合并糖尿病的冠状动脉旁路移植术患者应用内镜采集大隐静脉的早期结果分析

目的对比研究内镜采集大隐静脉(EVH)和直视切开采集大隐静脉(OVH)在糖尿病患者接受冠状动脉旁路移植术(CABG中的应用及术后的早期结果。方法选取2013年8月至2015年1月我院外科手术治疗的176例单纯CABG患者,所有患者均合并有2型糖尿病,其中EVH组80例,OVH组96例。对比两组患者的围术期结果和住院期间切口相关并发症。术后1年时随访并行冠状动脉CT检查,评价静脉桥血管的通畅率。结果两组均无死亡病例。在血糖水平、获取静脉长度和静脉损伤方面两组没有显著性差异。与OVH组相比,EVH组在获取静脉时间(P=0.028)、切口长度(P0.001)、腿部切口并发症、术后疼痛及患者满意度方面(P0.001)有明显优势。与OVH组相比,EVH组术后早期下地活动时间缩短(P=0.033)。两组患者术后住院时间、住院死亡率和静脉桥血管通畅率的差异无统计学意义。结论 EVH可以满足糖尿病患者接受CABG对移植静脉血管的手术要求,微创快速,安全有效。EVH与OVH比较术后1年静脉桥血管通畅率无显著性差异。     

微创采集大隐静脉对冠脉搭桥病人呼吸循环功能的影响

目的：探讨经内窥镜采集大隐静脉技术对呼吸循环功能的影响。方法：冠状动脉搭桥手术（CABG）40例，采集大隐静脉随机分为经开放切口（OVH）组和应用内窥镜（EVH）组。测定并比较两组采集过程中的循环动力学及血气指标。结果：两组各时点心率、平均动脉压无统计学差异；EVH组随CO2气体充填时间延长，二氧化碳分压、呼气末CO2分压、乳酸浓度进行性升高，与OVH组取血管过程中的相比差异有显著性（P〈0．05）。结论：EVH组循环指标能够维持稳定，应防范高碳酸血症对氧供需平衡的不良影响。     

No-touch与EVH获取大隐静脉桥血管的近中期临床结果分析

目的 比较no-touch和内窥镜获取（endoscopic vein harvesting, EVH）两种不同的大隐静脉移植物获取方式对冠状动脉旁路移植术（coronary artery bypass grafting, CABG）术后早期临床效果及近中期移植物通畅率的影响。 方法 回顾性分析西安交通大学第一附属医院心血管外科2018年7月至2019年12月行CABG患者151例,其中no-touch技术组获取大隐静脉56例;EVH组获取大隐静脉95例。所有患者采取胸骨正中切口入路,非体外或体外循环辅助下完成搭桥手术。统计两组间平均桥血管远端吻合口数量、左乳内动脉吻合口数量及静脉桥远端吻合数量的差异;分析比较两组术后死亡及早期并发症发生情况以及术后切口并发症如血肿、脂肪液化等差异。患者出院前及术后1年行冠脉动脉CT血管成像检查（CTA）以评估移植血管桥近中期的通畅情况。 结果 No-touch和EVH两组在年龄、性别构成、危险因素、术前诊断类型等方面均无统计学差异。术中两组左乳内动脉吻合口数量及静脉桥远端吻合数量等差异均无统计学意义。两组均无手术死亡。在术后早期并发症方面无显著性差异;但在下肢切口并发症中水肿、切口处麻木、疼痛在no-touch组中尤为显著（P<0.05）。术后冠脉CTA复查提示,术后早期桥血管总体通畅率、两组间左乳内动脉及大隐静脉桥血管通畅率均无差异。术后1年总体桥血管通畅率no-touch组要优于EVH组（P<0.05）,其中左乳内动脉通畅率无差异,大隐静脉桥血管no-touch组通畅率要明显高于EVH组（P<0.05）。 结论 No-touch技术获取静脉桥血管对于CABG患者的近、中期临床效果满意,且中期桥血管通畅率要优于EVH组。该技术可行、安全、有效,值得在CABG中进一步推广。     

