Christenson J T, Simonet F, Schmuziger M
The Cardiovascular Surgery Unit, Columbia Hôpital de la Tour, Geneva, Switzerland.
Cardiovasc Surg. 1998 Aug;6(4):389-97. doi: 10.1016/s0967-2109(98)00024-6.
The sequential bypass grafting technique has many advantages over coronary artery bypass grafting with single grafts. The aim of this study was to evaluate the consequences of sequential bypass graft failure. Between 1 January 1984 and 31 December 1996, 3846 patients underwent primary coronary artery bypass vein grafting. A total of 3490 patients received sequential vein bypass grafts and 356 patients received single vein bypass grafts (9%). There were 6177 sequential bypass grafts (3490 postero-lateral grafts (56%) and 2687 in the antero-lateral position (44%)) and 1468 single grafts (972 vein grafts and 496 internal thoracic artery grafts). Overall, there were 80 hospital deaths (2.1%). Mortality in relation to type of grafts used was: 13 deaths in 356 patients with only single graft (3.7%) and 67 deaths in 3490 patients who received sequential vein grafts (1.9%). Of 3766 hospital survivors, 3731 were followed for an average of 76 months. During follow-up, 85 patients died (2.3%), 15 patients (0.4%) underwent cardiac transplantation and 52 (1.4%) had re-do coronary artery bypass vein grafting. Graft-percutaneous transluminal coronary angioplasty was performed in 56 patients (1.5%), 37/1390 single bypass grafts (2.7%) and 19/6023 sequential bypass grafts (0.3%). There were 272/6023 symptomatic sequential graft occlusions (4.5%) (182 were in postero-lateral position and 90 in the antero-lateral position). There were 66/667 single vein graft occlusions (9.9%) and 15 symptomatic internal thoracic artery graft occlusions (2.1%) during follow-up. In 97% of patients, presenting symptoms of postero-lateral sequential bypass graft occlusion took the form of a renewed angina with a myocardial infarction rate of 3% and a mortality rate of 7%. Corresponding figures for antero-lateral sequential bypass grafts were 22, 78 and 68%, and anterior single vein bypass grafts were 70, 30 and 15%, respectively. The overall 10-year survival rate in patients with sequential bypass grafts was 81.2% and the cumulative patency rate (1464 angio-controls of 2576 sequential vein grafts) was 72.2%. A symptomatic occlusion of a postero-lateral sequential vein bypass results in a low incidence of myocardial infarction with low mortality, when the terminal anastomosis is connected to a high flow vessel. An antero-lateral sequential vein bypass graft has better long-term patency than single vein bypass, but should occlusion occur, it would usually be associated with a higher myocardial infarction and mortality rates than a single vein graft. The highest risk for failure of a sequential graft in the antero-lateral position occurs when the left anterior descending artery (LAD) is small or severely diseased. In this situation the single graft technique with internal thoracic artery appears to be safer.
序贯搭桥技术相较于单支血管冠状动脉搭桥术具有诸多优势。本研究旨在评估序贯搭桥失败的后果。在1984年1月1日至1996年12月31日期间，3846例患者接受了初次冠状动脉搭桥静脉移植术。共有3490例患者接受了序贯静脉搭桥，356例患者接受了单支静脉搭桥（9%）。共有6177例序贯搭桥（3490例在后外侧位置（56%），2687例在前外侧位置（44%））以及1468例单支血管搭桥（972例静脉搭桥和496例胸廓内动脉搭桥）。总体而言，有80例医院死亡（2.1%）。与所使用的血管移植物类型相关的死亡率为：356例仅接受单支血管搭桥的患者中有13例死亡（3.7%），3490例接受序贯静脉搭桥的患者中有67例死亡（1.9%）。在3766例医院幸存者中，3731例患者平均随访76个月。随访期间，85例患者死亡（2.3%），15例患者（0.4%）接受了心脏移植，52例患者（1.4%）进行了再次冠状动脉搭桥静脉移植术。56例患者（1.5%）进行了血管腔内冠状动脉成形术，其中37/1390例单支血管搭桥（2.7%），19/6023例序贯搭桥（0.3%）。6023例序贯搭桥中有272例（4.5%）出现有症状的闭塞（182例在后外侧位置，90例在前外侧位置）。随访期间，667例单支静脉搭桥中有66例（9.9%）闭塞，15例胸廓内动脉搭桥出现有症状的闭塞（2.1%）。在97%的患者中，后外侧序贯搭桥闭塞的症状表现为再次出现心绞痛，心肌梗死发生率为3%，死亡率为7%。前外侧序贯搭桥的相应数字分别为22%、78%和68%，前侧单支静脉搭桥的相应数字分别为70%、30%和15%。序贯搭桥患者的总体10年生存率为81.2%，累积通畅率（对2576例序贯静脉搭桥进行了1464次血管造影检查）为72.2%。当终末吻合口连接到高流量血管时，后外侧序贯静脉搭桥有症状的闭塞导致心肌梗死发生率低且死亡率低。前外侧序贯静脉搭桥的长期通畅性优于单支静脉搭桥，但一旦发生闭塞，通常比单支静脉搭桥伴有更高的心肌梗死和死亡率。当左前降支动脉（LAD）细小或严重病变时，前外侧序贯搭桥失败的风险最高。在这种情况下，采用胸廓内动脉的单支血管搭桥技术似乎更安全。
