Journal of Chest Surgery

The Korean Society for Thoracic and Cardiovascular Surgery (대한심장혈관흉부외과학회)
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Off-Pump Total Arterial Revascularization Using the Skeletonized Right Gastroepiploic Artery as a Third Arterial Conduit; Early and Midterm Results

제3동맥 도관으로서의 골격화된 우위대망동맥을 사용하여 시행한 심폐바이패스를 사용하지 않는 관상동맥 우회술;초기 및 중기 결과

  • 이현주 (서울대학교병원 흉부외과학교실) ;
  • 최재성 (서울대학교병원 흉부외과학교실) ;
  • 김기봉 (서울대학교병원 흉부외과학교실)
  • Published : 2003.09.01
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Abstract

The aim of this study was to evaluate the early and midterm results of off-pump total arterial revascularization using the skeletonized right gastroepiploic artery (RGEA) as a third arterial conduit. Material and Method: We prospectively analyzed 103 patients who underwent off-pump total arterial revascularization using bilateral internal thoracic arteries (ITAS) and RGEA. The RGEA was used as in situ graft in 88 patients, composite graft in 10 patients, and free graft in 5 patients. Postoperative coronary angiographies were performed before discharge in 100 patients, and at postoperative one year in 88 patients. Result: The RGEA showed a significantly higher free flow (130$\pm$95 ml/min) than that of right ITA(113$\pm$57 ml/min) or left ITA (107$\pm$55 ml/min), which was measured before anastomosis (p < 0.05). The total number of distal anastomoses was 3.8$\pm$0.7. The number of distal anastomoses per bilateral ITAs was 2.8$\pm$0.7 and the number of distal anastomosis per RGEA was 1.0. There were two morialities including one operative mortality. The late mortality was not related to cardiac events. Early postoperative morbidities were atrial fibrillation in 15 patients, bleeding reoperation in 4 patients, mediastinitis in 1 patients, perioperative myocardial infarction in 2 patient, and transient ARF in 3 patients. Postoperative coronary angiographies showed the early patency rate of 98.6％ (272/276) for ITAs and 97.0％ (97/100) for RGEA, respectively (p=ns), and the one-year patency rate of 95.9％ (234/244) for ITAs and 88.6％ (78/88) for RGEA, respectively (p=0.07). Flow competition between the RGEA and NCA (native coronary artery) was seen in 5 of the 100 patients (5.0％) immediate postoperatively and 7 of the 88 patients (8.0％) 1 year after surgery. Since July, 2000, we measured transit time flow intraoperatively and could reduce flow competition significantly Conclusion: The skeletonized RGEA demonstrated excellent early and midterm patency rates and could be used as a third arterial graft following the bilateral ITAs.

심폐바이패스를 사용하지 않는 관상동맥우회술에서 골격화된(skeletonized) 양측 내흉동맥 이외에 골격화된 우위대망동맥을 함께 사용한 환자들에서 수술 직후와 1년째의 성적을 비교하였다. 대상 및 방법: 1999년 8월부터 2001년 12월까지 서울대학교병원 흉부외과에서 골격화된 양측 내흉동맥과 우위대망동맥을 이용하여 시행한 103예의 관상동맥우회수술을 대상으로 하였다 이중 우위대망동맥을 유근이식편(in situ graft)으로 사용한 것이 88예, 근위부를 다른 혈관 도관에 연결(composite graft)하여 사용한 것이 10예, 대동맥에 연결(free graft)하여 사용한 것이 5예로 각각의 경우 수술 직후와 1년후 혈관조영검사를 통해 도관의 기능을 평가하였다. 결과: 평균 문합수는 3.8$\pm$0.7개였고 수술 직전 측정한 도관의 자유혈류량(free flow (ml/rnin))은 우위대망동맥이 130$\pm$95 ml/min로 좌내흉동맥(107$\pm$55 ml/min)과 우내흉동맥(113$\pm$57 ml/min)에 비해 유의하게 많았다(p<0.05). 수술 후 100명(97.1%)의 환자에게 평균 1.3$\pm$0.8일째에 혈관 조영 검사를 시행하였는데 내흉동맥은 98.6% (272/276),우위대망동맥은 97.0% (97/100)의 개통률을 보였다(p=ns). 퇴원 후에 평균 12.4$\pm$3.7개월째에 다시 88명(85.4%)의 환자에서 혈관 조영 검사를 시행하였다 개통률은 내흉동맥과 우위대망동맥이 각각 95.9%(234/244), 88.6%(78/88)로 내흉동맥이 조금 우세하였지만 통계적 유의성은 없었다(p=0.07). 우위대망동맥과 자신의 관상동맥 사이 혈류경쟁(flow competition)의 소견은 수술 직후에 5예, 1년 뒤에 7예에서 관찰되었는데 TTFM (transit time flow measurement)을 수술 중에 시행하여 혈류경쟁이 의심되는 경우에서 교정을 시행한 이후에는 각각 1예와 2예로 유의하게 줄어듦을 관찰할 수 있었다. 결론: 우위대망동맥은 내흉동맥에 이어 비교적 안전하게 사용할 수 있는 제3의 동맥 도관이며, 수술 중 혈류 측정, 대상 혈관의 정확한 수술 전 평가 등을 통해 중장기 개통률을 향상시킬 수 있다.

Keywords

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