동맥 도관만을 이용하여 체외심폐순환 없이 시행한 관상동맥우회술 = Off Pump Total Arterial Myocardial Revascularization

국문 초록 (Abstract)

배경: 관상동맥우회술에서 사용된 동맥 도관은 정맥 도관보다 우수한 장기 개존율을 보이며, 그에 따른 향상된 단기 및 장기 임상성적이 보고되어 있다. 또한, 심폐체외순환기를 사용하지 않고 시행하는 관상동맥우회술(Off pump coronary artery bypass grafting; Off pump CABG) 역시 기존의 심폐체외순환기를 사용하는 관상동맥우회술에 비해 좋은 수술성적이 보고되고 있다. 따라서 동맥 도관만을 이용한 Off pump CABG를 시행하면 보다 좋은 결과를 얻을 수 있을 것으로 생각하여, 저자들은 동맥 도관만을 이용하여 Off pump CABG을 시행한 환자들의 임상 결과를 분석하였다. 대상 및 방법: 2001년 1월부터 2004년 10월까지 Off pump CABG을 시행 받았던 630명의 환자 중 동맥 도관만을 사용하였던 325명을 대상으로 하였다. 대상 환자들의 수술 전 위험요인, 관상동맥질환의 정도 및 수술성적에 대해 조사하였다. 환자들의 평균 연령은 59.3 11.9 (36∼83세)세였고, 평균 좌심실박출계수는 55.4 14.0% (15∼86%)였다. 대상 환자의 81.9%에서 삼혈관 질환, 또는 좌주관상동맥 질환을 보였다. 동맥을 사용하는 적응증은 좌전하행지는 협착이 50% 이상, 회선동맥 분지는 80% 이상, 우관상동맥은 90% 이상인 경우로 하였다. 수술 후 7∼10일에 총 194명의 환자에서 multi-slice 컴퓨터 단층촬영을 시행하여 동맥 이식편의 개존율을 조사하였다. 결과: 이용된 동맥 도관은 좌내흉동맥 322예(99.1%), 요골동맥 297예(91.4%), 우내흉동맥 157예(48.3%), 그리고 우위대망동맥 12예(3.7%)였다. 환자당 평균 2.46 0.56개의 동맥을 획득하여, 좌전하행지 329곳, 대각지 123곳, 변연둔각지 285곳, 그리고 우관상동맥 191곳 등 총 928곳에 문합하여, 환자당 평균 2.86 0.78개의 문합률을 보였다. 수술 후 사망은 1예(0.3%)였다. 수술 후 뇌경색은 없었으며 주요 합병증으로는 종격동염 6예(1.8%), 신부전증 4예(1.2%), 심근경색이 3예(0.9%), 그리고 출혈로 인한 재수술이 3예(0.9%) 있었다. 총 혈관 개존율은 99.3% (581/585)였고, 좌내흉동맥, 요골동맥, 우내흉동맥 및 우위대망동맥의 개존율은 각각 100% (207/207), 99.2% (238/240), 98.5% (133/135) 및 100% (3/3)였다. 각각 두 개의 요골동맥과 우내흉동맥에서 부분협착이나 경쟁혈류가 관찰되었다. 결론: 동맥 도관만을 이용한 Off pump CABG를 시행하여 감염의 위험성을 증가시키지 않으면서 영구적인 신경학적 합병증을 일으키지 않았고 좋은 혈관 개존율을 보여주었다. 따라서 동맥 도관을 이용한 Off pump CABG는 관상동맥의 협착의 정도에 따라 효율적으로 시행 시 좋은 임상결과를 얻을 수 있을 것으로 생각된다.

다국어 초록 (Multilingual Abstract)

Background: Arterial conduits using in coronary artery bypass grafting (CABG) have been known a great long term patency rates, and improved short and long term clinical outcomes. It has been reported that Off pump CABG has better clinical results than CABG using cardiopulmonary bypass. To evaluate the advantage of arterial conduits over venous conduits and to avoid the adverse effects of cardiopulmonary bypass, we performed total arterial Off pump CABG. Material and Method: From January 2001 to October 2004, Off pump CABG using only arterial conduits was performed on 325 patients with a mean age of 59.3±11.9 years (36～83). Mean ejection fraction was 55.4±14.0% (15～86). Angiography showed left main disease or triple-vessel disease in 81.9% of the patients. Indications of using arterial conduits was stenosis ≥50% of left anterior descending artery, stenosis ≥80% of branches of left circumflex artery, and stenosis ≥90% of right coronary artery and its branches. Multi-slice computed tomography was performed on 194 patients to evaluate the short term patency rates. Result: A total of 928 distal anastomoses were performed and the average anastomoses per a patient were 2.86±0.78. There was 1 operative mortality. Postoperative complications were mediastinitis in 6 patients (1.8%), renal failure in 4 patients (1.2%), perioperative myocardial infarction in 3 patients (0.9%), reoperation for bleeding in 3 patients (0.9%). There was no postoperative stroke. Patency rate of arterial conduits was 99.3% (581/585). There were 4 stenoses or competitive flows in 2 radial arteries and 2 right internal mammary arteries. Conclusion: Total arterial Off pump CABG appears to be safe, showing a low surgical mortality and morbidity and excellent short term patency rates of arterial conduits.

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