非体外循环冠状动脉旁路移植术中不同方式获取大隐静脉的近中期临床效果

目的分析非体外循环冠状动脉旁路移植术(OPCABG)不同方式获取大隐静脉的近期和中期临床效果。方法选择在我科接受择期OPCABG的患者435例,根据获取大隐静脉的方式,分为内窥镜获取大隐静脉(edoscopic vein harvesting,EVH)组217例及开放式获取大隐静脉(open vein harvesting,OVH)组218例,比较2组围术期病死率、急性心肌梗死、低心排综合征和腿部切口并发症等不良事件发生率,随访6个月和1年,比较2组静脉桥血管狭窄或闭塞比例和腿部切口并发症。结果 EVH组围术期腿部切口并发症发生率明显低于OVH组(2.30%vs 12.84%,P=0.000)。EVH组与OVH组围术期病死率(1.38%vs 2.29%,P=0.724)、急性心肌梗死(1.38%vs1.83%,P=1.000)和低心排综合征发生率(1.84%vs 2.75%,P=0.751)比较,差异均无统计学意义。术后6个月随访,EVH组与OVH组发生桥血管狭窄或闭塞比例比较,差异无统计学意义(8.76%vs 9.17%,P=1.000),EVH组腿部切口相关并发症发生率明显低于OVH组(3.69%vs 17.89%,P=0.000)。术后1年随访,EVH组与OVH组发生桥血管狭窄或闭塞比例比较,差异无统计学意义(11.52%vs 14.22%,P=0.475),EVH组腿部切口相关并发症发生率明显低于OVH组(5.53%vs 25.69%,P=0.000)。结论 EVH与OVH围术期不良事件发生率相似,但EVH术后腿部切口相关并发症发生率低于OVH,较OVH有明显优势。     

内窥镜下取小腿大隐静脉用于冠状动脉搭桥的临床效果

目的:评价内窥镜下采集小腿大隐静脉,用于非体外循环冠状动脉搭桥术(off pump coronary artery bypass grafting,OPCABG)的临床效果。方法:选取OPCABG患者269例,根据小腿大隐静脉取材方式将患者分为,内窥镜血管采集(endoscopic vein harvesting,EVH)组和全程切开(open vein harvesting,OVH)组,比较两组取材时间、取材质量、切口并发症、围术期和术后近期随访时的临床效果及患者评价。结果:EVH组取材长度、血管质量和取材时间可满足冠状动脉搭桥手术需要。与OVH组相比,EVH组术后切口并发症发生率和下肢水肿发生率显著降低,且差异有统计学意义,但皮下组织瘀斑发生率较OVH组高。取材时间EVH组平均35 min,OVH组平均45 min,差异有统计学意义。远端吻合口数目EVH组3.2个/例,OVH组3.1个/例,差异无统计学意义。两组围术期心肌梗死发生率差异无统计学意义。本研究中,所有患者均痊愈出院,术后平均随访4～5个月,均无心绞痛再发。结论:CABG术中采取EVH取小腿大隐静脉的方法有效可行。其作为一种微创取血管的方法,取材质量良好、切口小、并发症更少,得到了医生和患者的认可。     

高龄CABG患者常规切开与内窥镜法采集大隐静脉下肢并发症的对比研究

【】 目的 对比高龄冠状动脉旁路移植术(CABG)患者常规切开与内窥镜法采集大隐静脉下肢并发症的发生情况,评价内窥镜下采集大隐静脉用于高龄CABG患者的临床效果。方法 选取2014年06月至2015年12月于我院行冠状动脉旁路移植术高龄患者196 例,分为内窥镜静脉采集组(EVH 组,98 例)和常规切开静脉采集组(CVH 组,98例),比较两种静脉采集方法的术后下肢并发症的情况。 结果 与CVH组相比,EVH组在切口长度、术后疼痛评分、术后并发症和住院时间均小于CVH组,两组差异具有统计学意义(P＜0.05);两组采集的大隐静脉质量、总手术时间及住院费用等方面差异无统计学意义(P＞0.05)。结论 应用内窥镜采集大隐静脉能够明显降低高龄患者冠状动脉旁路移植术后下肢并发症的发生率,早期效果满意。内窥镜采集大隐静作为一种微创取血管的方法,对于高龄冠状动脉旁路移植术患者是安全的和值得推荐的。     

