Stanford B型主动脉夹层腔内隔绝术中主动脉内膜脱套中转开腹1例

患者男, 42岁, 因"突发背部及腹部疼痛不适9 h"入院。CTA示:B型主动脉夹层(图1)。1周后在全身麻醉下行胸主动脉覆膜支架腔内隔绝术。沿左侧股动脉入路送入猪尾导管, 沿途逐段造影明确位于真腔, 将猪尾导管送至升主动脉(图2A), 交换8F长鞘至主动脉弓部。沿长鞘送入抓捕器捕获左侧肱动脉泥鳅导丝经左股动脉鞘管引出建立导丝轨道, 沿长鞘送入超硬导丝至升主动脉。沿左侧股动脉入路导入单内嵌分支覆膜支架(34-28-200 mm), 紧贴左颈总动脉远心端释放, 完全释放后回撤输送系统至支架下端。此时DSA透视下见支架逐渐向远端移动(图2B), 支架下端移位至第一腰椎水平后支架固定。左侧肱动脉入路引入导管造影示:支架内血流淤滞, 支架远端不显影, 考虑术中主动脉内膜脱套堆积于支架下端, 堵塞腹主动脉及内脏动脉(图2C)。与家属沟通后决定中转开腹, 采用腹部正中切口, 腹腔探查见肠管及肝脏颜色暗淡。将小肠推向右侧, 打开后腹膜, 显露腹主动脉, 离断左肾静脉, 游离肠系膜上动脉及双肾动脉, 分别套带控制。将肾动脉上方、下方腹主动脉套带控制, 阻断腹主动脉及双侧肾动脉后, 于腹主动脉前壁纵行切...     

16层螺旋CT血管成像检查评价冠状动脉搭桥血管

目的探讨16层螺旋CT冠状动脉造影评价冠脉桥血管的价值。方法10例冠状动脉搭桥术后患者在心电门控技术下采用16层螺旋CT行冠状动脉造影扫描，将所得原始数据进行薄层重叠400ms R-R间期重建，重建图像系列调入3D任务卡内进行容积再现、最大密度投影、曲面重建和多平面重建等图像后处理，全面观察桥血管有无狭窄、钙化及吻合口情况。结果10例冠状动脉搭桥术的患者共有29条桥血管，其CT图像均能清晰显示，满足临床诊断要求，可用于影像学评价；4例桥血管有不同程度的钙化和狭窄变细，经DSA检查得到证实。结论16层螺旋CTA作为一种无创性的检查在冠状动脉桥血管随访的诊断和评价中是安全可靠的检查技术，有很高的临床价值。     

经桡动脉和股动脉行冠状动脉造影 和支架植入术的对比分析

目的探讨经桡动脉和股动脉行冠状动脉介入的优缺点。方法回顾分析2004年6月到2005年6月在我院接受冠状动脉造影术和支架植入术的患者235例。按股动脉途径(125例)或桡动脉途径(110例)分为两组。比较两组造影使用的导管数、动脉穿刺成功率、X线照射时间,支架植入的手术操作时间、成功率、并发症发生率。结果①冠状动脉造影:经桡动脉、股动脉行冠状动脉造影血管穿刺成功率分别为94.5%、100%(P<0.05);X线照射时间分别为(3.35±1.25)min和(2.72±0.58)min(P<0.05);造影成功率分别为93.6%、100%(P<0.05)。②PTCA或支架植入:经桡动脉、股动脉植入单个支架的手术操作时间分别为(21.43±6.21)min、(15.24±4.15)min(P<0.05);成功率分别为92.7%、97.6%(P>0.05);血管并发症发生率分别为2.7%、11.2%(P<0.01)。结论①经桡动脉行冠状动脉造影及支架植入术不需卧床、损伤小、止血方便、血管并发症少,为其优点。②经桡动脉行冠状动脉介入要求术者有较高的技术水平,血管穿刺失败和桡动脉痉挛是影响造影和支架植入成功的重要原因,且推送导管过程中需持续透视,增加了术者和患者X线照射时间。③无论从桡动脉入路还是从股动脉入路都以手术成功为最终目的,选择何种路径当根据患者的具体情况确定。     

