artery territories (P=0.015 and P=0.030, respectively), but in the left anterior descending territory, the graft patency did not differ (P=0.053). Non-severe (<90%) native-vessel stenosis was a risk factor for poor patency in the left anterior descending, left circumflex, and right coronary artery territories (P<0.001 for all). Twenty-four of the 104 nonvisible or narrowed grafts (23%) on early imaging later became widely patent. Occlusion of the grafts or the string sign within postoperative 1 year did not have a negative impact on long-term survival (P=0.421).
The patency rate was suboptimal in case of non-severe target-vessel stenosis (<90%). The beating-heart technique may negatively influence the patency of anastomoses to the left circumflex and right coronary artery territories. Compromised graft patency observed on initial computed tomography did not lead to worse survival.
双侧胸廓内动脉Y形复合移植并序贯吻合是多支冠状动脉旁路移植的成熟策略。本研究调查了影响双侧胸廓内动脉Y形复合移植长期通畅的因素及其对生存的影响。
纳入因三支血管病变接受双侧胸廓内动脉Y形复合移植冠状动脉旁路移植术的患者。总共纳入415例（2003年至2020年）术后至少进行过一次冠状动脉计算机断层扫描或血管造影检查的病例。通过回顾病历和计算机断层扫描，分析移植血管事件（线样征或闭塞）的危险因素，并评估术后早期计算机断层扫描中线样征或闭塞对长期生存的影响。
患者的平均年龄为66±9岁，男性324例（78%）。双侧胸廓内动脉移植的平均吻合口数量为4.0±0.9个。平均随访时间为8.0±4.0年（四分位间距：4.8 - 11.5年）。心脏不停跳手术对左旋支和右冠状动脉区域的移植血管通畅有负面影响（分别为P = 0.015和P = 0.030），但在前降支区域，移植血管通畅情况无差异（P = 0.053）。非严重（<90%）的自身血管狭窄是前降支、左旋支和右冠状动脉区域移植血管通畅不良的危险因素（均P<0.001）。早期影像学上104例不可见或狭窄的移植血管中有24例（23%）后来变得广泛通畅。术后1年内移植血管闭塞或线样征对长期生存没有负面影响（P = 0.421）。
在非严重的靶血管狭窄（<90%）情况下，通畅率不理想。心脏不停跳技术可能对左旋支和右冠状动脉区域的吻合口通畅有负面影响。初始计算机断层扫描中观察到的移植血管通畅受损并未导致更差的生存情况。
