冠状动脉旁路移植加冠状动脉内膜剥脱术的近、远期效果分析

Short- and Long-term Results of Coronary Artery Bypass Grafting with Coronary Endarterectomy

目的探索冠状动脉弥漫性病变的外科治疗策略。方法2003年1月至2013年6月，中国医科大学附属第一医院对92例冠心病合并冠状动脉弥漫性病变患者行冠状动脉旁路移植术（coronary artery bypass grafting，CABG）加冠状动脉内膜剥脱术（coronary endarterectomy，CE），同期完成冠状动脉血运重建。其中男63例、女29例，年龄52～81（68．7±10．5）岁。CE术后和随访期间复查冠状动脉CT血管成像观察桥血管的通畅性，并观察患者心功能和心绞痛的改善情况。结果92例患者内膜剥脱后靶血管直径均〉1．5mm。术中有63例（69支CE桥）行桥血管血流量测定，显示59支（85．5％）桥血管血流量满意[血流量13～42（23．4±12．7）ml/min，搏动指数（PI）1．6～4．2（2．1±1．1）o术后6例（6．5％）围手术期发生心肌梗死，术后30d内死亡4例（4．3％），其中2例死于急性心肌梗死、心源性休克，1例死于术后低心排血量并发多器官功能衰竭，1例死于术后大面积脑梗死。术后随访73例，随访率83％（73／88），15例失访；随访时间6～108（49-3±26．7）个月。随访期间复查冠状动脉CT血管成像显示CE术后的桥血管通畅率为83．9％。随访期间死亡4例（5．5％），1例死于心力衰竭、肺部感染，1例不明原因猝死，1例死于脑出血，1例死于肺部恶性肿瘤。CE术后5年生存率为87％。CE术后6个月射血分数（EF）较术前增高（55．6％±9．7％VS．50．2％±10．5％，P〈0．05），患者心功能与术前比较明显改善，心绞痛明显缓解。结论CABG同期CE可提高弥漫性阻塞性冠状动脉粥样硬化患者的再血管化程度，近远期临床效果满意。

Objective To investigate surgical treatment strategies for diffuse coronary artery disease （CAD）. Methods From January 2003 to June 2013, 92 patients with diffuse CAD received complete coronary revascularization including coronary artery bypass grafting （CABG） and coronary endarterectomy （CE） in the First Affiliated Hospital of China Medical University. There were 63 male and 29 female patients with their age of 52-81 （68.7±10.5 ）years. After CE and during follow-up, coronary CT angiography （CTA） was used to assess graft patency, and improvement of patients＇ cardiac function and angina symptoms were observed. Results Target vessel diameter of the 92 patients was all larger than 1.5 mm after CE. Sixty-three patients （with 69 CE grafts） received intraoperative graft blood flow measurement, showing 59 grafts （85.5%） with satisfactory blood flow [ blood flow 13-42 （23.4 ±12.7 ） ml/min, pulsatility index （PI） 1.6-4.2 （2.1 ± 1.1 ） ]. Six patients （6.5%） had perioperative myocardial infarction （MI）, and 4 patients （4.3%） died within 30 days after surgery including 2 patients with acute MI and cardiogenic shock, 1 patient with low cardiac output syndrome and multiple organ failure, and 1 patient with massive cerebral infarction. Seventy-three patients （83%） were followed up for 6-108 （49.3 ± 26.7） months after discharge, and 15 patients were lost during follow-up. During follow-up, coronary CTA showed graft patency of 83.9% after CE. Four patients （5.5%） died including 1 patient with heart failure and pulmonaryinfection, 1 patient of unexplained sudden death, 1 patient with cerebral hemorrhage, and 1 patient with lung cancer. Five-year survival rate was 87% after CE. Six months after CE, ejection fraction （EF）was significantly higher than preo- perative EF （55.6%±9.7% vs. 50.2%± 10.5%, P 〈 0.05 ）, patients＇ cardiac function significantly improved, and their angina symptoms were significantly relieved. Conclusion CABG with CE can improve coronary revascularization for patients with diffuse CAD, and short- and long-term results are satisfactory.