介入性再通术治疗下肢动脉平齐闭塞病变

目的探讨介入性再通术治疗下肢动脉平齐闭塞病变的方法和疗效。方法17例经CT血管造影（CTA）或MR血管造影（MRA）诊断的下肢主要动脉起始部平齐闭塞患者,病变分别位于髂总动脉（4例）、髂外动脉（2例）、股浅动脉（8例）、胫后或胫前动脉（3例）,临床表现为静息痛等下肢严重缺血症状。经同侧、对侧股动脉或右肱动脉等途径,主要使用内膜下血管成形方法对平齐闭塞端血管进行顺行开通治疗。结果17例患者中,12例成功使导丝和导管经平齐闭塞端进入并通过闭塞端,完成再通治疗,其中11例（11/12）使用了内膜下血管成形技术,在髂、股动脉共植入支架19枚;1例髂总动脉、2例股浅动脉和2例胫（胫前、胫后）动脉平齐闭塞病变因无法使导管导丝嵌入闭塞起始部而终止再通操作,再通成功率为70.59%（12/17）。未发生与介入操作相关的并发症。再通术后临床症状明显改善或消失,踝臂指数（ABI）平均值从0.47上升至0.71。6个月近期随访无症状复发,8、12和24个月各有1例患者症状加重,其中1例复查CAT显示支架内完全闭塞。结论使用内膜下血管成形术对下肢动脉平齐闭塞病变进行再通治疗可以获得安全而良好的临床疗效,拓展了介入治疗对于复杂、严重下肢缺血病变的适用范围。     

利用超选择性动脉栓塞联合手术治疗颌面部血管畸形

一、临床资料本组患者25例，男15例，女10例，年龄最小15岁，最大者45岁，其中海绵状血管瘤3例，出现颌骨继发性畸形，X线片显示骨结构未受破坏；其中二例为颌骨内血管畸形，骨组织呈囊样变，体积和形态发生改变。采用Seldinger技术经皮穿刺股动脉［‘］，导丝插入血管，随后100厘米长导管插入，在连续X线透视下，不断调整导管方向，进入预外动脉各分支。先行颌面部病变区DSA，血管造影明确诊断及供血动脉后，再插入1．8FMagic导管送到靶动脉，冒烟证实为畸形的供血动脉，即用自由血流冲击法行栓塞治疗。栓塞材料为IBCA、真丝线段、真…     

X线介导子宫动脉栓塞术治疗子宫肌瘤现状

子宫动脉栓塞术(uterine artery embolization,UAE)常采用Seldinger法[1]在局部麻醉下行股动脉穿刺,置入F4或F5Cobra导管,在X线数字减影血管造影(DSA)下通过同轴导丝的引导,超选择性插管至子宫动脉并注入栓塞剂.常用栓塞剂有聚乙烯醇(PVA)、明胶海绵、真丝线段、钢圈等.一般行双侧子宫动脉栓塞.     

胸部小切口冠状动脉搭桥术66例报告

目的：探讨胸部小切口冠状动脉搭桥术的临床效果。方法2002年1月～2013年1月采用胸部小切口取左乳内动脉（ left internal mammary artery,LIMA）心脏不停跳冠状动脉搭桥术66例。胸骨下段小切口59例,采用全麻、单腔气管插管,平卧位,倒“L”胸骨下段切口;胸骨旁小切口5例,采用全麻、双腔气管插管,平卧位左胸抬高30＆#176;,左前外侧第4或第5肋切口,用特制牵开器（法国圣骑士公司）牵开肋骨,游离乳内动脉,使用冠脉固定器下行冠脉吻合;2例胸腔镜辅助下完成乳内动脉与左前降支的吻合。结果66例均完成左乳内动脉至前降支的吻合,2例追加大隐静脉降主动脉至第一对角支的吻合。无围术期死亡。60例随访0．5～8年,（5．5±2．5）年,心绞痛症状消失42例,明显减轻24例。术后冠状动脉CT检查16例,冠脉造影12例,LIMA与左前降支（ left anterior descending, LAD）吻合口满意率100％,支架内再狭窄1例,大隐静脉桥血管闭塞1例。结论胸部小切口冠状动脉搭桥术主要适用于心脏前壁冠状动脉尤其是前降支的的再血管化,安全可靠,中期疗效好,在合并高危因素或常规冠状动脉搭桥术和经皮冠状动脉介入术效果不满意者中应用更佳。     

