冠脉搭桥术中间断小切口采集大隐静脉的临床观察

目的 总结冠状动脉旁路移植术中使用间断小切口采集大隐静脉的经验,并与传统长切口采集大隐静脉作比较.方法 2006年2月至2008年2月,62例使用大隐静脉作为血管桥的冠脉搭桥病例采用间断小切口采集大隐静脉,与同期62例采用传统长切口取大隐静脉比较切口总长度、采集时间、下肢切口缝合时间、切口并发症等指标.结果 两组间年龄、性别、大隐静脉长度差异无统计学意义,均未出现与静脉桥血管质量相关的近、远期并发症.与传统长切口组相比,间断小切口组切口总长度短,静脉采集及下肢总手术时间长,切口并发症发生率低.结论 间断小切口采集大隐静脉较传统长切口采集时间长,技术复杂,但减少了术后伤口并发症发生率且更加美观.     

间断小切口与传统长切口采集大隐静脉的临床比较

目的比较间断小切口与传统长切口采集大隐静脉在冠状动脉旁路移植术(CABG)中的应用,总结其临床经验。方法 2007年11月至2009年1月,北京阜外心血管病医院对47例冠心病患者行CABG,男37例,女10例;年龄43～78岁,平均年龄61.3岁。将47例患者随机分为两组,间断小切口组(n=21):在CABG中采用间断小切口法采集大隐静脉;传统长切口组(n=26):在CABG中采用传统长切口采集大隐静脉。比较两组切口长度、大隐静脉采集时间、下肢切口缝合时间和切口并发症等指标。结果两组在采集大隐静脉的过程中均未发生大隐静脉主干损伤及与移植血管质量相关的手术并发症。两组大隐静脉桥支数及大隐静脉长度差异无统计学意义;间断小切口组的大隐静脉采集时间较传统长切口组长(51.9±11.5minvs.40.3±7.6min,P=0.000),但切口总长度(16.1±4.1cmvs.49.2±7.2cm,P=0.000)、切口缝合时间(11.0±3.0minvs.33.6±4.8min,P=0.000)及下肢总手术时间(62.6±14.9minvs.73.8±11.6min,P=0.006)明显缩短。术后随访47例(100%),随访时间3～26个月。术后1个月间断小切口组和传统长切口组分别有4.8%(1/21)和34.6%(9/26)发生下肢切口不愈合、血肿、感染等并发症,经相应治疗后均愈合。间断小切口组切口并发症发生率低于传统长切口组(P0.05)。结论间断小切口技术采集大隐静脉不增加手术时间,并且有助于减少术后下肢切口并发症的发生。     

内窥镜采集大隐静脉联合直视采集桡动脉在冠状动脉旁路移植术中的应用

目的总结在冠状动脉旁路移植术（CABG）中应用内窥镜采集大隐静脉（EVH）联合直视采集桡动脉技术的临床经验。方法回顾性分析2006年6月至2009年10月北京军区总医院收治的97例冠心病患者应用EVH联合直视下采集桡动脉技术行CABG的临床资料,其中男68例,女29例;年龄45~84岁（69.3±11.8岁）。行非体外循环冠状动脉旁路移植术（OPCAB）91例,体外循环CABG 6例。观察大隐静脉的采集长度和采集时间。结果每例患者移植血管3~5支（3.7±0.6支）,大隐静脉全部于单侧大腿采集,长度15~29 cm（22.0±6.0 cm）,采集时间29~52 min（32.0±11.0 min）;采集的桡动脉长度16~22 cm（22.0±6.0 cm）,采集时间25~42 min（30.0±9.0 min）。术后死亡3例,死于心肌梗死、恶性心律失常和消化道出血各1例。术后采集大隐静脉的皮肤切口均无感染,出现下肢水肿5例,淋巴漏1例,皮下血肿3例,均自行愈合。随访84例,随访时间6个月至1年,失访10例。随访期间死于脑血管意外1例,生存的患者心绞痛症状均缓解或消失。结论在CABG术中采用EVH联合直视采集桡动脉,减少了大隐静脉的采集长度,缩短了手术时间,有较好的临床应用价值。     

