Validation of a new and specific intraoperative measurement of vein graft resistance
Validation of a new and specific intraoperative measurement of vein graft resistance
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DOI：
10.1016/s0741-5214(97)70127-7
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发表时间：
1997-06-01
影响因子：
4.3
通讯作者：
Whittemore, AD
中科院分区：
文献类型：
--
作者：
Schwartz, LB;Belkin, M;Whittemore, AD
目的：临床研究表明，旁路移植成功的最重要预测因素是旁路导管的来源和质量。尝试在术中评估导管的血流动力学特性，包括评估血流（Q）、压力梯度（Delta P）和阻力（R），但没有效果。这是因为这些参数中的每一个都测量移植物和流出床的特性。迄今为止，还没有专门测量导管电阻特性的方法。本研究的目的是评估纵向阻抗 (Z(L)) 作为导管特异性阻力的测量方法，并评估其预测腹股沟下血管重建结果的潜力。方法：在 21 个月的时间里，在两个独立机构的 68 名患者中进行了 73 次腹股沟下自体静脉重建手术期间测量了 Z(L)。在基线时和动脉内注射罂粟碱 30 mg 最大外周血管舒张后测量静脉移植物超声传播时间 Q 和 Delta P（从近端到远端吻合）。使用数字采集系统在 200 Ha 处记录波形 10 秒。 R 计算为近端平均压力除以平均血流量（(Q) 超过 bar）。傅立叶变换后，Z(L) 计算为每个谐波的 Delta P/Q，总 Z(L)（积分 Z(L)）定义为 0 至 4 Ha 模量的积分。结果：所有血流动力学变量均受到罂粟碱血管舒张作用的显着影响（Delta P，3.9 +/- 0.5 vs 6.3 +/- 0.8 mm Hg；Q，78.2 +/- 7.0 vs 126 +/- 11 ml/min；R，134 +/- 17 与 72.7 +/- 6.2 x 10(3) dyne.sec.cm(-5)；p < 0.0001)，积分 Z(L) 除外，其保持不变（31.1 +/- 2.8 与 30.8 +/- 2.8 x 10(3) dyne.cm(-5)；p = NS）。随访 1 周至 17 个月（中位时间 5 个月）后，1 年初次通畅率、初次辅助通畅率和二次通畅率分别为 72% +/- 7%、77% +/- 6% 和 81% +/- 6%。使用 Cox 分析，原发性通畅与积分 Z(L) 下降显着相关 (P = 0.0001)，但与基线或罂粟碱刺激的 Delta (P) 超标、(Q) 超标、Delta (P) 超标/(Q) 超标或 R 积分 Z(L) > 47 x 10(3) dyne.cm(-5) 预测原发性失败，阳性和阴性预测值分别为 90%。结论：腹股沟下静脉移植物中积分 Z(L) 的术中测量与流出条件无关（即不随罂粟碱改变），因此仅描述导管的电阻特性。此外，这些初步数据表明积分 Z(L) 可预测短期初次通畅。积分 Z(L) 是第一个可用的针对导管的血流动力学测量，因此可能是比目前可用的方法更好的移植物通畅预测指标。
Purpose: Clinical studies have revealed that the most important predictor of successful bypass grafting is the origin and quality of the bypass conduit. Attempts at intraoperative evaluation of the hemodynamic properties of the conduit, including assessment of blood flow (Q), pressure gradients (Delta P), and resistance (R), have not been useful. This is because each of these parameters measures the characteristics of the graft plus the outflow bed. To date, no specific measurement of the resistive properties of the conduit only is available. The purpose of this investigation was to evaluate longitudinal impedance (Z(L)) as a measure of conduit-specific resistance and to evaluate its potential in predicting the outcome of infrainguinal vascular reconstructions.Methods: Z(L) was measured during surgery in 73 infrainguinal autologous vein reconstructions performed in 68 patients in two separate institutions over a 21-month period. Vein graft ultrasonic transit time Q and Delta P (from proximal to distal anastomosis) were measured at baseline and after maximal peripheral vasodilatation with an intraarterial injection of papaverine 30 mg. Waveforms were recorded for 10 seconds at 200 Ha using a digital acquisition system. R was calculated as proximal mean pressure divided by mean blood flow ((Q) over bar). After Fourier transformation, Z(L) was calculated as Delta P/Q at each harmonic and total Z(L) (integral Z(L)) was defined as the integral of moduli from 0 to 4 Ha.Results: All hemodynamic variables were significantly affected by papaverine vasodilatation (Delta P, 3.9 +/- 0.5 vs 6.3 +/- 0.8 mm Hg; Q, 78.2 +/- 7.0 vs 126 +/- 11 ml/min; R, 134 +/- 17 vs 72.7 +/- 6.2 x 10(3) dyne.sec.cm(-5); p < 0.0001), except integral Z(L), which remained constant (31.1 +/- 2.8 vs 30.8 +/- 2.8 x 10(3) dyne.cm(-5); p = NS). After follow-up of 1 week to 17 months (median, 5 months), the 1-year primary, primary-assisted, and secondary patency rates were 72% +/- 7%, 77% +/- 6%, and 81% +/- 6%, respectively. Using Cox analysis, primary patency was significantly associated with decreased integral Z(L) (P = 0.0001), but not with baseline or papaverine-stimulated Delta (P) over bar, (Q) over bar, Delta (P) over bar/(Q) over bar, or R integral Z(L) > 47 x 10(3) dyne.cm(-5) predicted primary failure with 90% positive and negative predictive value.Conclusions: In traoperative measurement of integral Z(L) in infrainguinal vein grafts is independent of outflow conditions (that is, does not change with papaverine), and hence describes the resistive properties of the conduit only. In addition, these preliminary data suggest that integral Z(L) is predictive of short-term primary patency. integral Z(L) is the first available hemodynamic measurement that is conduit specific and may therefore be a better predictor of graft patency than currently available methods.