p.49 抽出テキスト
Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e66 CLINICAL STATEMENTS AND GUIDELINES several large retrospective and registry studies,1,2,6,7,9,10 as well as most single-center prospective studies, found an association with reduced risk of stroke.3-5,8 Procedural risk, extra time required, and cost are minimal. The use of epiaortic ultrasound to evaluate the presence, location, and severity of atherosclerotic plaque in the ascending aorta allows for the intraoperative adjustment of operative technique to avoid atheroembolic complications. 12.5 Use of Cardiopulmonary Bypass in Patients Undergoing CABG Recommendations for Use of Cardiopulmonary Bypass in Patients Undergoing CABG Referenced studies that support the recommendations are summarized in Online Data Supplement 40. COR LOE Recommendations 2a B-R 1. In patients with significant calcification of the aorta, the use of techniques to avoid aortic manipulation (off-pump techniques or beating heart) is reasonable to decrease the incidence of perioperative stroke when performed by experienced surgeons.1,2 2b B-R 2. In patients with significant pulmonary disease, off-pump surgery may be reasonable to reduce perioperative risk when performed by experienced surgeons.2-6 Synopsis When the operative strategy for CABG for a patient is being planned, it may be determined that the risks of aortic manipulation preclude the safe use of a cross-clamp or cannulation of the ascending aorta, and significant pulmonary disease may increase risk of cardiopulmonary bypass. In such cases, the risks and benefits of alternative operative strategies (off-pump or beating heart) are considered, along with surgeon experience with such strategies. Excellent surgical results can be achieved by surgeons experienced in off-pump techniques with either on-pump or off-pump CABG.2,4-15 The major concerns with the off-pump approach relate to the technical difficulty of bypassing coronary arteries in the circumflex distribution, as well as the small and intramyocardial segments. These issues have resulted in a tendency toward fewer grafts per patient,2,16,17 a potential for incomplete revascularization,2,15 and a concern about long-term graft patency.17-20 Recommendation-Specific Supportive Text 1. Off-pump CABG was developed to reduce the risks associated with cardiopulmonary bypass and aortic manipulation and the associated potential for neurological, renal, and myocardial injury. There are discrepant findings between observational and retrospective studies and prospective RCTs.6,12,15,16,20,21 The use of an off-pump approach with minimized aortic manipulation may result in a decreased incidence of perioperative stroke in the presence of a calcified ascending aorta.1,2 Reported shortterm benefits of decreased blood product use and length of stay may be operator driven rather than procedure driven and may be achievable with either approach.22 Reduced perioperative renal injury may not be sustained on longer follow-up.23 To the extent that the off-pump technique permits less manipulation of the aorta, there appears to be a decreased incidence of perioperative stroke that is difficult to discern from individual studies.1,2 2. Off-pump CABG has been shown to be associated with earlier extubation, reduced blood transfusion, and reduced duration of mechanical ventilation compared with on-pump CABG and may improve outcomes for patients with increased pulmonary risk, which is perhaps related to avoidance of the systemic inflammatory response attributable to cardiopulmonary bypass and its impact on pulmonary function.2-6 13 PHARMACOTHERAPY IN PATIENTS UNDERGOING CABG 13.1 Insulin Infusion and Other Measures to Reduce Sternal Wound Infection in Patients Undergoing CABG Recommendations for Insulin Infusion and Other Measures to Reduce Sternal Wound Infection in Patients Undergoing CABG Referenced studies that support the recommendations are summarized in Online Data Supplement 41. COR LOE Recommendations 1 B-R 1. In patients undergoing CABG, an intraoperative continuous insulin infusion should be initiated to maintain serum glucose level <180 mg/dL to reduce sternal wound infection.1-3 1 B-R 2. In patients undergoing CABG, the use of continuous intravenous insulin to achieve and maintain an early postoperative blood glucose concentration of <180 mg/dL while avoiding hypoglycemia is indicated to reduce the incidence of adverse events, including deep sternal wound infection.3-6 1 B-NR 3. In patients undergoing CABG, a comprehensive approach to reduce sternal wound infection is recommended.7-14 2b B-R 4. In patients undergoing CABG, the usefulness of continuous intravenous insulin designed to achieve a target intraoperative blood glucose concentration <140 mg/dL is uncertain.4,15 Synopsis Sternal wound infection has become less common in CABG surgery, with current rates reported to be <1%.16 However, the associated risk of death may Downloaded from http://ahajournals.org by on October 7, 2026