机器人非体外循环冠状动脉旁路移植与支架置入杂交手术

目的 总结"达芬奇S"(da Vinic S)机器人下非体外循环冠状动脉旁路移植与支架置入杂交手术技术特点和优势.方法 2007年1～8月使用da Vinic S机器人系统,完成非体外循环冠状动脉旁路移植共42例,其中10例因双支冠脉病变,在机器人旁路手术后行支架置入术.病人平均年龄为(62.3±12.1)岁,其中男8例,女2例.病人冠状动脉造影均显示严重的前降支病变,并合并有回旋支或右冠状动脉的局限性狭窄.所有病人肺功能良好,无胸膜炎和左侧胸腔手术史.机器人手术过程中无需正中开胸,仅左侧胸壁打直径为1 cm的器械臂孔3个,术者于da Vinic S系统的操作台前、三维成像系统下遥控机器人全程游离乳内动脉;其中4例直接行全机器人非体外行循环下冠状动脉旁路移植术(TECAB),另6例于左侧胸壁第4肋间作6～8cm的小切口,在心脏跳动下行乳内动脉和前降支的吻合(SVST).术后1周左右经股动脉常规行回旋支或右冠状动脉支架置入术.置入术中行乳内动脉造影评价再血管化效果.结果 病人术后恢复顺利,并成功接受支架置入术,乳内动脉旁路血管通畅,无并发症发生.结论 应用机器人微创冠脉旁路手术和支架置入杂交手术治疗冠心病,可最大限度的减小手术创伤并实现完全再血管化.     

导丝引导下选择性胆管插管预防ERCP术后胰腺炎和高淀粉酶血症的作用

目的 探讨双"十"字交叉标准代替造影剂下的Metro斑马导丝引导下选择性胆管插管技术对ERCP(endoscopic retrograde choledochopancreatography)术后胰腺炎和高淀粉酶血症的预防作用.方法 需要接受ERCP的291例胆系疾病病人随机分为导丝组(149例)和对照组(142例),导丝组ERCP-1造影导管内置Metro导丝直接选择性胆管插管,借助导丝判断胆管,然后再注入造影剂以及其他治疗性操作;对照组则单纯ERCP-1造影选择性胆管插管,注入造影剂判断胆管,再进行其他治疗性操作.比较两组ERCP后胰腺炎和高淀粉酶血症的发生情况.结果 选择性胆管插管成功283例,其中导丝组145例,对照组138例.导丝组术后胰腺炎发生率和高淀粉酶血症发生率均明显低于对照组,且导丝组的胰腺炎严重程度有减轻的趋势.结论 借助双"十"字交叉标准代替造影剂下的Metro导丝引导下选择性胆管插管不仅可以降低ERCP术后胰腺炎和高淀粉酶血症的发生率,而且可以降低ERCP术后胰腺炎的严重程度.     

造影导丝在同侧鼻腔更换留置胃管中的应用

目的探讨在M型血管造影导丝引导下于同侧鼻腔更换留置胃管的方法及效果。方法将210例需更换胃管的患者随机分为对照组与观察组各105例。对照组采用传统方法更换胃管;观察组利用M型造影导丝的亲水特性和置入技巧将导丝插入患者的原胃管中,同时利用导丝引导技术将新胃管沿导丝置入胃内。结果观察组一次置管成功率显著高于对照组,相关不良反应及操作时间显著低于对照组(P<0.05,P<0.01)。结论利用导丝引导有明确的换管路径,尤其适用于插管困难的患者,安全有效。     

Hemostatic technique for internal mammary artery anastomotic bleeding

When internal mammary artery is used for myocardial revascularization, a not uncommon occurrence is intraoperative bleeding from the internal mammary artery to coronary artery anastomosis. The conventional method of hemostasis of placing additional sutures across the suture line may produce anastomotic stenosis or may aggravate the bleeding by producing tears, especially as these additional sutures are placed on a beating heart. We describe a simple technique by which hemostasis can be achieved without the risk of anastomotic stenosis or aggravation of the bleeding, as it avoids placing sutures over the anastomotic suture line.     

The role of the surgeon in percutaneous transluminal dilation of coronary stenosis.

