左腋动脉近端吻合在左胸小切口多支旁路移植手术中的应用

Application of axillary-coronary artery bypass in minimally invasive cardiac surgery-coronary artery bypass graft

目的探讨左腋动脉近端吻合(axillary coronary artery bypass,ACAB)技术在左胸小切口多支冠状动脉旁路移植手术(MICS-CABG)中应用的安全性与有效性。方法前瞻性收集2020年5月至2022年12月期间于北京大学第三医院接受冠状动脉旁路移植手术的206例患者的临床资料,包括采用左腋动脉近端吻合技术的左胸小切口多支冠状动脉旁路移植手术患者48例(MICS-ACAB组),同期行正中开胸非体外循环冠状动脉旁路移植手术患者158例(OPCABG组)。OPCABG组男122例,女36例;平均年龄(64.72±8.27)岁;MICS-ACAB组男38例,女10例;平均年龄(71.42±7.77)岁。选取围手术期主要心脑血管不良事件(包括卒中、死亡、心肌梗死和再次血运重建)和术后早期SF-36评分中的PCS评分为主要研究终点,分析患者手术并发症和近期旁路移植血管通畅率情况,评价腋动脉-冠状动脉旁路移植手术的临床效果。结果两组患者旁路移植血管中位数均为3支。两组围手术期主要心脑血管不良事件、二次手术、术后肾功能不全及术后住院时间等方面差异无统计学意义(P>0.05)。176例(85.4%)患者出院前行冠状动脉造影或冠状动脉CTA评估,结果显示MICS-ACAB组与OPCABG组旁路移植血管通畅率差异无统计学意义(95.2%对88.8%,P=0.368)。采用倾向性评分方法对围手术期结局进行校正,研究结果与上述结论一致。单因素分析与多元线性回归分析均表明,MICS-ACAB组患者术后7天SF-36评分中的生理功能评分明显高于OPCABG组[(31.77±5.97)分对(29.45±6.31)分,P=0.025]。术后1年随访结果显示,MICA-ACAB组患者发生主要心脑血管事件与术后发作心绞痛频率并未增加(P>0.05)。结论MICA-ACAB技术安全性良好,可以实现心脏完全血运重建,旁路移植血管通畅率满意,患者术后早期生活质量明显改善。

Objective:To explore the safety and effectiveness of axillary-coronary artery bypass(ACAB)of anterolateral incision multi-vessel coronary artery bypass surgery(MICS-CABG).Methods:Patients who underwent coronary artery bypass surgery in Peking University Third Hospital from May 2020 to December 2022 were included.48 and 158 patients were included in MICS-ACAB and OPCABG group respectively.The mean age of the OPCABG group was(64.72±8.27)years old,and the male proportion was 77.2%(122 cases).The mean age of the MICS-ACAB group was(71.42±7.77)years old,and the male proportion was 79.2%(38 cases).Major adverse cardiovascular and cerebrovascular events(MACCE,including stroke,death,myocardial infarction and revascularization)and postoperative PCS scores of SF-36 were selected as the primary endpoint.The surgical complications and angiography patency rate of grafts were recorded to evaluate the clinical effects of MICS-ACAB.Results:The median number of bypass graft in two groups was 3.There were no significant differences in perioperative MACCE,re-operation rate,renal failure and lenth of postoperative hospital stay between two groups(P>0.05).85.4%of patients reveived angiography assessment before discharge.There was no significant difference in graft patency between the MICS-ACAB group and OPCABG group(95.2%vs 88.8%,P=0.368).The results of propensity score matching analysis were consistent with the above conclusions.Both univariate analysis and multiple linear regression showed that MICS-ACAB could improve the PCS score of SF-36 at 7 days after surgery[(31.77±5.97)scores vs.(29.45±6.31)scores,P=0.025].Conclusion:The safety of MICS-ACAB is satisfactory,which can achieve the completely revascularization and the patency rate of grafts is desirable.This procedure can significantly improve quality of life of patients in early postoperative period.