内镜下与常规切开法采集大隐静脉在冠状动脉旁路移植术中应用的比较

目的探讨内镜下采集大隐静脉应用于冠状动脉旁路移植术(coronary artery bypass grafting,CABG)中的早期临床效果。方法2004年4月~2005年5月,对89例采用内镜下取大隐静脉行CABG(内镜组),在膝关节中部做2 cm切口,应用VasoV iew 5内镜血管采集系统游离获取大隐静脉,并与2003年4月~2005年3月38例采用传统切开法取大隐静脉行CABG(常规组)进行比较,比较2组术后下肢切口并发症、恢复行走时间、患肢疼痛麻木感及肿胀、术后6个月通畅率。结果内镜组取大隐静脉2~3支,平均2.6支;内镜组下肢并发症(6例)与常规组(8例)相比明显减少(2χ=4.197,P=0.040);内镜组患肢疼痛、麻木感7例及肿胀9例与常规组(分别为36、30例)相比明显减少(2χ=89.740,P=0.000;2χ=59.299;P=0.000);内镜组恢复行走时间(2.3±0.9)d比常规组(3.4±1.6)d明显缩短(t=-4.952,P=0.000);内镜组术后6个月通畅率96.0%(48/50)与常规组95.3%(19/20)相比无明显差别(2χ=0.000,P=1.000)。结论CABG中应用内镜下采集大隐静脉能够减少创伤,明显降低术后下肢并发症,减轻术后下肢切口疼痛。     

内窥镜血管采集系统和间断小切口获取大隐静脉在冠状动脉旁路移植术的应用研究

目的比较内窥镜和间断小切口获取大隐静脉在冠状动脉旁路移植术（coronary artery bypass graft,CABG）中应用的临床效果。方法 2009年8月～2012年8月,连续651例CABG术中,479例（A组）采用内窥镜血管采集系统,172例（B组）采用间断小切口获取大隐静脉,方法由患者决定。比较两组大隐静脉获取时间、切口长度和术后腿部并发症情况。结果 2组获取大隐静脉均获成功,静脉长度差异无显著性。与B组相比,A组获取静脉时间短[（18.01±3.49）min vs.（27.06±4.26）min,t=-27.417,P=0.000],皮肤切口长度短[（3.49±0.87）cm vs.（12.53±1.41）cm,t=-97.587,P=0.000],术后需要止痛剂、切口愈合延迟、下肢水肿的比例低[2.9%（14/479）vs.37.8%（65/172）,χ2=144.303,P=0.000;0（0/479）vs.5.8%（10/172）,P=0.000;1.0%（5/479）vs.18.0%（31/172）,χ2=69.526,P=0.000],但总住院费用高[（8.54±1.43）万元vs.（6.45±0.91）万元,t=17.893,P=0.000]。结论内窥镜血管采集系统获取大隐静脉安全可行,并发症少,美容效果显著,值得推广。     

内镜采集大隐静脉的冠状动脉旁路移植术1573例应用体会

目的对单中心8年间的1 573例冠状动脉旁路移植术中应用内镜大隐静脉采集术的患者进行疗效观察评估及经验总结。方法回顾性分析2009年1月至2016年4月沈阳军区总医院应用内镜采集大隐静脉的冠状动脉旁路移植术患者,共计1 573例,观察并分析围手术期心肌梗死、术后室颤等与血管桥采集质量相关的术后并发症的发生,同时观察下肢术后疼痛、水肿、切口感染等情况。集中选取2014年3月至5月间连续70例应用内镜采集大隐静脉的冠状动脉旁路移植术患者,于术后1周复查64排冠状动脉CT评估术后近期血管桥通畅情况。结果应用内镜采集的大隐静脉大体质量满意。住院期间死亡患者共18例。其中出现术后围手术期心肌梗死9例,死亡5例;出现术后频发室颤5例,死亡4例;出现术后脑梗死12例,死亡5例;出现4例多脏器功能衰竭,均死亡。术后下肢水肿和切口疼痛明显减轻,切口感染及愈合不良情况明显减少。术后近期血管桥通畅情况理想。结论长时间大样本量的应用,充分证明内镜大隐静脉采集术具有微创、减轻疼痛等优点,加快恢复进程,避免大面积瘢痕形成后导致运动不便,加之远期的美容效果,有效提高患者的生命质量,是一项成熟有效的技术。     