内窥镜获取大隐静脉技术在非体外冠状动脉旁路移植术的临床应用

目的:总结内窥镜获取大隐静脉技术(EVH)在非体外冠状动脉旁路移植手术(CABG)的应用以及早中期结果。方法:回顾分析2010年8月至2013年12月间,北京安贞医院心脏外科11病区73例采用内窥镜获取大隐静脉技术的CABG术早期、中期结果。结果:下肢切口为(4.0±2.0)cm;大隐静脉取材长度(32.1±6.8)cm,获取时间为(50.0±12.9)分钟。静脉壁损伤需要7-0Prolene线修补的漏口数平均为1.3个。1例术中转为开放获取大隐静脉,所有患者术后无下肢切口感染。围手术期无心肌梗死、脑卒中以及死亡事件发生。随访65例,随访时间1~34个月。冠状动脉CTA显示大隐静脉总体通畅率为86.0%。结论:内窥镜获取大隐静脉技术可能带来良好的早期和中期效果。     

冠状动脉旁路移植术中内窥镜采集大隐静脉200例经验总结

目的探讨内窥镜采集大隐静脉技术的学习曲线及减少对大隐静脉的损伤、提高移植血管的长期通畅率和临床效果的方法。方法选择2008年8月至2012年12月在广东省人民医院行冠状动脉旁路移植术的患者250例为研究对象,分为经内窥镜采集大隐静脉移植物组(200例)和桥式切开采集大隐静脉移植物组(50例)。比较两组术中大隐静脉损伤情况、手术时间以及术后伤口并发症的发生率。结果在完整学习曲线后,两组大隐静脉直接损伤情况比较,差异无统计学意义[(1.22±0.44)个vs.(1.23±0.51)个,P>0.05];两组手术时间比较,差异无统计学意义[(38±4)min vs.(38±6)min,P>0.05]。经过100例采集经验后,内窥镜组手术时间缩短[(27±4)min vs.(38±6)min,P<0.05];内窥镜采集组术后伤口愈合不良发生率较低(0%vs.22%,P<0.05)、血肿发生率低(0%vs.4%,P<0.05)。结论保证足够的培训期,拥有合理的采集技术下,冠状动脉旁路移植术中内窥镜采集大隐静脉对大隐静脉移植物的直接损伤与桥式切开采集比较无明显差异,但伤口并发症明显减少,手术时间缩短。     

电视内镜下大隐静脉采集术在老年冠状动脉搭桥术中的应用

目的介绍老年冠状动脉旁路移植术（CABG）中应用电视内镜采集大隐静脉血管桥的体会。方法纳入自2005年4月至2010年3月择期行老年CABG患者303例,年龄60～84（68.6±7.3）岁。术中在电视内镜辅助下采集大隐静脉血管桥197例（ESVH组）,采取全程切开采集大隐静脉（OSVH）106例,ESVH组与OSVH组患者在性别、体质量、在室射血分数、每例搭桥数目、伴发高血压、陈旧性心肌梗死、陈旧性脑梗死、糖尿病与慢性肾功能不全等无显著差异。比较两组的手术效果。结果 ESVH组与OSVH组耗时分别是（38.3±8.8）min和（35.5±7.2）min（P〈0.01）,ESVH组与OSVH组分别出现皮下血肿8例（4.1%）和2例（1.9%）,无显著差异（P〉0.05）。ESVH组术后无下肢皮肤感觉异常、脂肪坏死、切口愈合不良并发症,慢性下肢水肿发生率显著低于OSVH组（2.0%vs 19.8%,P〈0.05）;ESVH组术后下肢疼痛较轻,术后住院时间显著低于OSVH组[（8.4±1.8）vs（13.3±2.8）d.P〈0.001]。结论内镜采集大隐静脉桥创伤小,能明显减少老年冠状动脉搭桥术后下肢切口并发症。     

