Carrel T, Horber P, Turina M I
Clinic for Cardiovascular Surgery, University Hospital, Zürich, Switzerland.
Ann Thorac Surg. 1996 Nov;62(5):1289-94. doi: 10.1016/0003-4975(96)00627-3.
Several studies have demonstrated that single internal thoracic artery (ITA) grafting achieves better results than the use of vein grafts alone, but it is less clear whether bilateral ITA grafting produces better long-term results than a single ITA graft to the left descending coronary artery does.
We analyzed the early and midterm results of the surgical treatment of two-vessel coronary artery disease (left anterior descending artery and right coronary artery) in two groups of 80 consecutive patients operated on between 1985 and 1989 who received either a bilateral ITA graft or a unilateral ITA graft combined with a saphenous vein graft. Patients were selected from a data base so as to be rigorously matched for demographic and clinical factors as well as angiographic variables, with the researcher being blinded to any additional intraoperative or postoperative data. Follow-up examination was performed after a mean postoperative interval of 8 years.
Univariate analysis showed a somewhat higher incidence of sternal complications in the bilateral ITA group (4.8% versus 1.2%; p < 0.02) and a significantly lower reintervention-free survival at 8 years in the group of patients who received a unilateral ITA and saphenous vein graft (84% +/- 5.5% versus 95% +/- 1.5%; p < 0.02). The latter was predominantly due to the development of significant main stem lesions necessitating a redo procedure during the follow-up interval or to the need for percutaneous coronary angioplasty of circumflex artery lesions that were not critical at the time of the initial operation. Perioperative risk was similar in both groups of patients. Old age and a history of congestive heart failure were the most important predictors of perioperative mortality and morbidity for patients receiving bilateral ITAs. Multivariate analysis did not demonstrate any benefit from bilateral arterial grafting over unilateral ITA bypass combined with saphenous vein grafting in terms of overall survival and event-free and intervention-free survival.
Although bilateral ITA grafting can be performed with a perioperative risk comparable with that for unilateral ITA and saphenous vein grafting, long-term results (up to 8 years) of surgically treated two-vessel coronary artery disease are not improved by bilateral ITA grafting.
多项研究表明，单支胸廓内动脉（ITA）移植的效果优于单纯使用静脉移植，但双侧ITA移植的长期效果是否优于单支ITA移植至左冠状动脉前降支尚不清楚。
我们分析了1985年至1989年间连续接受手术治疗的两组各80例双支冠状动脉疾病（左前降支和右冠状动脉）患者的早期和中期结果，这两组患者分别接受双侧ITA移植或单侧ITA移植联合大隐静脉移植。从数据库中选择患者，以便在人口统计学、临床因素以及血管造影变量方面进行严格匹配，研究人员对任何额外的术中或术后数据不知情。术后平均8年进行随访检查。
单因素分析显示，双侧ITA组胸骨并发症发生率略高（4.8%对1.2%；p<0.02），接受单侧ITA和大隐静脉移植的患者组8年无再次干预生存率显著较低（84%±5.5%对95%±1.5%；p<0.02）。后者主要是由于随访期间出现严重主干病变需要再次手术，或由于初始手术时不严重的回旋支动脉病变需要进行经皮冠状动脉成形术。两组患者围手术期风险相似。高龄和充血性心力衰竭病史是接受双侧ITA患者围手术期死亡率和发病率的最重要预测因素。多因素分析未显示双侧动脉移植在总体生存率、无事件生存率和无干预生存率方面优于单侧ITA搭桥联合大隐静脉移植。
尽管双侧ITA移植的围手术期风险与单侧ITA和大隐静脉移植相当，但双侧ITA移植并不能改善双支冠状动脉疾病手术治疗的长期结果（长达8年）。
