王志坚,周玉杰,刘宇扬,赵迎新,史冬梅,郭永和,成万钧

• 1:首都医科大学附属北京安贞医院十二病房

摘要(Abstract)：

目的对比多支血管病变伴慢性肾脏疾病(CKD)患者经皮冠状动脉介入治疗(PCI)和冠状动脉旁路移植术(CABG)的2年临床预后。方法根据改良MDRD公式对北京安贞医院2004年到2006年因多支冠状动脉病变接受药物洗脱支架(DES)或CABG的患者的肾小球滤过率(GFR)进行计算,GFR<60mL/min诊断为CKD。共入选CKD患者1069例,其中724例接受DES,345例接受CABG。首要终点为2年内死亡、心肌梗死(MI)以及脑血管事件(CVE)的复合终点,次级终点为再次血管重建。结果在2年随访中,CABG组首要终点的发生率为9.9%,DES组为11.3%(P=0.528)。两组之间死亡率差异也无统计学意义(CABG组与DES组分别为3.5%比4.7%,P=0.422)。而DES组2年再次血管重建的比例显著高于CABG组(9.0%比4.1%,P=0.004)。Cox多因素回归分析表明,年龄、糖尿病、左心室功能不全(LVEF<30%)和急性冠状动脉综合征是复合终点发生的独立预测因素。结论在冠状动脉多支病变伴CKD患者中,CABG和DES两种血管重建策略显示出相同的死亡率和MI、CVE发生率。但DES组患者再次血管重建的发生率依然高于CABG组患者。

关键词(KeyWords)： 冠状动脉疾病;肾功能不全,慢性;血管成形术,经腔,经皮冠状动脉;冠状动脉旁路移植术

Abstract:

Keywords:

基金项目(Foundation):

