6 4层多排CT对冠状动脉旁路移植术后的中期随访：影响桥血管通畅性的危险因素研究

doi:10.24920/11811

摘要/Abstract

摘要：

目的使用64层多排螺旋CT评价冠状动脉旁路移植术后左内乳动脉桥（LIMA）和大隐静脉桥（SVG）血管的通畅性,并探讨影响冠脉旁路移植术后中期桥血管通畅性的危险因素。方法收集2012年8月至2015年12月接受冠脉旁路移植手术及并术后采用64层多排螺旋CT（MDCT）随访的病例。根据CT表现将桥血管的通畅状态分为通畅及不通畅两大类。搜集患者的临床资料及影像资料并比较通畅组和不通畅组间的差异。采用单因素及多因素Logistic回归分析影响桥血管通畅性的危险因素。结果 341个患者中有330支LIMA桥血管（326支吻合到前降支LAD,4支吻合到右冠状动脉RCA）和564支SVG桥血管（100支吻合到对角支D,220支吻合到钝缘支OM,238支吻合到右冠脉血流灌注区）。吻合到OM和右冠脉血流灌注区的SVG桥血管的通畅率明显高于吻合到D的通畅率（χ ²=15.471, P=0.004）。吻合口近端靶血管狭窄程度小于90%是LIMA桥血管闭塞的独立危险因素(OR =0.015, 95% CI=0.01-0.14, P=0.000),而高脂血症(OR =1.52, 95% CI=1.0-2.5, P=0.048)、糖尿病(OR =1.28, 95% CI=0.90-2.26, P=0.045)及出现胸痛或呼吸困难等冠心病症状(OR=1.81,95% CI=1.33-4.15,P=0.003) 是SVG桥血管闭塞的独立危险因素.结论当冠状动脉旁路移植术吻合口近端前降支的狭窄率小于90%时,LIMA桥血管中期闭塞的危险性升高。高脂血症、糖尿病史及典型的冠心病的症状是SVG桥血管中期闭塞的危险因素。吻合口远端靶血管的选择也是影响SVG术后通畅性的重要因素。

关键词: 冠状动脉旁路移植, 计算机断层扫描, 心血管危险因素, 移植血管通畅性

Abstract:

Objective To identify the risk factors that are associated with the midterm coronary artery bypass grafting (CABG) functionality by assessing patency of left internal mammary artery (LIMA) graft and saphenous vein (SV) graft with 64-slice multi-detector computed tomography (64-MDCT).Methods Patients who underwent CABG operation and postoperative 64-MDCT follow-up examinations from August 2012 to December 2015 were included. The graft patent status was classified into patent and poor patent according to MDCT findings predominantly on 3D reconstructed images by two radiologists. The clinical data and imaging findings of the patients were collected and compared between the patent group and poor patent group. Univariate analysis and the multivariate logistic regression analysis were performed to identify the risk factors that affect graft patency.Results Among 341 patients in the study, there were 330 LIMA grafts [326 anastomosed to the left anterior descending artery (LAD), 4 to right coronary artery (RCA)] and 564 SV grafts (SVG) [100 anastomosed to the diagonal branch (D), 226 to the obtuse marginal branch (OM), and 238 to the RCA territory]. The approximal vessel stenosis exceeding 90% occurred in 268 of 292 patent LIMA grafts, and in 1 of 34 poor patent grafts (χ ²=167, P<0.001). The patency rate was higher when SVG was anastomosed to OM (85.4%) or RCA territory (81.9%) than to D (69.0%) (χ ²=15.471, P=0.004). The proximal target vessel stenosis < 90% (OR= 0.015, 95% CI: 0.01-0.14, P=0.000) was independently associated with the closure risk of LIMA grafts, the dyslipidemia (OR= 1.52, 95% CI: 1.0-2.5, P=0.048), history of diabetes (OR = 1.28, 95% CI : 0.90-2.26, P=0.045) and typical angina symptoms (OR=1.81, 95% CI :1.33-4.15, P=0.003) were independently associated with the closure risk of SVG. Conclusions The proximal LAD stenosis less than 90% was adversely associated with graft patency in LIMA recipients; dyslipidemia, diabetes and angina symptoms were associated with the midterm failure in SVG recipients. The choice of the target anastomosis sites may affect the patency of SVG.

Key words: coronary artery bypass graft, computed tomography, cardiovascular risk factor, graft vessel patency

Li Tao, Yang Li, Zhang Weiguo, Luo Chuncai, Huang Zili, Li Jinfeng, Li Xin. Midterm Follow-up of Coronary Artery Bypass Grafting with 64-Slice Multi-detector Computed Tomography: Identification of Risk Factors Affecting Graft Patency[J].Chinese Medical Sciences Journal, 2018, 33(2): 69-76.

