Rasmussen C, Thiis J J, Clemmensen P, Efsen F, Arendrup H C, Saunamäki K, Madsen J K, Pettersson G
Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark.
Eur J Cardiothorac Surg. 1997 Dec;12(6):847-52. doi: 10.1016/s1010-7940(97)00268-6.
Perioperative ischaemia and infarction after CABG are associated with increased morbidity and mortality.
To study causes of perioperative ischaemia and infarction by acute re-angiography and to treat incomplete re-vascularization caused by graft failure or any other cause.
Between 1990 and 1995, 2003 patients underwent an isolated CABG operation. Myocardial ischaemia was suspected if one or more of the following criteria were present: New changes in the ST-segment in the ECG; a CKMB value greater than 80 U/L; new Q-waves in the ECG; recurrent episodes of, or sustained ventricular tachyarrhythmia; ventricular fibrillation; haemodynamic deterioration and left ventricular failure. Acute coronary angiography was performed in stable patients, while haemodynamically severely compromised patients were rushed to the operating room.
A total of 71 (3.5%) patients of all CABGs with suspected graft failure were identified and included in the study. Patients were grouped according to whether they had an acute re-angiography (n = 59; group 1) or an immediate re-operation (n = 12; group 2) performed. In group 1, the acute re-angiography demonstrated graft failure/incomplete re-vascularization in 43 patients (73%). The angiographic findings were: Occluded vein graft(s) in 19 (32%); poor distal run-off to the grafted coronary artery in ten (17%); internal mammary artery stenosis in four (7%); internal mammary artery occlusion in three (5%); vein graft stenoses in three (5%); left mammary artery subclavian artery steal in two (3%); and the wrong coronary artery grafted in one (2%). Based on the angiography findings, 27 patients were re-operated and re-grafted. At the time of re-operation, 18 patients (67%) had evolving infarction documented by ECG or CKMB. Two patients (3%) experienced stroke in immediate relation to the re-angiography. The 30-day mortality was three (7%). In group 2, graft occlusions were found in 11 patients (92%). The 30-day mortality was six (50%).
An acute re-angiography demonstrated graft failure or incomplete re-vascularization in the majority of patients with myocardial ischaemia early after CABG. Re-operation for re-re-vascularization was performed with low risk. Few patients with circulatory collapse could be saved by an immediate re-operation without preceding angiography.
冠状动脉旁路移植术（CABG）后围手术期缺血和梗死与发病率和死亡率增加相关。
通过急性再血管造影研究围手术期缺血和梗死的原因，并治疗由移植物失败或任何其他原因导致的不完全再血管化。
1990年至1995年期间，2003例患者接受了单纯CABG手术。如果出现以下一项或多项标准，则怀疑存在心肌缺血：心电图ST段出现新变化；肌酸激酶同工酶（CKMB）值大于80 U/L；心电图出现新的Q波；反复发作或持续性室性心律失常；心室颤动；血流动力学恶化和左心室衰竭。对病情稳定的患者进行急性冠状动脉造影，而血流动力学严重受损的患者则紧急送往手术室。
在所有疑似移植物失败的CABG患者中，共识别出71例（3.5%）并纳入研究。根据患者是否进行急性再血管造影（n = 59；第1组）或立即再次手术（n = 12；第2组）进行分组。在第1组中，急性再血管造影显示43例患者（73%）存在移植物失败/不完全再血管化。血管造影结果为：19例（32%）静脉移植物闭塞；10例（17%）移植冠状动脉远端血流不佳；4例（7%）乳内动脉狭窄；3例（5%）乳内动脉闭塞；3例（5%）静脉移植物狭窄；2例（3%）左乳动脉锁骨下动脉窃血；1例（2%）移植到错误的冠状动脉。根据血管造影结果，27例患者接受了再次手术并重新移植。再次手术时，18例患者（67%）通过心电图或CKMB记录到有进展性梗死。2例患者（3%）在急性再血管造影后立即发生中风。30天死亡率为3例（7%）。在第2组中，11例患者（92%）发现移植物闭塞。30天死亡率为6例（50%）。
急性再血管造影显示，大多数CABG术后早期心肌缺血患者存在移植物失败或不完全再血管化。再次手术进行再血管化的风险较低。少数循环衰竭患者在未进行血管造影的情况下立即再次手术可挽救生命。
