齊弘煒 綜述 袁彪 審校

(首都醫(yī)科大學(xué)附屬北京同仁醫(yī)院心血管疾病診療中心，北京100730)

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中國(guó)常用動(dòng)脈化冠狀動(dòng)脈旁路移植術(shù)的通暢率及療效

齊弘煒 綜述 袁彪 審校

(首都醫(yī)科大學(xué)附屬北京同仁醫(yī)院心血管疾病診療中心，北京100730)

目前冠狀動(dòng)脈旁路移植術(shù)通常采用一支乳內(nèi)動(dòng)脈加一支或多支大隱靜脈作為橋血管，大隱靜脈會(huì)逐漸粥樣硬化而閉塞，動(dòng)脈的通暢率遠(yuǎn)高于大隱靜脈。左乳內(nèi)動(dòng)脈已常規(guī)應(yīng)用于冠狀動(dòng)脈旁路移植術(shù)，同應(yīng)用雙側(cè)乳內(nèi)動(dòng)脈相比，左乳內(nèi)動(dòng)脈加大隱靜脈被認(rèn)為是遠(yuǎn)期死亡、心臟事件的獨(dú)立危險(xiǎn)因素。乳內(nèi)動(dòng)脈用于左側(cè)冠狀動(dòng)脈時(shí)通暢率一樣；原位或復(fù)合橋移植時(shí)所有的乳內(nèi)動(dòng)脈通暢率相同，但吻合于主動(dòng)脈時(shí)通暢率降低，所以原位乳內(nèi)動(dòng)脈通暢率高于游離乳內(nèi)動(dòng)脈。胃網(wǎng)膜右動(dòng)脈和橈動(dòng)脈宜吻合于近端狹窄嚴(yán)重者。雙側(cè)乳內(nèi)動(dòng)脈+胃網(wǎng)膜右動(dòng)脈可避免觸及主動(dòng)脈，最大程度地減少腦部并發(fā)癥的發(fā)生。70歲以下冠狀動(dòng)脈旁路移植術(shù)、預(yù)期壽命5年以上者，應(yīng)選擇雙側(cè)乳內(nèi)動(dòng)脈；60歲以下沒(méi)有或很少合并癥的冠狀動(dòng)脈旁路移植術(shù)患者可考慮全動(dòng)脈化搭橋手術(shù)。

冠狀動(dòng)脈旁路移植術(shù)；全動(dòng)脈化；通暢率；療效

目前最常用的心肌再血管化手術(shù)方式是采用一支乳內(nèi)動(dòng)脈(IMA)加一支或多支大隱靜脈(SVG)作為橋血管，動(dòng)脈和靜脈移植物的生物學(xué)特性存在明顯差異(如結(jié)構(gòu)、血管壁營(yíng)養(yǎng)供給、內(nèi)皮細(xì)胞及對(duì)血管活性物質(zhì)的反應(yīng))，這些差異導(dǎo)致了其作為橋血管遠(yuǎn)期通暢率的差異，SVG會(huì)逐漸粥樣硬化而閉塞，動(dòng)脈的通暢率遠(yuǎn)高于SVG。SVG閉塞已經(jīng)成為了冠狀動(dòng)脈旁路移植術(shù)(CABG)的絆腳石，于是全動(dòng)脈化及盡量減少SVG使用的再血管化外科手術(shù)呼之而出?，F(xiàn)對(duì)動(dòng)脈化CABG做一簡(jiǎn)要綜述。

1 IMA橋的應(yīng)用

1986年Loop等[1]的報(bào)道顛覆了SVG橋優(yōu)于IMA橋的觀點(diǎn)，從此IMA常規(guī)用于CABG，目前公認(rèn)左乳內(nèi)動(dòng)脈(LIMA)-前降支吻合是CABG的金標(biāo)準(zhǔn)，自然而然地人們想到雙側(cè)乳內(nèi)動(dòng)脈(BIMA)可能更有優(yōu)勢(shì)。1999年報(bào)道了應(yīng)用BIMA在病死率、再次手術(shù)及經(jīng)皮冠狀動(dòng)脈介入術(shù)方面明顯優(yōu)于單側(cè)乳內(nèi)動(dòng)脈(SIMA)[2]。更為精細(xì)的骨骼化乳內(nèi)動(dòng)脈(sIMA)具有除此之外的其他優(yōu)點(diǎn)。sIMA指去除動(dòng)脈周圍組織，最外層僅為動(dòng)脈外膜的IMA。優(yōu)點(diǎn)：長(zhǎng)度較帶蒂的IMA長(zhǎng)(增加2～4 cm)，自身血流量也較大(增加10%～20%)，而且它盡量保留了胸骨血供的側(cè)支循環(huán)，使得術(shù)后胸骨愈合快，感染等并發(fā)癥機(jī)會(huì)少。

