Dietl C A, Benoit C H, Gilbert C L, Woods E L, Pharr W F, Berkheimer M D, Madigan N P, Menapace F J
Department of Cardiovascular Surgery, Geisinger Medical Center, Danville, Pa 17822-1343, USA.
Circulation. 1995 Nov 1;92(9 Suppl):II92-7. doi: 10.1161/01.cir.92.9.92.
The graft of choice for the left anterior descending coronary artery is the left internal mammary artery because of superior long-term patency. However, controversy exists regarding the graft of choice for the right coronary artery and for the posterior descending branch.
Two types of pedicled arterial grafts were used for the right coronary and the posterior descending arteries in patients undergoing coronary bypass surgery between January 1991 and September 1994. Group A comprised 114 patients with a right internal mammary artery (RIMA) graft, and group B consisted of 127 patients with an in situ right gastroepiploic artery (R-GEA) graft. Mean age was 56.9 years in group A and 63.3 years in group B; 7.9% (9 of 114) and 33.9% (43 of 127) were diabetics in groups A and B, respectively. Overall mortality was 2.6% (3 deaths) for group A and 3.9% (5 deaths) for group B (P = NS). However, the prevalence of perioperative myocardial infarction in the right coronary artery distribution was significantly higher for group A (5.3%, or 6 of 114) than for group B (0.8%, or 1 of 127; P < .05), and the reoperation rate for graft failure (from 0 to 12 months after surgery) was significantly higher for the RIMA (4.4%, or 5 of 114) than for the R-GEA (0%; P < .05). Also, the prevalence of deep sternal wound infection in diabetics was significantly higher in group A (22.2%, or 2 of 9) than in group B (4.6%, or 2 of 43; P < .05).
Our preliminary results suggest that the failure rate of the RIMA graft is significantly higher, especially if used as a pedicled graft to the posterior descending artery. The risk of sternal wound complications is greater in diabetics if both internal mammary arteries are used for grafting. Therefore, the R-GEA graft is preferred in diabetics and whenever the posterior descending artery is the target vessel.
由于长期通畅率较高，左前降支冠状动脉的首选移植血管是左乳内动脉。然而，对于右冠状动脉和后降支的首选移植血管存在争议。
1991年1月至1994年9月期间，在接受冠状动脉搭桥手术的患者中，两种带蒂动脉移植血管被用于右冠状动脉和后降支。A组包括114例行右乳内动脉（RIMA）移植的患者，B组由127例行原位右胃网膜动脉（R-GEA）移植的患者组成。A组平均年龄为56.9岁，B组为63.3岁；A组和B组的糖尿病患者分别占7.9%（114例中的9例）和33.9%（127例中的43例）。A组总死亡率为2.6%（3例死亡），B组为3.9%（5例死亡）（P=无显著性差异）。然而，A组右冠状动脉分布区域围手术期心肌梗死的发生率（5.3%，即114例中的6例）显著高于B组（0.8%，即127例中的1例；P<.05），且RIMA移植血管失败（术后0至12个月）的再次手术率（4.4%，即114例中的5例）显著高于R-GEA（0%；P<.05）。此外，糖尿病患者中A组深部胸骨伤口感染的发生率（22.2%，即9例中的2例）显著高于B组（4.6%，即43例中的2例；P<.05）。
我们的初步结果表明，RIMA移植血管的失败率显著更高，特别是当用作后降支的带蒂移植血管时。如果双侧乳内动脉都用于移植，糖尿病患者发生胸骨伤口并发症的风险更大。因此，在糖尿病患者以及后降支为目标血管时，R-GEA移植血管是更优选择。
