Journal of Chest Surgery

The Korean Society for Thoracic and Cardiovascular Surgery (대한심장혈관흉부외과학회)
권호 표지

Risk Factors of Neurologic Complications After Coronary Artery Bypass Grafting

관상동맥 우회수술후 신경계 합병증의 위험인자

  • Park, Kay-Hyun (Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Chae, Hurn (Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Park, Choong-Kyu (Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Jun, Tae-Gook (Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Park, Pyo-Won (Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine)
  • 박계현 (성균관대학교 의과대학, 삼성서울병원 흉부외과) ;
  • 채헌 (성균관대학교 의과대학, 삼성서울병원 흉부외과) ;
  • 박충규 (성균관대학교 의과대학, 삼성서울병원 흉부외과) ;
  • 전태국 (성균관대학교 의과대학, 삼성서울병원 흉부외과) ;
  • 박표원 (성균관대학교 의과대학, 삼성서울병원 흉부외과)
  • Published : 1999.09.01
Download PDF
⟨ Previous Next ⟩

Abstract

Background: As the early outcome after coronary artery bypass grafting(CABG) has been stabilized, neurologic complication has now become one of the most important morbidity. The aim of this study was to find out the risk factors associated with the neurologic complications after CABG. Material and Method: In 351 patients who underwent CABG, the incidence and features of neurologic complications, with associated perioperative risk factors, were retrospectively reviewed. Neurologic complication was defined as a new cerebral infarction confirmed by postoperative neurologic examination and radiologic studies, or delayed recovery of consciousness and orientation for more than 24 hours after the operation. Result: Neurologic complications occurred in 18 patients(5.1%), of these nine(2.6%) were diagnosed as having new cerebral infarctions(stroke). Stroke was manifested as motor paralysis in four patients, mental retardation or orientation abnormality in four, and brain death in one. Statistical analysis revealed the following variables as significant risk factors for neurologic complications by both univariate and multivariate analyses: cardiopulmonary bypass longer than 180 minutes, atheroma of the ascending aorta, carotid artery stenosis detected by Duplex sonography, and past history of cerebrovascular accident or transient ischemic attack. Age over 65 years, aortic calcification detected by simple X-ray, and intraoperative myocardial infarction were significant risk factors by univariate analysis only. Neither the severity of carotid artery stenosis nor technical modifications such as cannulation of the aortic arch or single clamp technique, which were expected to affect the inciden e of neurologic complications, had significant relationship with the incidence. Conclusion: This study confirmed the strong association between neurologic complications after CABG and atherosclerosis of the arterial system. Therefore, to minimize the incidence of neurologic complications, systematic evaluation focused on atherosclerotic lesions of the arterial system followed by adequate alteration of operative strategy is needed.

배경: 최근 관상동맥 우회수술의 조기 성적이 향상됨에 따라 뇌 경색을 비롯한 신경계 합병증이 수술 후 경과를 결정하는 중요한 합병증으로서 비중이 증가하고 있다. 이에 본 연구에서는 관상동맥 우회수술 후에 발생하는 신경계 합병증의 발생 양상을 분석하고 그 위험인자를 규명하고자 하였다. 대상 및 방법: 관상동맥 우회수술을 시행받은 351명의 환자를 대상으로 신경계 합병증의 발생 여부와 형태, 위험인자를 분석하였다. 신경계 합병증은 새로운 뇌 경색이 확진된 경우와 수술후 의식 및 지남력의 완전한 회복이 24시간 이상 지연된 경우로 정의하였다. 결과: 대상 환자중 18명(5.1%)에서 신경계 합병증이 발생하였으며 그 중 뇌 경색이 확진된 환자는 9명(2.6%)이었다. 운동마비를 동반한 뇌 경색이 4명에서 발생하였고 4명은 정신 지체나 지남력 장애의 형태로 나타났으며 뇌사 판정을 받은 환자가 1명 있었다. 나머지 9명은 뇌 경색의 증거는 발견되지 않았으나 의식 및 지남력의 완전 회복이 지연된 환자들이었다. 통계적 분석 결과 180분 이상의 심폐 바이패스, 수술중 상행 대동맥의 죽상경화반이 진단된 경우, 초음파 검사로 진단된 경동맥 협착, 뇌졸중이나 일과성 뇌허혈의 과거력 등이 단변량 및 다변량 분석 모두에서 의미있는 위험인자로 분석되었다. 그밖에 고령(65세 이상), 흉부 단순 촬영상 대동맥의 석회화가 발견된 경우, 수술중 심근 경색 등도 단변량 분석시 의미있는 위험인자였다. 대동맥궁 삽관이나 single clamp technique 등 신경학적 합병증의 예방에 기여할 것으로 기대되었던 수술 수기상의 변형은 합병증 발생 빈도에 별다른 영향을 미치지 않은 것으로 분석되었으며 경동맥 협착의 정도 역시 합병증 발생 빈도와 상관관계가 없었다. 결론: 이상의 결과로 관상동맥 우회수술 후의 신경계 합병증의 발생 원인은 복합적이긴 하지만 근본적으로는 동맥계의 동맥경화성 병변과 밀접한 관계가 있음을 확인하였다. 따라서 합병증의 예방을 위해서는 수술전 동맥경화성 병변에 대한 전신적인 평가와 함께 고위험군 환자들의 경우 적극적인 수술 수기의 변형을 검토할 필요가 있다고 판단된다.