動(dòng)脈再血管化實(shí)驗(yàn)(ART)觀察了BIMA與SIMA的療效[3]，30 d和1年的早期病死率和主要并發(fā)癥相同，胸骨創(chuàng)傷需再處理者BIMA略高。中期研究結(jié)果尚在進(jìn)行中。

5年時(shí)無(wú)癥狀患者計(jì)劃冠狀動(dòng)脈造影發(fā)現(xiàn)，原位IMA通暢率為95.5%，游離IMA為91.4%，兩者之間無(wú)顯著差異(P=0.13)；SVG通暢率略高于游離動(dòng)脈橋(P=0.07)，但明顯低于原位IMA(P=0.01)。5年時(shí)無(wú)癥狀患者隨意的冠狀動(dòng)脈造影顯示原位LIMA和右乳內(nèi)動(dòng)脈(RIMA)通暢率95.8%，和計(jì)劃冠狀動(dòng)脈造影相同，明顯高于游離動(dòng)脈橋(P=0.02)和SVG(P<0.01)；游離動(dòng)脈橋和SVG通暢率分別為89.1%和82.4%，無(wú)顯著差異(P=0.09)[4]。Kurlansky等[5]報(bào)道原位RIMA吻合至左冠狀動(dòng)脈還是右冠狀動(dòng)脈效果無(wú)差異，但大多數(shù)術(shù)者認(rèn)為L(zhǎng)IMA之外的RIMA應(yīng)吻合至狹窄嚴(yán)重的血管，其通暢的前向血流有助于提高遠(yuǎn)期通暢率。

與傳統(tǒng)的LIMA加SVG相比，應(yīng)用BIMA近期病死率相近，但10年的病死率及心肌梗死等心臟事件明顯減少，LIMA加SVG被認(rèn)為是遠(yuǎn)期死亡、心臟事件的獨(dú)立危險(xiǎn)因素[6]。

對(duì)比BIMA和LIMA長(zhǎng)期生存的meta分析顯示[7]，27項(xiàng)觀察實(shí)驗(yàn)包含了79 063例患者(BIMA 19 277例，LIMA 59 786例)，BIMA組長(zhǎng)期生存率明顯高于LIMA組(P<0.000 01)，搭橋患者BIMA橋應(yīng)是一線選擇。Yi等[8]的meta分析包含了15 583例患者，顯示10年生存率BIMA優(yōu)于SIMA，這種優(yōu)勢(shì)在第二個(gè)10年似乎仍在繼續(xù)。Benedetto等[9]的meta分析尋找CABG的最佳第二條血管：術(shù)后造影通暢率RIMA和橈動(dòng)脈(RA)明顯優(yōu)于SVG，RIMA優(yōu)于RA。

雖然有如此多的優(yōu)點(diǎn)，BIMA的應(yīng)用在歐洲<10%，美國(guó)<5%，中國(guó)尚無(wú)統(tǒng)計(jì)數(shù)據(jù)。

2 RA血管橋的應(yīng)用

2.1 RA應(yīng)用概述

RA是具有高度痙攣特性的第三類動(dòng)脈。1971年Carpentier首先使用，后因較高的狹窄和早期閉塞率而被拋棄。這可能和早期的單純?nèi)〕鯮A、不用血管擴(kuò)張劑、金屬探條擴(kuò)張RA這些方法有關(guān)。隨著后來(lái)認(rèn)識(shí)的提高、方法的改進(jìn)，目前已常規(guī)用于臨床實(shí)踐。

2.2 RA橋生存率

與靜脈橋相比，RA 能適應(yīng)動(dòng)脈壓力，不含靜脈瓣且內(nèi)徑均一，獲取后不影響術(shù)后活動(dòng)，可減少早期、晚期病死率和致殘率，提高遠(yuǎn)期生存率。在患者接受程度方面，Zhu等[10]認(rèn)為獲取RA比獲取SVG有較高的患者舒服度及較少的疤痕不適程度。與其他動(dòng)脈移植血管相比，肥胖、糖尿病、以往有腹部手術(shù)史者均不影響RA的獲取，使其可用于大多數(shù)患者。

