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
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
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DOI：
10.1016/0735-1097(96)00206-9
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发表时间：
1996-09-01
影响因子：
24
通讯作者：
Burton, JR
中科院分区：
文献类型：
--
作者：
FitzGibbon, GM;Kafka, HP;Burton, JR
目标。我们试图通过血管造影检查大量以静脉为主的冠状动脉旁路移植术的长期命运，并将移植物通畅和疾病与患者生存和再手术联系起来。关于旁路移植术的通畅和疾病，我们已经知道了很多，但是移植物的命运和患者预后之间的确切关系还没有得到证实和记录。在1969年至1994年的25年间，共有1388名患者接受了第一次冠状动脉搭桥手术，平均年龄为48.9岁，234名患者接受了第二次搭桥手术，平均年龄为53.3岁，15名患者接受了第三次搭桥手术，平均年龄为58.2岁。大多数是男性军人或退伍军人；12%的人年龄小于或等于39岁。在5284个移植物中，91%为静脉移植物，9%为动脉移植物。在早期对5065例（98%的成活率）移植物进行血管造影，术后1年对3993例移植物进行血管造影，5年对1978例移植物进行血管造影；其他检查也在术后22.5年进行，353例移植术后大于或等于15年。根据通畅程度和病变程度对移植物进行分级。在研究结束时，所有患者的状态都是已知的。孤立的首次冠状动脉搭桥手术的围手术期死亡率为1.4%，再次手术的死亡率为6.6%。静脉移植早期通畅88%，1年通畅81%，5年通畅75%，大于等于15年通畅50%；当排除B级次优移植物时，A级优秀移植物的比例在大于或等于12.5年后下降到40%。早期研究后，静脉移植闭塞率为2.1%/年。内乳动脉移植通畅性明显改善，但随时间延长而降低。静脉移植物疾病出现时间为1年，发生率大于等于2.5年，5年移植物占48%，大于等于15年移植物占81%；后者44%的移植物仅缩小了50%。术后5年生存率为93.6%，10年生存率为81.1%，15年生存率为62.1%，20年生存率为46.7%（150例），23年生存率为38.4%（25例）。生存率随着年龄的增长而下降，但曲线接近于老年患者的“正常”预期寿命。7年后，所有年龄段的生存曲线都停止了急剧下降。再手术率在5年至10 ~ 14年期间上升，然后下降到稳定水平。静脉移植引起的冠状动脉粥样硬化栓塞是与再手术相关的发病率和死亡率的主要原因。静脉移植物的通畅程度和病情的发生与再手术及生存密切相关。冠状动脉旁路移植术后病变和闭塞是常见的，且随时间延长而增加。它们是临床预后的主要决定因素，特别是通过再手术率和生存率来衡量。术中移植物动脉粥样硬化栓塞是再手术的主要危险。再手术绝对是值得的，但也会带来必须处理的可识别风险。
Objectives. We sought to examine, angiographically, the long-term fate of a large number of mainly venous coronary bypass grafts and to correlate graft patency and disease with patient survival and reoperation.Background. Much is known about bypass graft patency and disease, but the precise relation between graft fate and patient outcome has not been substantiated and documented.Methods. A total of 1,388 patients underwent a first coronary artery bypass graft procedure at a mean age of 48.9 years, 234 had a second bypass procedure at a mean age of 53.3 years, and 15 had a third bypass procedure at a mean age of 58.2 gears during the 25-year period from 1969 to 1994. Most were male military personnel or veterans; 12% were less than or equal to 39 years old. Of 5,284 grafts placed, 91% were venous and 9% arterial. Angiograms were performed on 5,065 (98% of surviving) grafts Early, on 3,993 grafts at 1 year and on 1,978 grafts at 5 years after operation; other examinations mere also performed up to 22.5 years after operation, and 353 grafts were examined after greater than or equal to 15 years. Grafts were graded for patency and disease. The status of all patients was known at the study's end.Results. The perioperative mortality rate was 1.4% for an isolated first coronary bypass procedure, 6.6% for reoperation. Vein graft patency was 88% early, 81% at 1 year, 75% at 5 years and 50% at greater than or equal to 15 gears; when suboptimal grafts, graded B, were excluded from calculation, the proportion of excellent grafts, graded A, decreased to 40% after greater than or equal to 12.5 years. After the early study, the vein graft occlusion rate was 2.1%/year. Internal mammary artery graft patency was significantly better but decreased with time. Vein graft disease appeared by 1 year and the rate accelerated by greater than or equal to 2.5 years, involving 48% of grafts at 5 years and 81% at greater than or equal to 15 gears; 44% of the latter grafts mere narrowed >50%. Survival of all patients was 93.6% at 5 years, 81.1% at 10 years, 62.1% at 15 years, 46.7% (150 patients) at 20 years and 38.4% (25 patients) at 23 years after operation. Survival decreased as age increased, but curves approximated ''normal'' life expectancy for older patients. Survival curves at all ages shelved a steeper decline after 7 years. The rate of reoperation increased between 5 years and 10 to 14 years, then decreased to stable levels. Coronary atheroembolism from vein grafts was the major cause of morbidity and mortality associated with reoperation. Vein graft patency and disease mere temporally and closely related to reoperation and survival.Conclusions. Coronary bypass graft disease and occlusion are common after coronary artery bypass grafting and increase with time. They are major determinants of clinical prognosis, specifically measured by reoperation rate and survival. Intraoperative graft atheroembolism was a major reoperation hazard. Reoperation is definitely worthwhile but entails identifiable risks that must be dealt with.