Percutaneous transluminal dilation (PTD) of coronary artery stenosis is performed by means of a balloon-tipped catheter introduced from a peripheral artery. It was attempted in 45 patients; stenosis was passed in 33 and was successfully dilated in 28 patients (62%). The method failed in 17 patients: in 6 of them an abrupt closure of a stenosed artery or a beginning infarction necessitated an emergency revascularization. There were no deaths or serious complications, but an infarction developed in 1 patient despite immediate bypass grafting. PTD was successful in 5 out of 7 patients who had recurrent angina after previous coronary bypass grafting: in 2 of them stenosis of a distal coronary artery and in 3 a stenosed bypass graft were dilated. PTD is a new method of treatment of coronary artery disease and is an addition rather than an alternative to coronary bypass grafting. The best results can be expected in patients with single-vessel disease, with a short history of angina (less than 1 year), and with narrow, noncalcified proximal stenosis. Some late complications of bypass grafting are also amenable to this method of treatment.     

Bypass to anterior descending coronary artery in patients with aneurysm or scarring of left ventricle.

Fifteen cases who have had myocardial infarction with aneurysm formation or severe scarring of the left ventricle as a result of occlusion of left anterior descending coronary artery are presented. Bypass to left anterior descending coronary artery using internal mammary artery or saphenous vein was done in all of these patients. Ten of these had plication or excision of the left ventricular aneurysm. All of them survived the operation and are doing well. Early results in this series of patients indicate that left anterior descending coronary artery bypass in these patients is of great value by allowing perfusion to patent brances of left anterior descending coronary artery.     

The right gastroepiploic artery in coronary artery bypass grafting

The right gastroepiploic artery (RGEA) has been used as a conduit in coronary artery bypass grafting. Although some reports presenting good results justify its use in clinical settings, there is still much concern about using the RGEA in bypass surgery. The RGEA demonstrates different behaviors from the internal thoracic artery (ITA) in bypass surgery due to its histological characteristics and anatomical difference, which might contribute to the long-term outcome. Now that left ITA (LITA) to left anterior descending artery (LAD) is the gold standard, other grafts are expected to cover the rest of the coronary arteries. It should be elucidated how we can use other grafts and what we can expect from them. RGEA, as an arterial graft, can be used as an in situ graft or a free graft. The RGEA is mainly used to graft to the right coronary artery (RCA) because of its anatomical position, and its patency is not inferior to that of the saphenous vein (SVG). The RGEA can cover the lateral walls when its length is long enough or by making a composite graft with other grafts. However, when used to graft to the LAD, its mid-term patency is not favorable.     

The use of intraoperative Doppler assessment to guide the surgical treatment of anomalous right coronary arteries

Abstract   Despite its rarity, anomalous origin of the right coronary artery (RCA) from the left coronary sinus can pose risk of sudden death. Because of this risk, many patients elect surgical correction of this anomaly. Surgical strategies for correction of this include ostioplasty, coronary artery reimplantation, and, more commonly, coronary artery bypass grafting. After coronary artery bypass grafting, some advocate ligation of the proximal RCA, speculating that competitive flow will cause graft failure. As no objective criteria for this have been established, we propose a method using of intraoperative Doppler flow measurements to guide the decision to preserve the proximal anomalous native vessel. We present three cases in which an RCA with an anomalous origin from the left sinus was corrected with coronary artery bypass grafting with the assistance of intraoperative Doppler flow measurements to guide the decision to preserve the proximal anomalous native vessel. In each case, the RCA was bypassed using a saphenous vein graft (SVG) that was used to bypass origin of the RCA. Flow through the graft was compared with and without ligation of the proximal RCA, before creation of the proximal anastomosis. In each case, flow through the SVG was not significantly reduced with the proximal RCA patent and ligation was not performed.     

Unstable Coronary Artery Disease: Comparison of Medical and Surgical Treatment

In eighty-eight patients with arteriographic findings of obstructive coronary artery disease and the clinical picture of unstable angina pectoris, a decision on operative or nonoperative management was made by the attending physician. Fifty-three of them subsequently underwent aortocoronary saphenous vein bypass grafting and 35 were continued on a program of medical therapy. A marked difference in the course after the first 30 days was noted, with most of the surgically managed patients being either asymptomatic or greatly improved following coronary artery bypass. Two-thirds of the medically treated patients had persistent severe angina pectoris and none was asymptomatic in a follow-up period averaging 20 months. There were 2 late deaths in the medical group and none in the surgical group.These findings indicate that coronary artery bypass operations can be performed with low risk during the unstable phase of coronary artery disease and that relief of angina can be anticipated. In contrast, nonoperative management of unstable coronary artery disease carries an appreciable risk of death or myocardial infarction, and the majority of patients treated nonoperatively continue to experience angina.     

