非体外循环冠状动脉旁路移植术加颈动脉内膜剥脱术治疗冠心病合并颈动脉狭窄

目的总结非体外循环冠状动脉旁路移植术（OPCAB）加颈动脉内膜剥脱术（CEA）治疗冠心病合并颈动脉狭窄的临床经验,探讨治疗方法和效果。方法回顾性分析2003年1月至2009年12月期间南京医科大学附属南京第一医院121例冠心病合并颈动脉狭窄患者同期行OPCAB和CEA治疗的临床资料,其中男81例,女40例;年龄62~72岁（67.2±4.5岁）。均为3支冠状动脉病变,左主干病变3例。单侧颈动脉狭窄（≥50%）95例,双侧狭窄（≥50%）26例。术后观察围手术期脑卒中、心肌梗死、心绞痛及其他并发症的发生情况,并进行随访。结果所有患者均行单侧CEA,其中左侧71例,右侧50例,颈动脉阻断时间20.5±7.0 min。在OPCAB中,每例远端吻合口数为2.9±0.3个。围术期无死亡,无心绞痛、心肌梗死和脑卒中发生,手术前后自觉神经精神症状好转87例,无明显变化32例,加重2例。随访121例,随访率100%,随访时间67.5±12.5个月。患者生活质量良好,无脑卒中、新发生的心肌梗死和新发生的神经精神症状。结论同期行OPCAB和CEA治疗冠心病合并颈动脉狭窄是较好的治疗方法,能显著减少OPCAB术后脑卒中的发生,而远期疗效尚待积累手术经验、远期随访观察,并进一步的研究阐明。

Treatment of Coronary Heart Diseases and Carotid Arteriostenosis Through Off-pump Coronary Artery Bypass Grafting Combined with Carotid Endarterectomy

Objective To investigate the effect of combined carotid endarterectomy（CEA） and off-pump coronary artery bypass grafting（OPCAB） on patients with carotid arteriostenosis and coronary heart diseases.Methods A total of 121 consecutive patients with carotid arteriostenosis and coronary artery diseases underwent CEA and OPCAB between January 2003 and December 2009 in Nanjing First Hospital of Nanjing Medical University.There were 81 males and 40 females,with their ages ranged from 62 to 72 years（67.2±4.5 years）.All patients had 3-vessel coronary artery lesions,and there were 3 cases of left main coronary artery lesion.Unilateral carotid arteriostenosis（≥50%） occurred in 95 patients,and bilateral（≥50%） in 26 patients.The occurrence of stroke,myocardial infarction,angina pectoris and other complications after operation was observed,and follow-up was carried out.Results All patients underwent unilateral CEA including 50 on the right side and 71 left.The mean block time of carotid artery in CEA was 20.5±7.0 minutes.The average number of distal grafts per patient in OPCAB was 2.9±0.3.None of the patients had stroke or myocardial infarction and no perioperative death occurred.Eighty-seven patients felt well in terms of their neuro-psycho symptoms;32 felt no change;and 2 worsened.Follow-up was done for all the patients with a follow-up rate of 100%.The mean time of the follow-up was 67.5±12.5 months.During this period,none of the patients manifested stroke,myocardial infarction or neuro-psycho symptoms.Conclusion Concomitant OPCAB and CEA is a safe and effective procedure in patients with carotid arteriostenosis and coronary artery diseases.It can reduce the rate of postoperative stroke significantly.However,long-term outcome of the procedure needs operative experience accumulation,long-term follow-up and observation,and serious research and illumination.