内窥镜采集大隐静脉的临床效果及应用体会

目的 通过对比冠状动脉旁路移植术中传统的全程切开采集大隐静脉(open saphenous vein harvest,OVH)与内窥镜辅助采集大隐静脉(endoscopic saphenous vein harvest,EVH)两种术式评价EVH的应用效果和总结应用体会.方法 观察两种术式:(1)获取大隐静脉手术时间;(2)采集大隐静脉总手术时间;(3)修补血管次数;(4)术后并发症;(5)采用VAS(Visual Analog Scale)评分,评估术后4d和第4周下肢切口疼痛.结果 EVH组伤口并发症发生率为10.7%,OVH组为36.7%,两组对比EVH组有明显减少(P<0.01);切口疼痛VAS评分,EVH组术后第4天、第4周分别为(2.4±0.6)和(1.0±0.6),OVH分别为(3.2±0.8)和(1.6±0.8),术后第4天疼痛EVH组明显轻(P<0.01),术后第4周疼痛两组差异无统计学意义(P=0.56);手术时间:采集大隐静脉手术总时间EVH组(39.7±4.2)min,OVH组(40.3±5.3)min,两组差异无统计学意义(P=0.66),获取大隐静脉手术时间EVH组(36.3±3.9)min,OVH组(29.0±5.1)min,两组差异有统计学意义(P<0.01);EVH组修补血管次数(1.7±0.7),OVH组(1.1±0.8),两组差异有统计学意义(P=0.04).结论 EVH和OVH相比显著减少了术后切口并发症和疼痛,不延长总手术时间.     

冠状动脉旁路移植术中内镜获取大隐静脉疗效的meta分析

目的系统评价冠状动脉旁路移植术（coronary artery bypass grafting,CABG）中应用内镜获取大隐静脉的安全性。方法计算机检索CochraneLibrary（2012年第2期）、Pubmed、Medline、EMbase、中国生物医学文献数据库（CBM）、中国期刊全文数据库（CNKI）、数字化期刊数据库（万方）、中文科技期刊全文数据库（维普）等数据库,查找自建库至2013年9月,检索语种不受限制,收集有关GABG术中内镜获取大隐静脉疗效和安全性的随机对照试验,由2位评价者根据纳入、排除标准独立选择文献,评价纳入研究的方法学质量,然后采用RevMan5．2软件进行meta分析。结果共纳入12篇RCT文献,共1510例,其中内镜组857例,切开组653例。meta分析显示：与切开组比较,内镜组术后切口感染率低（OR=0．24,95％CI：0．16—0．36,P〈0．0001）,术后疼痛发生率低（OR=-1．06,95％CI：-1．26--0．86,P〈0．0001）,术后并发症发生率低（OR=0．28,95％C1：0．19—0．42,P〈0．0001）;2组住院时间（WMD=0．17,95％CI：-0．22～0．56,P=0．40）、死亡率无统计学差异（OR=0．88,95％CI：0．30～2．64,P=0．82）。结论CABG中应用内镜采集大隐静脉能够减少创伤,明显降低术后下肢感染,术后疼痛、术后并发症及住院时间下降,尤其适用于存在高危因素的患者。     

