Lytle B W, Loop F D, Taylor P C, Goormastic M, Stewart R W, Novoa R, McCarthy P, Cosgrove D M
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, OH 44195.
J Thorac Cardiovasc Surg. 1993 Apr;105(4):605-12; discussion 612-4.
Does coronary artery reoperation improve the survival of patients with stenoses in saphenous vein bypass grafts to coronary arteries? To examine this question, we retrospectively reviewed 1117 patients who had coronary bypass grafting and then underwent a postoperative coronary angiogram that showed a stenosis (> or = 20%) of at least one vein graft. Reoperation within 1 month of the postoperative angiogram was performed for 394 patients (REOP group) whereas 723 patients (MED group) received initial medical treatment (no reoperation or percutaneous transluminal coronary angioplasty within 1 year). Compared with the MED group, patients in the REOP group were older, more symptomatic, more likely to have left main stenosis, and had fewer patent bypass grafts (all p < 0.001). In-hospital mortality for the REOP group was 4.3%. Mean postangiogram follow-up of the entire group was 73 months. On the basis of the interval between the primary operation and the postoperative angiogram, patients were designated as having early (< 5 years) or late (> or = 5 years) saphenous vein graft stenosis. Univariate and multivariate analyses were used to identify factors influencing the survival of these subgroups. Reoperation was not identified as a variable improving the survival of patients with early vein graft stenoses. For patients with late vein graft stenoses, moderate or severe impairment of left ventricular function (p < 0.0001), advanced age (p < 0.0001), triple-vessel or left main stenosis (p = 0.0011), and stenosis in a vein graft to the left anterior descending artery (p = 0.0019) decreased survival, whereas reoperation improved survival (p = 0.0007). The improvement in survival with reoperation was particularly strong for patients with a stenotic vein graft to the left anterior descending artery. For that subset, survival was 84% and 74% for the REOP group versus 76% and 53% for the MED group at 2 and 4 years after catheterization, respectively (p = 0.004). For patients with stenotic vein grafts to the right coronary artery or circumflex coronary artery (or both), survival was 92% and 87% for the REOP group versus 89% and 78% for the MED group at 2 and 4 years after catheterization, respectively (p = 0.13). Even for patients with class I or II symptoms, reoperation prolonged survival (p = 0.002 with multivariate testing). Reoperation improves the survival of patients with late vein graft stenoses, particularly those with stenotic grafts to the left anterior descending coronary artery.
冠状动脉再次手术能否提高冠状动脉大隐静脉旁路移植血管狭窄患者的生存率？为探讨这一问题，我们回顾性分析了1117例行冠状动脉旁路移植术且术后冠状动脉血管造影显示至少有一支静脉移植血管狭窄（≥20%）的患者。术后血管造影1个月内行再次手术的患者有394例（再次手术组），而723例患者（药物治疗组）接受初始药物治疗（1年内未再次手术或未行经皮冠状动脉腔内血管成形术）。与药物治疗组相比，再次手术组患者年龄更大、症状更多、更可能有左主干狭窄，且通畅的旁路移植血管更少（均p<0.001）。再次手术组的院内死亡率为4.3%。全组血管造影后的平均随访时间为73个月。根据初次手术与术后血管造影之间的间隔时间，患者被分为大隐静脉移植血管早期狭窄（<5年）或晚期狭窄（≥5年）。采用单因素和多因素分析来确定影响这些亚组患者生存的因素。再次手术未被确定为可改善早期静脉移植血管狭窄患者生存率的变量。对于晚期静脉移植血管狭窄患者，左心室功能中度或重度受损（p<0.0001）、高龄（p<0.0001）、三支血管或左主干狭窄（p=0.0011）以及左前降支静脉移植血管狭窄（p=0.0019）会降低生存率，而再次手术可提高生存率（p=0.0007）。对于左前降支有狭窄静脉移植血管的患者，再次手术对生存率的改善尤为显著。对于该亚组患者，导管插入术后2年和4年时，再次手术组的生存率分别为84%和74%，而药物治疗组分别为76%和53%（p=0.004）。对于右冠状动脉或左旋支冠状动脉（或两者）有狭窄静脉移植血管的患者，导管插入术后2年和4年时，再次手术组的生存率分别为92%和87%，而药物治疗组分别为89%和78%（p=0.13）。即使对于I级或II级症状的患者，再次手术也能延长生存期（多因素检验p=0.002）。再次手术可提高晚期静脉移植血管狭窄患者的生存率，尤其是那些左前降支冠状动脉有狭窄移植血管的患者。
