李嘉辉,宋现涛,左惠娟,张文怡,杨雪瑶

• 1:首都医科大学附属北京安贞医院心内科北京市心肺血管疾病研究所

摘要(Abstract)：

目的探讨冠状动脉旁路移植术(CABG)后左乳内动脉-左前降支(LIMA-LAD桥血管的转归及影响因素。方法入选2002年11月至2016年12月北京安贞医院心内科因CABG术后胸闷、胸痛症状复发接受冠状动脉造影的患者共632例。收集患者基本信息、发病相关临床信息、既往病史、实验室化验指标以及CABG时长、术前LIMA管径、峰流速等资料。根据冠状动脉造影结果评价LIMA-LAD桥血管狭窄程度,将LIMA-LAD桥血管狭窄≥50%的患者归入狭窄组(139例),LIMA-LAD桥血管狭窄<50%的患者归入非狭窄组(493例)。结果 632例患者中男性518例(82.0%),平均年龄(59.78±8.70)岁;再发心绞痛582例(92.1%),急性心肌梗死50例(7.9%)。所有患者CABG距离冠状动脉造影时间为(52.14±42.77)个月。狭窄组患者外周血管疾病比例(2.9%比8.3%,P=0.025)、CABG距离造影时间[29.0(14.0,73.0)个月比42.0(18.5,79.0)个月,P=0.041]、CABG术前LIMA峰流速[64.60(54.75,80.00)cm/s比70.00(58.35,84.10)cm/s,P=0.025]均低于非狭窄组,而CABG术前LAD狭窄<75%的比例(22.3%比6.7%,P<0.001)显著大于非狭窄组,差异均有统计学意义。logistic回归分析结果显示,CABG术前LAD狭窄<75%(OR 3.796,95%CI 2.046～7.045,P<0.001)与术后LIMA-LAD桥血管狭窄存在相关性,冠心病危险因素(如高血压病、糖尿病、吸烟)以及CABG手术时长等与桥血管狭窄无明显相关性。结论 CABG术前LAD靶血管狭窄程度可能影响术后LIMA-LAD桥血管狭窄的发生,术前评估冠状动脉应考虑靶血管狭窄程度对LIMA桥血管通畅性的影响。

关键词(KeyWords)： 冠状动脉旁路移植术;左乳内动脉;胸廓内动脉;危险因素

Abstract:

Keywords:

基金项目(Foundation): 首都临床特色应用研究与成果推广(Z161100000516139);; 心血管疾病精准医学北京实验室(PXM2018_014226_000013)

作者(Author): 李嘉辉,宋现涛,左惠娟,张文怡,杨雪瑶

参考文献(References)：

• [1]Hoye A,Lemos PA,Arampatzis CA,et al.Effectiveness of the sirolimus-eluting stent in the treatment of patients with a prior history of coronary artery bypass graft surgery.Coron Artery Dis,2004,15(3):171-175.
• [2]Sabik JF 3rd,Blackstone EH,Gillinov AM,et al.Occurrence and risk factors for reintervention after coronary artery bypass grafting.Circulation,2006,114(1 Suppl):I454-I460.
• [3]Brilakis ES,Rao SV,Banerjee S,et al.Percutaneous coronary intervention in native arteries versus bypass grafts in prior coronary artery bypass graf ting patients:a report f rom the National Cardiovascular Data Registry.JACC Cardiovasc Interv,2011,4(8):844-850.
• [4]Parang P,Arora R.Coronary vein graft disease:pathogenesis and prevention.Can J Cardiol,2009,25(2):e57-e62.
• [5]中国冠状动脉旁路移植术后二级预防专家共识组.中国冠状动脉旁路移植术后二级预防专家共识(2016版).中华胸心血管外科杂志,2016,32(10):577-583.
• [6]中国医师协会内分泌代谢科医师分会,中国住院患者血糖管理专家组.中国住院患者血糖管理专家共识.中华内分泌代谢杂志,2017,33(1):1-10.
• [7]王刚,张涛,李建,等.内窥镜获取大隐静脉在冠状动脉旁路移植术中的临床研究.中国介入心脏病学杂志,2016,24(4):191-194.
• [8]Hlatky MA,Boothroyd DB,Reitz BA,et al.Adoption and effectiveness of internal mammary artery grafting in coronary artery bypass surgery among medicare beneficiaries.J Am Coll Cardiol,2014,63(1):33-39.
• [9]Otsuka F,Yahagi K,Sakakura K,et al.Why is the mammary artery so special and what protects it from atherosclerosis?Ann Cardiothorac Surg,2013,2(4):519-526.
• [10]Shelton ME,Forman MB,Virmani R,et al.A comparison of morphologic and angiographic findings in long-term internal mammary artery and saphenous vein bypass grafts.J Am Coll Cardiol,1988,11(2):297-307.
• [11]He GW,Fan L,Grove KL,et al.Expression and function ofendothelial nitric oxide synthase messenger RNA and protein are higher in internal mammary than in radial arteries.Ann Thorac Surg,2011,92(3):845-850.
• [12]Fernández-jiménez R,Kempny A,Prapa M,et al.Giant saphenous vein graft aneurysm compressing right ventricular outflow tract and main pulmonary artery.Circulation,2013,127(5):650-651.
• [13]Fukuda I,Takeyasu N,Noguchi Y.Spontaneous recanalization of functionally occluded bilateral internal thoracic artery T graft.JCardiovasc Surg(Torino),2003,44(2):209-211.
• [14]Shelton ME,Forman MB,Virmani R,et al.A comparison of morphologic and angiographic findings in long-term internal mammary artery and saphenous vein bypass grafts.J Am Coll Cardiol,1988,11(2):297307.
• [15]胡晓鹏,许建屏,胡盛寿,等.冠状动脉旁路移植术后桥血管造影特点分析.中国心血管病研究,2007,5(2):88-91.
• [16]李丽,赵强,盖鲁粤,等.冠状动脉旁路移植术后移植血管的转归及影响因素分析.中国循环杂志,2017,32(2):128-131.
• [17]Raza S,Blackstone EH,Houghtaling PL,et al.Influence of diabetes on long-term coronary artery bypass graft patency.J Am Coll Cardiol,2017,70(5):515-524.
• [18]Harskamp RE,Alexander JH,Ferguson Jr TB,et al.Frequency and predictors of internal mammary artery graf t failure and subsequent clinicaloutcomes:insights from the PREVENT IV trial.Circulation,2016,133(2):131-138.
• [19]Sabik JF 3rd,Lytle BW,Blackstone EH,et al.Does competitive flow reduce internal thoracic artery graft patency?Ann Thorac Surg,2003,76(5):1490-1496.
• [20]Davies PF.Hemodynamic shear stress and the endothelium in cardiovascular pathophysiology.Nat Clin Pract Cardiovasc Med,2009,6(1):16-26.
• [21]Botman CJ,Schonberger J,Koolen S,et al.Does stenosis severity of native vessels influence bypass graft patency?A prospective fractional flow reserve-guided study.Ann Thora Surg,2007,83(6):2093-2097.
• [22]Toth G,De Bruyne B,Casselman F,et al.Fractional flow reserveguided versus angiography-guided coronary artery bypass graft surgery.Circulation,2013,128(13):1405-1411.
• [23]Gaudino M,Antoniades C,Benedetto U,et al.Mechanisms,consequences,and prevention of coronary graft failure.Circulation,2017,136(18):1749-1764.