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Clinical characteristics	Patient groups		In total	t or χ²value	Pvalue
Clinical characteristics	Patent grafts (n=231)	Poor patent grafts (n=110)	In total	t or χ²value	Pvalue
Sex
Male, n (%)	188(81.4)	85(77.3)	273	0.79	0.37
Female, n (%)	43(18.6)	25(22.7)	68	0.79	0.37
Age, years	62.7±10.3	62.5±10.0	62.6±10.2	0.42	0.87
Bypass grafts, n (%)	574	320	894
Body Mass Index	30.1±5.8	30.5±6.1	30.2±5.9	0.55	0.45
History of
Diabetes, n (%)	72(31.2)	41(37.3)	113	1.25	0.26
Hypertension, n (%)	157(68.0)	61(55.5)	218	5.06	0.025
Dyslipidemia, n (%)	58(25.1)	38(34.5)	96	3.28	0.07
Smoking, n (%)	118(51.1)	48(43.6)	166	1.65	0.20
Cerebrovascular disease, n (%)	28 (12.1)	26 (23.6)	54	7.41	0.006
Post-operative adjuvant medication
Beta blocker, n (%)	101(43.7)	48(43.6)	149	0.00	0.98
ACE inhibitor, n (%)	58(25.1)	27(24.5)	85	0.01	0.9
Statin, n (%)	107(46.3)	49(44.5)	156	0.10	0.76
Calcium channel blocker, n (%)	21(9.1)	9(8.2)	30	0.08	0.78
Symptomatic, n (%)	39(16.9)	15(13.6)	54	0.59	0.44

Graft type	Target vessel	Patent, n (%) (n=751)	Poor patent, n (%) (n=143)	In total (n=894)
LIMA*		294(89.1)	36(10.9)	330
	LAD	292(89.6)	34(10.4)	326
	RCA	2(50.0)	2(50.0)	4
SV**		457(81.0)	107(19.0)	564
	D	69(69.0)	31(31.0)	100
	OM	193(85.4)	33(14.6)	226
	RCA territory	195(81.9)	43(18.1)	238

Variates	Patency of LIMA grafts				Patency of SV grafts
Variates	Patent n=294	Poor patent, n=36	χ²	P value	Patent n=457	Poor patent n=107	χ²	Pvalue
Male, n (%)	266(90.5)	29(80.6)	6.85	0.03	372(81.4)	82(76.6)	1.22	0.27
Hypertension, n(%)	259(88.1)	33(91.7)	0.68	0.71	383(83.8)	79(73.8)	8.06	0.005
Dyslipidemia, n(%)	259(88.1)	32(88.9)	2.53	0.28	340(74.4)	91(85.0)	3.56	0.04
Diabetes, n (%)	267(90.8)	32(88.9)	1.08	0.58	345(75.5)	89(83.2)	4.39	0.036
Smoking, n (%)	268(91.2)	31(86.1)	2.76	0.25	376(82.3)	84(78.5)	1.36	0.24
Cerebrovascular disease, n (%)	230(78.2)	33(91.7)	10.47	0.005	366(80.1)	86(80.4)	0.00	0.98
Symptomatic, n(%)	255(86.7)	32(88.9)	0.57	0.75	326(71.3)	88(82.2)	5.18	0.023
Proximal target vessel stenosis >90%, n (%)	290(98.6)	14(38.9)	169	<0.001	NA	NA	NA	NA

Risk factors	LIMA graft closure (n=330)		SV graft closure (n=564)
Risk factors	Odds ratio (95% CI)	Pvalue	Odds ratio (95% CI)	Pvalue
Gender	3.82(0.73-20.05)	0.11	1.38 (0.77-2.50)	0.28
Hypertension	1.99(0.39-10.05)	0.41	0.61(0.38-0.98)	0.04
Dyslipidemia	1.48 (0.30-7.37)	0.64	1.52(1.00-2.5)	0.048
Diabetes	0.14(0.02-1.32)	0.09	1.28(0.90-2.26)	0.045
Smoking	0.53(0.10-2.93)	0.47	0.96(0.59-1.57)	0.88
Cerebrovascular disease	2.55(0.41-15.93)	0.32	1.0(0.53-1.88)	1.00
Symptomatic	1.01(0.09-11.25)	0.99	1.81(1.33-4.15)	0.003
Proximal target vessel stenosis <90%	0.015(0.01-0.14)	0.000	NA	NA

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