隨著時(shí)間的推移，對(duì)RA橋生存率的認(rèn)識(shí)也隨之而變。1998年Borger等[11]報(bào)道與RIMA相比，作為第二選擇的RA血管橋，一般認(rèn)為雖然圍術(shù)期和中期心臟并發(fā)癥發(fā)生率和病死率沒(méi)有差別，但胸骨感染率低，輸血量少。RA可安全地應(yīng)用于中至重度左心功能低下和年齡> 65歲的患者。2003年Caputo等[12]的研究認(rèn)為，用RA作為除LIMA以外的第二根動(dòng)脈移植血管比用RIMA作為第二根動(dòng)脈移植血管具有早期和中期臨床優(yōu)勢(shì)。2014年Navia等[13]報(bào)道了1 700例非體外循環(huán)下CABG長(zhǎng)期療效隨訪結(jié)果，除LIMA外，第二支血管橋選擇RIMA或RA，顯示BIMA在術(shù)后生存、再次干預(yù)/住院及聯(lián)合終點(diǎn)方面均明顯優(yōu)于LIMA+RA。

Hayward等[14]報(bào)道6年生存率(P=0.36)和無(wú)事件生存率(P=0.08)RA和游離RIMA無(wú)差異。平均6年隨訪，70歲以下患者生存率RA有優(yōu)于游離RIMA的趨勢(shì)，但差異不顯著，70歲以上組患者RA和SVG結(jié)果相同[15]。

2.3 RA橋造影通暢率

2.3.1 RA橋早、中期通暢率

Desai等[16]報(bào)道1年時(shí)冠狀動(dòng)脈造影RA閉塞率8.2%，SVG閉塞率13.6%(P= 0.009)，線樣征分別為7%和0.9%(P=0.001)，RA的通暢率取決于靶血管的狹窄程度。而Goldman等[17]報(bào)道1年時(shí)造影通暢率RA和SVG無(wú)差異(89% vs 89%，P=0.98)。RA通暢性和臨床結(jié)果研究(RAPCO) 5年中期結(jié)果不支持RA比游離RIMA有較高的通暢率，以及同游離RIMA或隱靜脈移植血管相比臨床相關(guān)事件較少的假設(shè)[18]。術(shù)后平均5.5年造影顯示，移植橋失功(閉塞+線樣征)70歲以下患者RA和游離RIMA無(wú)差異，70歲以上患者RA和SVG無(wú)差異[19]。RA通暢性研究(RAPS)顯示，5年以上[平均(7.7±1.5)年]RA橋的功能閉塞率(12.0% vs 19.7%，P=0.03)和完全閉塞率(8.9% vs 18.6%，P=0.002)均低于SVG橋[20]。Collins等[21]報(bào)道其單中心吻合至回旋支分支血管的結(jié)果，5年時(shí)造影RA通暢率98.3%，SVG通暢率86.4%(P=0.04)，其中各有10%和23%的通暢血管有狹窄，RA的通暢率甚至超過(guò)了報(bào)道的IMA通暢率。

2.3.2 RA橋中期通暢率meta分析

中期(3年以上)血管造影meta分析提示[22]，RA閉塞率明顯低于SVG(6.7% vs 17.2%，P<0.000 1)，線樣征RA明顯高于SVG(3.1% vs 0%，P=0.03)，移植橋失功RA明顯低于SVG(9.6% vs 18.8%，P=0.000 5)，移植橋完全通暢率RA明顯高于SVG(88.6% vs 75.8%，P=0.005)。認(rèn)為近段狹窄嚴(yán)重者應(yīng)用RA比SVG在中期造影方面有明顯優(yōu)勢(shì)，但RA線樣征增多。

2.3.3 RA橋早、中期通暢率影響因素

術(shù)后1年造影的隨機(jī)對(duì)照研究提示，糖尿病和靶血管直徑細(xì)增加了橋血管的閉塞，吻合口近端狹窄嚴(yán)重可降低閉塞率；RA閉塞率男性(8.6%)和女性(5.3%)之間無(wú)顯著差異(P=0.06)，而SVG男性明顯低于女性(12.0% vs 23.3%，P=0.02)；外周血管病史和RA閉塞風(fēng)險(xiǎn)有關(guān)，但和早期SVG閉塞無(wú)關(guān)[23]。右冠狀動(dòng)脈粗大、狹窄較輕者更適合應(yīng)用SVG或支架治療。