Keywords

References

  1. Ann Thorac Surg v.46 The changing mortality of myocardial revascularization: coronary artery bypass and angioplasty Naunheim KS;Fiore AC;Wadley JJ(et al)
  2. Ann Thorac Surg v.60 The changing mortality of myocardial revascularization: coronary artery bypass and angioplasty Naunheim KS;Fiore AC;Wadley JJ(et al)
  3. Ann Thorac Surg v.57 Coronary artery bypass grafting: The Society of Thoracic Surgeons National Database experience Edwards FH;Clark RE;Schwartz M
  4. 대한흉부외과학회 제30차 추계학술대회 초록집 v.67 허혈성 심장질환의 수술 1019례 임상 연구 강면식;윤치순;유경종(등)
  5. N Engl J Med v.335 Adverse cerebral outcomes after coronary artery bypass surgery Roach GW;Kanchuger M;Mora Mangano C(et al)
  6. J Thorac Cardiovasc Surg v.104 Differential effects of advanced age on neurologic and cardiac risks of coronary artery operations Tuman KJ;McCarthy RJ;Najafi H;Ivankovich AD
  7. Ann Thorac Surg v.40 Stroke following coronary artery bypass grafting: a ten-year study Gardner TJ;Horneffer PJ;Manolio TA(et al)
  8. N Engl J Med v.319 Stroke following coronary-artery bypass surgery. A case-control estimate of the risk from carotid bruits Reed Ⅲ GL;Singer DE;Picard EH;DeSanctis RW
  9. J Card Surg v.10 Risk factors for stroke following coronary bypass surgery Rao V;Christakis GT;Weisel RD(et al)
  10. J Thorac Cardiovasc Surg v.112 Risk factors for stroke in patients undergoing coronary artery bypass grafting Mickleborough LL;Walker PM;Takagi Y;Ohashi M;Ivanov J;Tamariz M
  11. Ann Thorac Surg v.63 Risk factors and solutions for the development of neurobehavioral changes after coronary artery bypass grafting Hammon JW, Jr.;Stump DA;Kon ND(et al)
  12. Ann Thorac Surg v.61 Defining neuropsychological dysfunction after coronary artery bypass grafting Mahanna EP;Blumenthal JA;White WD(et al)
  13. J Am Coll Cardiol v.20 Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography Katz ES;Tunick PA;Rusinek H;Ribakove G;Spencer FC;Kronzon I
  14. N Engl J Med v.326 The prevalence of ulcerated plaques in the aortic arch in patients with stroke Amarenco P;Duyckaerts C;Tzourio C;Henin D;Bousser M-G;Hauw J-J
  15. J Thorac Cardiovasc Surg v.103 Management of the severely atherosclerotic ascending aorta during cardiac operations. A strategy for detection and treatment Wareing TH;Davila-Roman VG;Barzilai B;Murphy SF;Kouchoukos NT
  16. J Card Surg v.11 Intraoperative epiaortic ultrasound during cardiac surgery Nicolosi AC;Aggarwal A;Almassi H;Olinger GN
  17. J Am Coll Cardiol v.28 Intraoperative transesophageal echocardiography and epiaortic ultrasound for assessment of atherosclerosis of the thoracic aorta Davila-Roman VG;Philips KJ;Daily BB;Davila RM;Kouchoukos NT;Barzilai B
  18. Cardiac surgery and the brain The potential role of carotid artery disease Harrison MGJ;Smith P;Taylor K
  19. J Vasc Surg v.5 The risk of stroke in patients with asymptomatic carotid stenosis undergoing cardiac surgery: a follow-up study Brenner BJ;Brif DK;Alpert J;Goldenkranz RJ;Parsonnet V
  20. J Vasc Surg v.12 The role of carotid screening before coronary artery bypass Faggioli GL;Curl GR;Ricotta JJ
  21. Ann Thorac Surg v.41 The atherosclerotic ascending aorta and transverse arch: a new technique to prevent cerebral injury during bypass:experience with 13 patients Culliford AT;Colvin SB;Rohrer K;Baumann FG;Spencer FC
  22. Ann Thorac Surg v.59 Effect of cannula length on aortic arch flow: protection of the atheromatous aortic arch Grossi EA;Kanchuger MS;Schwartz DS(et al)
  23. Ann Thorac Surg v.63 no.5 Determination of size of aortic emboli and embolic load during coronary artery bypass grafting Barbut D;Yao FS;Lo YW(et al)
  24. J Card Surg v.10 The effect of the single aortic cross-clamp technique on cardiac and cerebral complications during coronary bypass surgery Aranki SF;Sullivan TE;Cohn LH
  25. Ann Thorac Surg v.59 CABG in calcified aorta under circulatory arrest Reddy DD;Floten HS;Gately HL
  26. Ann Thorac Surg v.55 Coronary revascularization in a patient with porcelain aorta and calcified great vessels Accola KD;Jones EL
  27. Ann Thorac Surg v.55 Strategy for the reduction of stroke incidence in cardiac surgical patients Wareing TH;Davila-Roman VG;daily Bb(et al)