Journal of Chest Surgery

The Korean Society for Thoracic and Cardiovascular Surgery (대한심장혈관흉부외과학회)
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Clinical Outcome of Emergency Coronary Artery Bypass Grafting after Failed Percutaneous Transluminal Coronary Angioplasty

경피적 관상동맥 성형술의 실패에 의해 발생한 응급환자의 임상경과

  • Kim, Do-Kyun (Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine) ;
  • Yoo, Kyung-Jong (Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine) ;
  • Youn, Young-Nam (Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine) ;
  • Yi, Gi-Jong (Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine) ;
  • Lee, Sak (Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine) ;
  • Chang, Byung-Chul (Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine) ;
  • Kang, Meyun-Shick (Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine)
  • 김도균 (연세대학교 의과대학 신촌세브란스병원 흉부외과) ;
  • 유경종 (연세대학교 의과대학 신촌세브란스병원 흉부외과) ;
  • 윤영남 (연세대학교 의과대학 신촌세브란스병원 흉부외과) ;
  • 이기종 (연세대학교 의과대학 신촌세브란스병원 흉부외과) ;
  • 이식 (연세대학교 의과대학 신촌세브란스병원 흉부외과) ;
  • 장병철 (연세대학교 의과대학 신촌세브란스병원 흉부외과) ;
  • 강면식 (연세대학교 의과대학 신촌세브란스병원 흉부외과)
  • Published : 2007.03.05
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Abstract

Background: Failed percutaneous transluminal coronary angioplasty (PTCA) is occasionally required for emergency coronary artery bypass grafting (CABG). The aim of this study was to assess the outcome of patients receiving emergency CABG after failed PTCA. Material and Method: Between May 1988 and May 2005, 5712 patients underwent PTCA, where 84 (1.4%) failed. 27 patients underwent emergency CABG after failed PTCA. The mean age was $63.7{\pm}8.9\;(46{\sim}80)$ years, with 14 male patients (51.9%). Result: All patients underwent emergent surgical revascularization within 6 hours. 22 patients underwent conventional CABG and 5 underwent off-pump CABG. The causes of PTCA failure were coronary obstruction due to new thrombi formation during the procedure (n=4), coronary dissection (n=17), coronary artery rupture (n=3) and 3 due to other causes. The rate of in-hospital operative mortality after emergent operation was 18.5% (5/27). A univariate analysis revealed that patients who died more often had left anterior descending artery disease, a preprocedural shock status, postoperative use of multiple isotropics and postoperative use of intra-aortic balloon pump. The mean follow up duration was $53.6{\pm}63.4$ months. Conclusion: Although PTCA is known to be life saving, there is still a high risk for morbidity and mortality following emergency CABG after failed PTCA, despite the advancement in PTCA techniques. This result will help identify and more effectively treat patients selected for PTCA when emergency CABG is required.

배경: 경피적 관상동맥 성형술(angioplasty, translumial, percutaneous coronary, PTCA)은 현재 거의 모든 관상동맥 협착증 환자에서 시도되고 있다. 따라서 PTCA 실패로 인한 치명적인 응급 상황도 나타나고 있다. 이 연구에서는 PTCA의 실패로 응급 관상동맥 우회술이 필요했던 환자의 임상결과를 분석하고자 한다. 대상 및 방법: 1988년 5월부터 2005년 5월까지 총 5,712예의 PTCA를 시행했고 그 중 실패 후 발생한 응급 환자는 84명(1.4%)이었고 이 중 응급 수술이 가능했던 27명(32.1%)을 대상으로 하였다. 환자들의 평균 연령은 $63.7{\pm}8.9\;(46{\sim}80)$세이었고, 그 중 남자가 14명(51.9%)이었다. PTCA 전 진단은 급성 심근경색(12명), 불안정형 협심증(13명), 안정형 협심증(2명)이었다. 결과: PTCA 실패의 원인으로는 새로운 색전에 의한 관상동맥 폐쇄가 4명, 시술 도중 관상동맥 박리가 17명, 관상동맥 파열이 3명, 기타가 3명이었다. 수술이 가능했던 환자들은 6시간 내로 응급수술을 시행했고 그 중 22명은 고식적 관상동맥 우회술(coronary artery bypass grafting, CABG)을 받았고 5명은 off-pump CABG (OPCAB)을 받았다. 평균 사용된 이식편의 수는 $2.58{\pm}0.95$개였다. 수술 환자 중에서는 18.5%의 사망률을 보였다(5/27). 단변량 분석에서는 수술 환자들의 사망률은 좌전하행지 침범유무, 수술 전 쇼크상태, 수술 후 2가지 이상의 수축 촉진제의 사용, 수술 후에도 대동맥 풍선 펌프를 사용한 경우가 통계적으로 유의하게 나타났다. 결론: PTCA는 환자들이 수술에 비해 상대적으로 안전하다고 생각하지만 PTCA 실패로 인한 응급상황이 발생 시에는 매우 높은 사망률을 보이며 관상동맥 우회술을 시행하더라도 수술 사망률 및 수술 부작용이 상대적으로 높다. 따라서, 치명적인 합병증이 생길 수 있으므로 신중한 환자의 선택이 요구되며 합병증의 발생 시 적극적인 수술 치료를 준비해야 한다.