作者(Author): 王志坚,周玉杰,刘宇扬,赵迎新,史冬梅,郭永和,成万钧

参考文献(References)：

• [1]Rodriguez A,Bernardi V,Navia J,et al.Argentine Randomized Study:Coronary Angioplasty With Stenting Versus Coronary By-pass Surgery in Patients With Multiple-Vessel Disease(ERACIⅡ):30-day and one-year follow-up results:ERACIⅡInvesti-gators.J Am Coll Cardiol,2001,37:51-58.
• [2]Serruys PW,Unger F,Sousa JE,et al.Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease.N Engl J Med,2001,344:1117-1124.
• [3]Morrison DA,Sethi G,Sacks J,et al.Angina With Extremely Serious Operative Mortality Evaluation(AWESOME):percuta-neous coronary intervention versus coronary artery bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass:a multicenter,randomized trial:Inves Investigators of the Department of Veter-ans Affairs Cooperative Study#385,the Angina With Extremely Serious Operative Mortality Evaluation(AWESOME).J Am Coll Cardiol,2001,38:143-149.
• [4]SoS Investigators.Coronary artery bypass surgery versus percuta-neous coronary intervention with stent implantation in patients with multivessel coronary artery disease(the Stent or Surgery tri-al):a randomized controlled trial.Lancet,2002,360:965-970.
• [5]Mercado N,Wijns W,Serruys PW,et al.One-year outcomes of coronary artery bypass graft surgery versus percutaneous coronary intervention with multiple stenting for multisystem disease:a me-ta-analysis of individual patient data from randomized clinical tri-als.J Thorac Cardiovasc Surg,2005,130:512-519.
• [6]Park DW,Yun SC,Lee SW,et al.Long-term mortality after percutaneous coronary intervention with drug-eluting stent implan-tation versus coronary artery bypass surgery for the treatment of multivessel coronary artery disease.Circulation,2008,117:2079-2086.
• [7]Brener SJ,Lytle BW,Casserly IP,et al.Propensity analysis of long-term survival after surgical or percutaneous revascularization in patients with multivessel coronary artery disease and high-risk features.Circulation,2004,109:2290-2295.
• [8]Hannan EL,Racz MJ,Walford G,et al.Long-term outcomes of coronary-artery bypass grafting versus stent implantation.N Engl J Med,2005,352:2174-2183.
• [9]Javaid A,Steinberg DH,Buch AN,et al.Outcomes of coronary artery bypass grafting versus percutaneous coronary interventionwith drug-eluting stents for patients with multivessel coronary ar-tery disease.Circulation,2007,116:I200-206.
• [10]Influence of diabetes on5-year mortality and morbidity in a ran-domized trial comparing CABG and PTCA in patients with mul-tivessel disease:the Bypass Angioplasty Revascularization Inves-tigation(BARI).Circulation,1997,96:1761-1769.
• [11]Hoffman SN,TenBrook JA,Wolf MP,et al.A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty:one-to eight-year outcomes.J Am Coll Cardiol,2003,41:1293-1304.
• [12]Blackman DJ,Pinto R,Ross JR,et al.Impact of renal insuffi-ciency on outcome after contemporary percutaneous coronary in-tervention.Am Heart J,2006,151:146-152.
• [13]Best PJ,Lennon R,Ting HH,et al.The impact of renal insuffi-ciency on clinical outcomes in patients undergoing percutaneous coronary interventions.J Am Coll Cardiol,2002,39:1113-1119.
• [14]Cooper WA,O'Brien SM,Thourani VH,et al.Impact of renal dysfunction on outcomes of coronary artery bypass surgery:results from the Society of Thoracic Surgeons National Adult Cardiac Da-tabase.Circulation,2006,113:1063-1070.
• [15]Hillis GS,Croal BL,Buchan KG,et al.Renal function and out-come from coronary artery bypass grafting:impact on mortality af-ter a2.3-year follow-up.Circulation,2006,113:1056-1062.
• [16]Reddan DN,Szczech LA,Tuttle RH,et al.Chronic kidney dis-ease,mortality,and treatment strategies among patients with clinically significant coronary artery disease.J Am Soc Nephrol,2003,14:2373-2380.
• [17]Ix JH,Mercado N,Shlipak MG,et al.Association of chronic kidney disease with clinical outcomes after coronary revasculariza-tion:the Arterial Revascularization Therapies Study(ARTS).Am Heart J,2005,149:512-519.
• [18]Anavekar NS,McMurray JJ,Velazquez EJ,et al.Relation be-tween renal dysfunction and cardiovascular outcomes after myo-cardial infarction.N Engl J Med,2004,351:1285-1295.
• [19]Shlipak MG,Heidenreich PA,Noguchi H,et al.Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients.Ann Intern Med,2002,137:555-562.
• [20]Ma YC,Zuo L,Chen JH,et al.Modified glomerular filtration rate estimating equation for Chinese patients with chronic kidney disease.J Am Soc Nephrol,2006,17:2937-2944.
• [21]K/DOQI Clinical practice guidelines for chronic kidney disease:evaluation,classification,and stratification.Kidney disease out-come quality initiative.Am J Kidney Dis,2002,39:S1-S246.
• [22]Cannon CP,Battler A,Brindis RG,et al.American College of Cardiology key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes.A report of the American College of Cardiology Task Force on Clinical Data Standards(Acute Coronary Syndromes Writing Committee).J Am Coll Cardiol,2001,38:2114-2130.
• [23]Serruys PW,Ong ATL,Morice MC,et al,for the ARTSⅡIn-vestigators.Arterial Revascularization Therapies Study,partⅡ:sirolimus-eluting stents for the treatment of patients with multives-sel de novo coronary lesions.Eurointervention,2005,1:147-156.
• [24]Halkin A,Mehran R,Casey CW,et al.Impact of moderate re-nal insufficiency on restenosis and adverse clinical events after paclitaxel-eluting and bare metal stent implantation:results from the TAXUS-IV Trial.Am Heart J,2005,150:1163-1170.
• [25]Kuchulakanti PK,Torguson R,Chu WW,et al.Impact of chro-nic renal insufficiency on clinical outcomes in patients undergoing percutaneous coronary intervention with sirolimus-eluting stents versus bare metal stents.Am J Cardiol,2006,97:792-797.
• [26]Jeong YH,Hong MK,Lee CW,et al.Impact of significant chro-nic kidney disease on long-term clinical outcomes after drug-elu-ting stent versus bare metal stent implantation.Int J Cardiol,2008,125:36-40.