3 胃網(wǎng)膜右動(dòng)脈血管橋的應(yīng)用

3.1 胃網(wǎng)膜右動(dòng)脈應(yīng)用概述

既往文獻(xiàn)報(bào)道，胃網(wǎng)膜右動(dòng)脈(RGEA)動(dòng)脈粥樣硬化發(fā)生率低，組織學(xué)特性與IMA相似，原位移植能達(dá)到心臟的后壁和側(cè)壁。骨骼化RGEA(sRGEA)的管徑、長(zhǎng)度、血流量都有所增加，另外，sRGEA還可以保留胃的靜脈和淋巴管道。獲取RGEA只需將胸骨正中切口稍微向下延長(zhǎng)，毋須前臂或下肢的其他切口，創(chuàng)傷相對(duì)較小，腹部并發(fā)癥并未增加[24]，且認(rèn)為RGEA橋血管血流量隨著需氧量的增加而增加；對(duì)于完全通暢的RGEA，橋血管隨著時(shí)間的推移其管徑逐漸增加[25]。原位RGEA橋血管由于管徑太小、血流量太少而引起競(jìng)爭(zhēng)性血流，這是影響其通暢率的最主要因素[26-27]。應(yīng)用超聲刀獲取sRGEA，可以在一定程度上增加長(zhǎng)度、管徑和血流量，且超聲刀的使用并不影響內(nèi)皮細(xì)胞的功能。

3.2 RGEA早、中期療效

RGEA橋血管已取得了良好的早期和中期臨床、血管造影結(jié)果。隨著時(shí)間的推移，冠狀動(dòng)脈本身狹窄會(huì)逐漸加重，RGEA橋血管的遠(yuǎn)期預(yù)后優(yōu)勢(shì)會(huì)更加明顯。對(duì)靶血管的選擇是影響預(yù)后最重要的因素。單純sRGEA的CABG患者術(shù)后1個(gè)月、27個(gè)月通暢率分別為97.6%和91.5%[28]。Ali等[29]對(duì)2000～2007年發(fā)表的關(guān)于RGEA橋血管的文獻(xiàn)進(jìn)行了分析總結(jié)，sRGEA取得了很好的早期和中期通暢率，3個(gè)月、1年、2年和4年的平均通暢率分別為97.7%、92.4%、91.5%和86.4%，并且支持sRGEA的證據(jù)在增加。Suma等[24]對(duì)1986～2006年1 352例應(yīng)用RGEA橋血管(包括骨骼化和非骨骼化RGEA)行CABG的患者進(jìn)行了研究，5年、10年和15年實(shí)際生存率分別為91.7%、81.4%和71.3%，非心臟事件生存率分別為95.8%、91.7%和88.6%，RGEA橋血管平均2.1個(gè)月、2.4年和8.7年的通暢率分別為95%、88%和87%。

4 IMA+RGEA療效

4.1 IMA+RGEA早、中期療效

Kim等[30]對(duì)175例BIMA吻合于左冠狀動(dòng)脈系統(tǒng)、sRGEA吻合于右冠狀動(dòng)脈系統(tǒng)的CABG患者進(jìn)行了對(duì)照研究，術(shù)后早期、術(shù)后1年RGEA和BIMA通暢率分別為98.8%、99.3%，91.9%、97.2%；競(jìng)爭(zhēng)性血流的發(fā)生率分別為5.6%、2.5%，6.8%、4.4%。Hirose等[31]對(duì)1991～2001年1 000例CABG患者隨訪研究發(fā)現(xiàn)原位RGEA和LIMA術(shù)后1年、3年和5年通暢率分別為98.7%、91.1%、84.4%，99.6%、98.8%、97.0%(P<0.000 5)。

4.2 BIMA+RGEA遠(yuǎn)期療效

Tavilla等[32]采用帶蒂的BIMA和RGEA應(yīng)用于3支血管病變的患者，7年、10年實(shí)際生存率為91%、87%；出院后5年、10年無(wú)心絞痛發(fā)生率分別為97%和86%。與BIMA和SVG復(fù)合橋血管相比，7年實(shí)際生存率相當(dāng)，心絞痛的發(fā)生率明顯減低。但Esaki等[33]對(duì)1989～1999年采用BIMA吻合于左冠狀動(dòng)脈系統(tǒng)，RGEA原位橋血管(99例)和SVG(212例)吻合于右冠狀動(dòng)脈系統(tǒng)的患者進(jìn)行了為期7年的隨訪研究，采用多因素分析的方法發(fā)現(xiàn)，RGEA橋血管不是一個(gè)重要的生存預(yù)測(cè)因素，認(rèn)為與SVG相比，RGEA橋血管并不能改善BIMA CABG患者的遠(yuǎn)期預(yù)后。