External shunt for off-pump coronary artery bypass grafting: distal coronary perfusion catheter

We invented a simple external shunt catheter for off-pump coronary artery bypass grafting. This catheter maintains coronary perfusion from femoral artery, prevents ischemia, reduces back-bleeding, and acts as a suture guide by preventing accidental missuturing of the posterior coronary wall. The insertion and withdraw technique is easier than intraluminal shunt. This catheter would be a useful tool for myocardial protection during off-pump revascularization.     

Influence of orientation of bi-leaflet valve prostheses on coronary perfusion pressure in humans

Orientation of a bi-leaflet prosthesis (BLP) might influence coronary perfusion. The aim of this study was to investigate the influence of the orientation on coronary perfusion pressure during hyperemia and adrenergic stimulation. During hyperemia perfusion pressure determines coronary blood flow. Fourteen patients with normal coronary angiogram underwent aortic valve replacement (AVR) by a BLP, and seven received a bio-prosthesis. Patients receiving a BLP were randomized to either orientation A (hinge mechanism perpendicular to a line drawn between the coronary ostia) or B (hinge mechanism parallel to the line between the ostia). Six months after surgery all patients underwent cardiac catheterization. Pressures were measured during resting conditions, during maximum hyperemia, and during maximum adrenergic stimulation with a guiding catheter in the aortic arch (P(ao)), simultaneously with a sensor tipped guide wire in the coronary artery (P(cor)) and in the aortic root (P(root)). P(ao)-P(root) described a flow-induced pressure drop in the aortic root (Venturi effect) and the gradient P(root)-P(cor) described coronary ostium abnormalities. Only small non-significant differences in myocardial perfusion pressure were found between different orientations of a bi-leaflet prosthesis or between bi-leaflet prostheses and bio-prostheses in P(ao)-P(root) and P(root)-P(cor).     

The possibility of using celiac trunk branches as coronary artery bypass grafts

The internal mammary artery has proved to be superior to the saphenous vein for coronary artery bypass grafting, because of its arterial nature and closer approximation in size to the coronary arteries. But the internal mammary artery cannot reach the posterior surface of the heart as a pedicled graft. Two suitable intra-abdominal grafts can reach that surface, viz. the right gastroepiploic artery and the splenic artery. In experiments on eight dogs (weight 9-13.5 kg), the gastroepiploic artery was found to be too small for coronary artery anastomosis, and therefore the splenic artery was used. The size approximation with coronary artery (diameter less than 1 mm) was good. Four dogs survived the month of the study. In two of them the anastomosis was patent, in another the splenic artery was patent despite occlusion of the anastomosis, and in the fourth dog both anastomosis and graft were thrombosed. The possibility of using visceral arterial grafts in coronary surgery is discussed.     

Preserving the left arm vein in cases of hemodialysis access generating left internal mammary artery steal syndrome

In patients undergoing chronic hemodialysis (HD) through an arm arteriovenous fistula (AVF), coronary insufficiency can occur if the patient undergoes a coronary artery bypass graft (CABG) using the ipsilateral internal mammary artery (1-4). Therefore, the creation of a new AVF after CABG should avoid using the arm ipsilateral to the side where the internal thoracic artery was used. In cases where coronary syndrome appears when this advice is not followed, treatment should be offered aimed at overcoming the hemodynamic interference between the diminished coronary supply through the left or right internal mammary artery by closure of the existing fistula, with or without temporary central venous line insertion until the maturation of a new fistula. We suggest a different approach by moving only the arterial inflow site of the AVF to the controlateral subclavian artery, but in addition, leaving the well functioning venous outflow tract intact. In cases of left internal mammary steal it is achieved by creating a conduit running from the right subclavian artery to the left cephalic vein; therefore, creating a new arterial inflow source, connected to the existing functioning old venous outflow tract to maintain an immediately functioning new fistula without a coronary steal.