提示: 手机请竖屏浏览!

桡动脉或隐静脉桥血管用于冠状动脉旁路术
Radial-Artery or Saphenous-Vein Grafts in Coronary-Artery Bypass Surgery


Mario Gaudino ... 心脑血管疾病 • 2018.05.31
相关阅读
• 静脉桥血管获取方法是否会影响结局 • 桡动脉桥血管优于隐静脉桥血管

冠脉搭桥的动脉桥血管有了B选项

 

赵强*,朱云鹏

上海交通大学医学院附属瑞金医院

* 通讯作者

 

桡动脉数据库国际联盟(Radial Artery Database International Alliance,RADIAL)研究是一项池式汇总分析(pool analysis),继2018年美国心胸外科学会(AATS)年会公布最新数据后,2018年4月30日又在线发表于NEJM 1。其研究数据证实,在经典的冠状动脉旁路移植术(冠脉搭桥术,CABG)中,相较于传统的隐静脉桥血管,应用桡动脉作为桥血管可以改善中远期临床预后。

查看更多

摘要


背景

与使用隐静脉桥血管相比,使用桡动脉桥血管进行冠状动脉旁路移植术(CABG)可能获得较好的术后结局。然而,比较桡动脉桥血管和隐静脉桥血管的随机对照试验,单项的统计学功效不足以测出临床结局的差异。我们对随机对照试验进行一项患者水平的汇总分析,以比较使用桡动脉桥血管和隐静脉桥血管进行的CABG。

 

方法

我们确定了6项试验。主要结局为死亡、心肌梗死或再次血运重建构成的复合结局。次要结局为随访血管造影显示桥血管通畅。使用混合效应Cox回归模型估计对结局的疗效。

 

结果

总共1,036例患者被纳入分析(534例患者用桡动脉桥血管,502例患者用隐静脉桥血管)。在60个月±30个月的平均(±SD)随访时间后,与使用隐静脉桥血管相比,使用桡动脉桥血管时,心脏不良事件的发生率显著较低(风险比,0.67;95%置信区间[CI],0.49~0.90;P=0.01)。在随访血管造影(平均随访时间,50个月±30个月)中,使用桡动脉桥血管的闭塞风险也显著较低(风险比,0.44;95% CI,0.28~0.70;P<0.001)。与使用隐静脉桥血管相比,使用桡动脉桥血管与心肌梗死发生率名义上较低(风险比,0.72;95% CI,0.53~0.99;P=0.04)、再次血运重建发生率较低(风险比,0.50;95% CI,0.40~0.63;P<0.001)相关,但不与任何原因死亡率较低(风险比,0.90;95% CI,0.59~1.41;P=0.68)相关。

 

结论

与使用隐静脉桥血管相比,使用桡动脉桥血管进行CABG引起了5年随访时较低的心脏不良事件发生率和较高的通畅率(由威尔康奈尔医学院[Weill Cornell Medicine]等资助)。





作者信息

Mario Gaudino, M.D., Umberto Benedetto, M.D., Stephen Fremes, M.D., Giuseppe Biondi-Zoccai, M.D., M.Stat., Art Sedrakyan, M.D., Ph.D., John D. Puskas, M.D., Gianni D. Angelini, M.D., Brian Buxton, M.D., Giacomo Frati, M.D., David L. Hare, M.D., Philip Hayward, M.D., Giuseppe Nasso, M.D., Neil Moat, M.D., Miodrag Peric, M.D., Kyung J. Yoo, M.D., Giuseppe Speziale, M.D., Leonard N. Girardi, M.D., and David P. Taggart, M.D. for the RADIAL Investigators*
From the Departments of Cardiothoracic Surgery (M.G., L.N.G.) and Healthcare Policy and Research (A.S.), Weill Cornell Medicine, and the Icahn School of Medicine at Mount Sinai (J.D.P.), New York; Bristol Heart Institute, Bristol (U.B., G.D.A.), Royal Brompton and Harefield Trust, London (N.M.), and the University of Oxford, Oxford (D.P.T.) — all in the United Kingdom; Schulich Heart Centre, Sunnybrook Health Science, University of Toronto, Toronto (S.F.); the Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome (G.B.-Z., G.F.), the Department of Angiocardioneurology, IRCCS Neuromed, Pozzilli (G.B.-Z., G.F.), and Anthea Hospital, Bari (G.N., G.S.) — all in Italy; the University of Melbourne (B.B., D.L.H.), and the Austin Hospital (P.H.), Melbourne, VIC, Australia; Dedinje Cardiovascular Institute and Belgrade University School of Medicine, Belgrade, Serbia (M.P.); and Yonsei University College of Medicine, Seoul, South Korea (K.J.Y.). Address reprint requests to Dr. Gaudino at the Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E. 68th St., New York, NY 10065, or at mfg9004@med.cornell.edu. *A complete list of the RADIAL investigators is provided in the Supplementary Appendix, available at NEJM.org.