冠状动脉旁路移植术中内窥镜采集大隐静脉100例

目的内窥镜采集静脉技术已经运用于冠脉旁路移植术,以减少术后的伤口并发症的发生,但是,其学习曲线较长,如何尽量减少对大隐静脉的损伤,提高移植血管的长期通畅率和临床效果仍有待研究。方法我们对比研究了150例冠脉旁路移植术中大隐静脉的损伤情况和术后伤口并发症,其中分为经内窥镜采集静脉移植物病人组(100例)和桥式切开采集静脉移植物病人组(50例)。移植物的采集方法由外科医生决定。术中出现静脉分支直接断裂处距离静脉主干≤1mm,需要缝线修补视为大隐静脉直接损伤,统计两组术中静脉损伤情况、手术时间以及术后伤口并发症的发生率,包括伤口愈合不良、血肿以及患者主诉症状。结果内窥镜采集静脉移植物病人组(100例)和桥式切开采集静脉移植物病人组(50例)。完整学习曲线后的大隐静脉直接损伤无明显差异[(1.22±0.44)个vs.(1.23±0.51)个,P>0.05],手术时间无明显差异[(38±4)min vs.(38±6)min,P>0.05],内窥镜采集组术后伤口愈合不良发生率较低(5%vs.22%,P<0.01)、两组血肿发生率无明显差异(6%vs.4%,P<0.05),患者轻度不适感无明显差异(20%vs.18%,P<0.05),内窥镜采集组患者中、重度不适感较低(11%vs.26%,5%vs.20%,P<0.01)。结论术者应树立在采集过程中对静脉移植物"No touch"的观念。必须保证足够的培训期,拥有合理的采集技术下,冠脉旁路移植术中内窥镜采集静脉和桥式切开采集静脉对静脉移植物的直接损伤无明显差异,其伤口并发症明显减少。但两者静脉移植物的远期狭窄差异仍需合理的前瞻性研究明确。     

微创静脉桥获取术在冠脉搭桥术中的应用及学习曲线

目的研究冠脉搭桥术中应用内窥镜获取大隐静脉的可行性,探讨住院医师学习此项技术的学习曲线。方法选取北京宣武医院2007年1月至2008年2月间行择期冠脉搭桥术118例,分为内窥镜大隐静脉获取术（EVH）组40例,全程切开大隐静脉获取术（OVH）组78例。对其高危因素,术后并发症进行比较,并对EVH组所取静脉进行组织学评价。EVH组患者,按手术时间先后分4个亚组（G1～G4）,每组10例,比较获取时间、静脉长度、手术结果等情况。结果两组患者在下肢切口并发症的高危因素上无差别,但并发症的总发生率有显著差别。两组各有1例死亡,均死于术后循环衰竭。两组静脉获取时间相当,获取的静脉长度比较有差别。两组术后住院时间无明显差别,但费用有显著差别。4个亚组在静脉长度上无明显差异,长度-时间指数由G1组的0.41±0.08显著提高到G4组的0.75±0.06,这一变化代表了微创EVH的学习曲线。结论微创EVH作为一种新兴技术有着广泛的应用前景,在降低术后下肢伤口并发症上有明显优势,尤其适用于存在高危因素的患者。但对它的熟练掌握需要一个学习过程。     

Endoscopic saphenous vein harvesting for CABG -- a randomized,prospective trial

BACKGROUND: The saphenous vein is an established conduit for coronary revascularization. Disadvantages of traditional harvest technique are significant pain and morbidity. We compared the endoscopic harvest technique with the traditional method. METHOD: 140 coronary artery bypass graft (CABG) patients were randomized into 2 groups: endoscopic vein harvesting (EVH; n = 80) and traditional open vein harvesting (OVH; n = 60). Analysis included preoperative risk factors for wound complication, harvesting time, graft injury, and intraoperative and postoperative complications. Patient follow-up lasted 3 months. RESULTS: The preoperative risk profiles of the groups were comparable. In the EVH group, 5 patients (7.1 %) had to be switched to the open technique. EVH time was 45 +/- 6.2 min vs. 31.1 +/- 6.5 min. Two patients (2.5 %) had to be revised because of bleeding complication vs. 6 (10 %) in the OVH group. No local infections or wound complications were observed in the EVH group vs. 11 (18 %) cases in the OVH group. Two OVH cases (3.6 %) were readmitted for wound debridement. All EVH patients reported less pain and were completely satisfied by the cosmetic results. CONCLUSION: EVH is a safe and efficient technique for CABG. Morbidity was significantly lower, with reduced pain and better cosmetic results. EVH time was significantly longer compared to the traditional harvesting technique.     

Endoscopic Vein Harvest in Lower-Extremity Bypass—Is It Preferable to Prosthetic Bypass or Standard Vein Harvest?

