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Сообщение от Abugov

Честно говоря, в книжку не заглядывал, но общее впечатление:
При шунтировании субтотально стенозированного сосуда чаще происходит окклюзия нативного русла. При шунтировании малозначимых стенозов, сосуд конкурирует с шунтом, часто не в пользу последнего. Естественная прогрессия атеросклеротического поражения, по-видимому, за рамками дискуссии.
Дима, ты об этом хотел поговорить?

Нельзя сказать, что существет тонна литературы по этому вопросу. Однако, кое-что имеется в принципе совпадающее с Вашими впечатлениями. Для меня
не совсем понятно почему происходит прогрессия проксимальных стенозов, особенно в сосудах шунтированых венами.

Predictors of Progression of Native Coronary Narrowing to Total Occlusion After Coronary Artery Bypass Grafting

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Evaluation of the proximal stenosis of native coronary vessels after coronary artery bypass grafting
This study was designed to evaluate proximal native coronary stenosis (PNCS) after coronary artery bypass grafting (CABG). In 36 patients undergoing postoperative coronary arteriography, the PNCS bypassed with internal thoracic artery (ITA), saphenous vein graft (SVG) and right gastroepiploic artery (RGEA) progressed in 9 of 23 vessels (39%), in 15 of 28 vessels (53%), in 4 of 11 vessels (36%), respectively. Stenosis of no grafted coronary vessels progressed in 3 of 26 vessels (11%). Twelve native coronary vessels (9: 99% and 3: 90% stenosis vessels) bypassed with grafts were obstructed. This study confirms that the PNCS progresses significantly by CABG just after the operation and that it tends to progress highly with SVG in comparison with arterial grafts such as ITA or RGEA. Because operative mortality for repeated CABG is approximately twice as high as that for primary CABG, it is important to decide whether early postoperative percutaneous transluminal angioplasty is needed or not, in considering of future graft failure and stenosis progression of the native coronary vessels by CABG.
Authors S Hirai, Y Hamanaka, N Mitsui, K Morifuji, M Sutoh (Affiliation: Department of Thoracic and Cardiovascular Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan.)
Journal Kyobu geka. The Japanese journal of thoracic surgery (Kyobu Geka) Vol. 58 Issue 9 Pg. 795-8 (Aug 2005) ISSN: 0021-5252 Japan

Effect of coronary artery bypass grafting on native coronary artery stenosis. Comparison of internal thoracic artery and saphenous vein grafts.
Hamada Y, Kawachi K, Yamamoto T, Nakata T, Kashu Y, Watanabe Y, Sato M.
Department of Surgery II, Ehime University School of Medicine, Sigenobu, Ehime, Japan.
J Cardiovasc Surg (Torino). 2001 Apr;42(2):159-64.

BACKGROUND: The purpose of this study was to investigate the influence of coronary artery bypass grafting on the degree of stenosis of the native coronary artery. METHODS: Experimental design: retrospective data analysis. Setting: University hospital. Patients: consecutive patients undergoing coronary artery bypass grafting (n=52). Bypasses using internal thoracic artery grafts (n=26) and saphenous vein grafts (n=37) to incompletely occluded coronary arteries were studied. Interventions: coronary artery bypass grafting using internal thoracic artery or saphenous vein grafts. Measures: stenosis of the native coronary artery on angiography. RESULTS: Three recipient coronary arteries bypassed with internal thoracic artery grafts (12%) and 14 recipient coronary arteries bypassed with saphenous vein grafts (38%) showed progression of narrowing (p=0.024). Two recipient coronary arteries bypassed with internal thoracic artery grafts (8%) and 13 recipient coronary arteries bypassed with saphenous vein grafts (35%) showed total occlusion (p=0.016). Hypertension, hyperlipidemia, diabetes mellitus, and smoking history did not correlate with progression of stenosis of the native coronary arteries. Graft flow measured during surgery in the saphenous vein grafts was not significantly different between the group that exhibited progression of the native stenosis and the group that did not. CONCLUSIONS: Coronary artery bypass grafting with saphenous vein grafts may result in progression of stenosis of the recipient coronary artery. This is less likely after coronary artery bypass grafting with internal thoracic artery grafts. This difference may be due to the ability of the pedicled internal thoracic artery graft to regulate flow. Thus competitive flow in the native coronary artery is minimized. This has significant clinical implications.