 

参考文献

1. ElBardissi AW, Aranki SF, Sheng S, O’Brien SM, Greenberg CC, Gammie JS. Trends in isolated coronary artery bypass grafting: an analysis of the Society of Thoracic Surgeons adult cardiac surgery database. J Thorac Cardiovasc Surg 2012;143:273-281.

2. Gaudino M, Taggart D, Suma H, Puskas JD, Crea F, Massetti M. The choice of conduits in coronary artery bypass surgery. J Am Coll Cardiol 2015;66:1729-1737.

3. Gowda S, Desai PB, Kulkarni SS, Hull VV, Math AAK, Vernekar SN. Markers of renal function tests. N Am J Med Sci 2010;2:170-173.

4. Fitzgibbon GM, Kafka HP, Leach AJ, Keon WJ, Hooper GD, Burton JR. Coronary bypass graft fate and patient outcome: angiographic follow-up of 5,065 grafts related to survival and reoperation in 1,388 patients during 25 years. J Am Coll Cardiol 1996;28:616-626.

5. Fine JP, Gray RJ. A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc 1999;94:496-509.

6. Collins P, Webb CM, Chong CF, Moat NE. Radial artery versus saphenous vein patency randomized trial: five-year angiographic follow-up. Circulation 2008;117:2859-2864.

7. Nasso G, Coppola R, Bonifazi R, Piancone F, Bozzetti G, Speziale G. Arterial revascularization in primary coronary artery bypass grafting: direct comparison of 4 strategies — results of the Stand-in-Y Mammary Study. J Thorac Cardiovasc Surg 2009;137:1093-1100.

8. Song S-W, Sul S-Y, Lee H-J, Yoo K-J. Comparison of the radial artery and saphenous vein as composite grafts in off-pump coronary artery bypass grafting in elderly patients: a randomized controlled trial. Korean Circ J 2012;42:107-112.

9. Buxton BF, Raman JS, Ruengsakulrach P, et al. Radial artery patency and clinical outcomes: five-year interim results of a randomized trial. J Thorac Cardiovasc Surg 2003;125:1363-1371.

10. Petrovic I, Nezic D, Peric M, et al. Radial artery vs saphenous vein graft used as the second conduit for surgical myocardial revascularization: long-term clinical follow-up. J Cardiothorac Surg 2015;10:127-127.

11. Deb S, Cohen EA, Singh SK, Une D, Laupacis A, Fremes SE. Radial artery and saphenous vein patency more than 5 years after coronary artery bypass surgery: results from RAPS (Radial Artery Patency Study). J Am Coll Cardiol 2012;60:28-35.

12. Gaudino M, Tondi P, Benedetto U, et al. Radial artery as a coronary artery bypass conduit: 20-year results. J Am Coll Cardiol 2016;68:603-610.

13. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011;124(13):e652-e735.

14. Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014;35:2541-2619.

15. Aldea GS, Bakaeen FG, Pal J, et al. The Society of Thoracic Surgeons clinical practice guidelines on arterial conduits for coronary artery bypass grafting. Ann Thorac Surg 2016;101:801-809.

16. Gaudino M, Di Franco A, Rahouma M, et al. Unmeasured confounders in observational studies comparing bilateral versus single internal thoracic artery for coronary artery bypass grafting: a meta-analysis. J Am Heart Assoc 2018;7(1):e008010-e008010.

17. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1-6.

18. Garcia S, Sandoval Y, Roukoz H, et al. Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies. J Am Coll Cardiol 2013;62:1421-1431.

19. Lopes RD, Mehta RH, Hafley GE, et al. Relationship between vein graft failure and subsequent clinical outcomes after coronary artery bypass surgery. Circulation 2012;125:749-756.

20. Shavadia J, Norris CM, Graham MM, Verma S, Ali I, Bainey KR. Symptomatic graft failure and impact on clinical outcome after coronary artery bypass grafting surgery: results from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry. Am Heart J 2015;169:833-840.

服务条款 | 隐私政策 | 联系我们