Purpose Endoscopic saphenous vein harvest (EVH) was compared with prosthetic bypass (PB) and open vein harvest (OVH) to determine its impact on short-term complications and long-term patency in lower-extermity bypass(LEB). Methods Thirty-six patients underwent PB, 19 patients underwent OVH, and 33 patients underwent EVH between March 2003 and July 2004 There were statistically significant differences in the incidence of coronary artery disease, diabetes mellitus, and hypertension among the three groups. Sixty-five percent of total procedures (57/88) were performed for limb salvage. Sixty-eight percent of EVH patient, 79% of OVH patients, and 58% of PB patients underwent bypass for ischemic rest pain or limb salvage. Results Total 30-day complications or death occurred in 3% EVH , 15.8% OVH, and 16.7% PB (p =0.14). Mean length of stay was 5 days for PB,8 days for OVH and 7 days for EVH (p = 0.39). Mean follow up was 11.5 ± 7.8 months (range-1–30) with a median of 11 months. Conclusions Thirty-day overall complication rates clinically were less in the EVH group than in the OVH and PB groups. One-year patency and limb salvage were similar in all groups. Length of stay was equivalent in all groups. EVH is a perferred method for saphenous vein harvest because of a decrease in the incidence of perioperative complications and equivalent length of stay and one-year patency.     

What is the impact of endoscopic vein harvesting on clinical outcomes following coronary artery bypass graft surgery?

Objective Endoscopic vein harvesting (EVH) is increasingly used as an alternative to open vein harvesting (OVH) for coronary artery bypass graft (CABG) surgery. Concerns about the safety of EVH with regard to midterm clinical outcomes following CABG have been raised. The objective of this study was to assess the impact of EVH on short-term and midterm clinical outcomes following CABG. Design This was a retrospective analysis of prospectively collected multi-centre data. A propensity score was developed for EVH and used to match patients who underwent EVH to those who underwent OVH. Setting Blackpool Victoria Hospital, Plymouth Derriford Hospital and the University Hospital of South Manchester were the main study settings. Patients There were 4709 consecutive patients who underwent isolated CABG using EVH or OVH between January 2008 and July 2010. Main outcome measures The main outcome measure was a combined end point of death, repeat revascularisation or myocardial infarction. Secondary outcome measures included in-hospital morbidity, in-hospital mortality and midterm mortality. Results Compared to OVH, EVH was not associated with an increased risk of the main outcome measure at a median follow-up of 22 months (HR 1.15; 95% CI 0.76 to 1.74). EVH was also not associated with an increased risk of in-hospital morbidity, in-hospital mortality (0.9% vs 1.1%, p=0.71) or midterm mortality (HR 1.04; 95% CI 0.65 to 1.66). Conclusions This multi-centre study demonstrates that at a median follow-up of 22 months, EVH was not associated with adverse short-term or midterm clinical outcomes. However, before the safety of EVH can be clearly determined, further analyses of long-term clinical outcomes are required.     

内窥镜获取大隐静脉在冠脉搭桥术中的应用研究

目的探讨内窥镜获取大隐静脉在冠脉搭桥术中的应用价值。方法根据自愿原则将569例冠脉搭桥患者分2组：内窥镜组303例、常规组266例,比较两组手术操作和并发症情况。结果内窥镜组术后并发症明显少于常规组,在获取时间、美容效果及术后恢复方面具有优势。在近期症状改善、搭桥支数等方面两种方法基本相同。结论内窥镜获取大隐静脉具有明显优势,随费用的降低,可考虑成为常规首选方法。     

Current status of endoscopic vein harvest in cardiac and peripheral vascular surgery

Endoscopic harvesting of the saphenous vein (EVH) has been shown to minimize the morbidity associated with saphenous vein harvest for either coronary artery bypass or lower extremity bypass. However, the long-term benefit of a bypass procedure is predicated on conduit patency. Several studies suggest decreased patency with EVH compared with open vein harvest. Possible reasons for this discrepancy have been investigated by microscopic, electron microscopic, and functional studies of venous endothelium and contractile function of harvested veins with conflicting results. This review details the results of these studies. In addition, the clinical results of coronary bypass graft and lower extremity bypass with open vein harvest and EVH are described in regard to early wound complications and short- and long-term patency.