但是，術(shù)后血脂水平對(duì)橋血管通暢率也有影響，這方面的研究也支持應(yīng)用選擇動(dòng)脈橋[34]。并且雙側(cè)IMA+RGEA可避免接觸升主動(dòng)脈，可將潛在的腦卒中風(fēng)險(xiǎn)降到最低。老年、升主動(dòng)脈硬化嚴(yán)重者需要“主動(dòng)脈不接觸技術(shù)”。

5 國(guó)內(nèi)全動(dòng)脈化搭橋手術(shù)應(yīng)用狀況

相對(duì)于國(guó)外全動(dòng)脈化搭橋的臨床實(shí)踐、療效觀察及基礎(chǔ)研究，國(guó)內(nèi)多為臨床實(shí)踐的文獻(xiàn)報(bào)道，但100例以上的報(bào)道不多。

全動(dòng)脈化的方法很多：應(yīng)用LIMA、BIMA、RGEA和RA的，BIMA“Y”形橋，IMA和RA“Y”形橋，BIMA應(yīng)用為P形橋，應(yīng)用LIMA、BIMA和RA，應(yīng)用BIMA和RA，部分報(bào)道應(yīng)用雙側(cè)RA。

sIMA的應(yīng)用報(bào)道不多，有時(shí)是單側(cè)IMA骨骼化[35]。國(guó)內(nèi)應(yīng)用RA的病例也明顯多于RGEA，技術(shù)瓶頸可能是主要原因。

2014版歐洲心肌再血管化指南提出[36]：預(yù)期壽命5年以上的患者，70歲以下的患者應(yīng)選擇BIMA，最小程度的主動(dòng)脈操作；2011年美國(guó)CABG指南提出[37]：60歲以下沒(méi)有或很少合并癥的CABG患者可考慮全動(dòng)脈化搭橋手術(shù)(Ⅱb，C級(jí))；合適的情況下應(yīng)用第二條IMA吻合至回旋支或右冠狀動(dòng)脈可提高生存率及降低再干預(yù)概率(Ⅱa，B級(jí))。

綜合國(guó)外文獻(xiàn)，LIMA應(yīng)為CABG的常規(guī)選用血管，且應(yīng)常規(guī)吻合至前降支；BIMA效果最佳，而骨骼化BIMA可達(dá)到需要搭橋的靶血管，其他動(dòng)脈血管可選擇RGEA和/或RA，且原位移植比游離血管效果更理想。

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Effects and Patency of Coronary Artery Bypass Grafting Used in China

QI Hongwei,YUAN Biao

(Cardiovascular Center,Beijing Tongren Hospital,Capital Medical University,Beijing 100730,China)

One internal-mammary-artery(IMA) and one or more saphenous vein(SV) were commonly used in coronary artery bypass grafting. However, SV will occlude with progressive atherosclerosis. The expansion of obstructions (patency) of arterial grafts was much better than saphenous vein grafts(SVG). Left IMA(LIMA) was routinely used in coronary artery bypass grafting. However in comparison with group bilateral IMA(BIMA), LIMA+SV(s) was an independent risk factor from lower chances of cardiac death, acute myocardial infarction, acute myocardial infarction in a grafted area and cardiac events. Both IMA have similar patency when used on left-sided coronaries and as in-situ or composite grafts, but have inferior patency if anastomosed to aorta. Therefore the patency of IMA in-situ was superior than the free IMA. Right gastroepiploic artery and radial artery was suitable anastomose to the coronary artery with severe proximal stenosis. BIMA with right gastroepiploic artery could decrease the central nervous system complications as far as possible because of it does not touch the aorta. When a patient undergoes their first coronary surgery and is younger than 70 years, BIMA grafting should not be denied, especially if their life expectancy is higher than 5 years. Complete arterial revascularization may be reasonable for patients less than or equal to 60 years of age with few or no co-morbidities.

coronary artery bypass grafting; complete arterial revascularization; angiographic patency; outcome

國(guó)家自然科學(xué)基金(81370237)

齊弘煒(1970—)，副主任醫(yī)師，博士，主要從事心外科相關(guān)臨床研究。Email: qiheart@sohu.com

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A

10.3969/j.issn.1004-3934.2015.05.009

2014-11-06

2015-05-07