2023年欧洲心胸外科协会和美国胸外科医师协会《冠状动脉旁路移植术旁路血管选择专家共识》解读

Interpretation on Expert systematic review on the choice of conduits for coronary artery bypass grafting endorsed by the European Association for Cardio-Thoracic Surgery and the Society of Thoracic Surgeons in 2023

欧洲心胸外科协会与美国胸外科医师协会最近颁布了《冠状动脉旁路移植术旁路血管选择专家共识》,对旁路血管的选择提出建议。左胸廓内动脉仍然是冠状动脉旁路移植旁路血管选择的“金标准”。桡动脉较大隐静脉并发症发生率低、远期通畅率高,建议开放手术获取,术后第1年需使用血管扩张药。尚无证据证实右胸廓内动脉远期通畅率高于大隐静脉。双胸廓内动脉有更好的远期生存率,但高风险患者可能发生胸骨不愈合。胸廓内动脉旁路骨骼化优势尚不明确。大隐静脉内镜获取较开放手术获取可减少切口并发症但中远期通畅率偏低,非接触获取较开放手术获取通畅率高,但中远期临床获益不明且增加切口并发症。胃网膜右动脉临床应用有限,建议骨骼化且用于低竞争血流的靶血管。

Expert systematic review on the choice of conduits for coronary artery bypass grafting:endorsed by the European Association for Cardio-Thoracic Surgery and the Society of Thoracic Surgeons published in 2023 made recommendations for the selection of bypass vessels.The left internal thoracic artery-anterior descending branch anastomosis represents the accepted gold standard.Radial artery could achieve a better long-term patency rate and a reduction in adverse cardiac events compared to the great saphenous vein.Radial artery graft using an open harvesting method should be chosen to graft the target vessel with low competitive coronary flow,with the use of vasodilators for the first year.There was no clear evidence of better patency for the right internal thoracic artery compared to the great saphenous vein.The bilateral internal thoracic artery had better long-term survival compared to great saphenous vein but may be associated with a higher risk of deep sternal wound infection and should be avoided in high-risk patients.The impact of skeletonization of the internal thoracic artery on graft patency and cardiovascular outcomes was unclear.Endoscopic vein harvest reduced the risk of leg wound complications and was associated with reduced long-term patency.The patency of the no-touch great saphenous vein was significantly better than that of conventional great saphenous vein.A significantly higher risk of complications at the harvesting site and no clear evidence of better long-term clinical outcomes were found in the no-touch great saphenous vein compared to the conventional.There was limited data on the use of right gastroepiploic artery and skeletonized harvesting,which should be used to bypass target vessels in patients with low competitive flow.