Keywords

References

  1. Lofti M, Mackie K, Dzavik V, Seidelin PH. Impact of delays to cardiac surgery after failed angioplasty and stenting. J Am Coll Cardiol 2004;43:337-42 https://doi.org/10.1016/j.jacc.2003.08.045
  2. Barakate MS, Banon PG, Hughes CF, Horton MD, Callaway A, Hurst T. Emergency surgery after unsuccessful coronary angioplasty: a review of 15 year' experience. Ann Thorac Surg 2003;75:1400-5 https://doi.org/10.1016/S0003-4975(02)05026-9
  3. Reinecke H, Fetsch T, Roeder N, et al. Emergency coronary bypass grafting after failed coronary angioplasty: what has changed in a decade? Ann Thorac Surg 2000;70:1997-2003 https://doi.org/10.1016/S0003-4975(00)02172-X
  4. Louberyre C, Morice MC, Berzin B, et al. Emergency coronary bypass surgery following coronary angioplasty and stenting. Cathet Cardiovasc Intervent 1999;48:441-8
  5. Haan CK, O'brien S, Edwards FH, Peterson ED, Ferguson TB. Trends in emergency coronary artery bypass grafting after percutaneous coronary intervention, 1994-2003. Ann Thorac Surg 2006;81:1658-65
  6. Shook TL, Sun GW, Burstein S, et al. Comparison of percutaneous transluminal coronary angioplasty outcome and hospital costs for low-volume and high-volume operators. Am J Cardiol 1996;77:331 https://doi.org/10.1016/S0002-9149(97)89138-2
  7. Shaw RE, Anderson HV, Brindis RG, et al. Development of a risk adjustment mortality model using the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) experience: 1998-2000. J Am Coll Cardiol 2002; 39;11:4-12 https://doi.org/10.1016/S0735-1097(02)01889-2
  8. Klein LW, Shaw RE, Krone RJ, et al. Mortality after emergent percutaneous coronary intervention in cardiogenic shock secondary to acute myocardial infarction and usefulness of a mortality prediction model. Am J Cardiol 2005; 96:35-41
  9. Lazar HL, Jacobs AK, Aldea GS, Shapira OM, Lancaster D, Shemin RJ. Factors influencing mortality after emergency coronary artery bypass grafting for failed percutaneous transluminal coronary angioplasty. Ann Thorac Surg 1997;64: 1747-52 https://doi.org/10.1016/S0003-4975(97)00997-1
  10. Wang N, Gundry SR, Van Arsdell G, et al. Percutaneous transluminal coronary angioplasty failures in patients with multivessel disease: is there an increased risk? J Thorac Cardiovasc Surg 1995;110:214-23 https://doi.org/10.1016/S0022-5223(05)80028-5
  11. Borkon AM, Failing TL, Piehler JM, Killen DA, Hoskins ML, Reed WA. Risk analysis of operative intervention for failed coronary angioplasty. Ann Thorac Surg 1992;54: 884-91 https://doi.org/10.1016/0003-4975(92)90641-G
  12. Boylan MJ, Lytle BW, Taylor PC, et al. Have PTCA failures requiring emergent bypass oeration changed? Ann Thorac Surg 1995;59:283-7 https://doi.org/10.1016/0003-4975(94)00943-2
  13. Caes F, Van Nooten G. Use of internal mammary artery for emergency grafting after failed coronary angioplasty. Ann Thorac Surg 1994;57:1295-9 https://doi.org/10.1016/0003-4975(94)91377-3
  14. Nollert G, Amend J, Reichart B. Use of the internal mammary artery as a graft in emergency coronary artery bypass grafting after failed PTCA. Thorac Cardiovasc Surg 1995;43:142 https://doi.org/10.1055/s-2007-1013788
  15. Michihata T, Oki A, Iyano K, et al. Risk assessment in urgent or emergent coronary artery bypass grafting for acute coronary syndrome. Kyobu Geka 1999;52:667-72