糖尿病患者行冠状动脉旁路移植术中应用腔镜采集大隐静脉的临床研究

目的探讨腔镜大隐静脉采集法(endoscopic vein harvesting,EVH)对糖尿病患者行冠状动脉旁路移植术(CABG)后恢复和桥血管再狭窄的影响。方法采用非随机临床对照研究的方法,纳入2010年12月至2012年2月华西医院行冠状动脉旁路移植术合并2型糖尿病的患者,按所采用的静脉桥血管采集方式,将患者分为腔镜大隐静脉采集法(EVH)组和开放大隐静脉采集法(CVH)组,评价两组患者围手术期并发症情况。随访期间采用介入或CT冠状动脉造影评价桥血管再狭窄情况。结果共纳入51例患者,其中EVH组24例,CVH组27例。两组患者年龄、体重、基础病变程度差异均无统计学意义。两组术中体外循环时间和主动脉阻断时间差异均无统计学意义[(67.2±9.8)min vs.(68.3±14.5)min,P>0.05;(62.4±11.3)min vs.(65.2±10.3)min,P>0.05]。两组患者术后主要并发症发生率差异无统计学意义。与CVH比较,EVH能显著缩短桥血管采集时间[(35.6±6.4)minvs.(45.2±11.4)min,P<0.05],降低腿部切口延迟愈合发生率[0.0%(0/24)vs.18.5%(5/27),P<0.05]。CVH组随访9.1个月,EVH组随访9.4个月。随访期间两组并发症(胸痛、大隐静脉再狭窄)发生率差异无统计学意义(P>0.05)。结论对于合并糖尿病行CABG的患者,EVH是一种安全有效、微创快速的桥血管采集方法。     

不接触获取大隐静脉技术在冠状动脉旁路移植术中的应用

目的总结不接触获取大隐静脉在冠状动脉旁路移植术中的使用体会和近期效果。方法回顾性分析54例使用不接触获取大隐静脉血管桥进行冠状动脉旁路移植术患者的临床资料及随访资料。结果大隐静脉作为单支桥吻合前降支1例,吻合第一对角支2例,吻合后降支3例,作为序贯桥吻合回旋支和(或)右冠50例。搭桥数目2~5支,平均3.20支。术后腿部切口顺利愈合,无再发心肌梗死,无死亡病例。出院后随访1~13个月,无死亡或心脏性事件。结论不接触技术获取的大隐静脉在冠状动脉旁路移植术中具有良好的早期效果,可以安全使用。     

Endoscopic saphenous vein harvesting versus `open'' technique. A prospective study

Objective: Preparation of the great saphenous vein for coronary artery bypass grafts is usually performed through one or many cutaneous incisions. A technique of endoscopic harvesting is now available. An aim of the study was to compare both methods, prospectively. Methods: Sixty coronary artery bypass grafting patients were randomly assigned to two groups according to saphenous vein harvesting technique: 30 patients to group 1 – open harvesting technique (OHT) and 30 patients to group 2 – endoscopic harvesting technique (EHT). The results were assessed on the basis of (1) clinical outcome (hematomas, inflammations), (2) length of the cutaneous incisions compared to length of the segment of vein harvested, (3) time of harvesting, (4) postoperative pain. Results: Both groups were comparable in terms of: age, sex, diabetes, peripheral artery disease, site of harvesting, number of anastomoses, and length of the vein harvested. Both the length of the cutaneous incisions and the postoperative pain were decreased in the EHT group. Harvesting time was increased in the OHT group. Conclusions: Endoscopic saphenous vein harvesting allows improved aesthetic aspect, less postoperative discomfort, with an increased time in harvesting in the beginning.     

The back-approach technique of endoscopic saphenous vein harvesting in coronary artery bypass grafting

PurposeOne of the concerns during endoscopic saphenous vein harvesting (EVH) in coronary artery bypass grafting (CABG) is injury to the vein or its branches. The cutting edge of bipolar electrocautery scissors, used to divide the side branches of the saphenous vein, can cause vascular injury leading to reduced graft patency. We have developed a novel back-approach technique using a C-ring to divide the wide side branches of the saphenous vein during EVH. The aim of the study was to describe the technique and assess early outcomes of EVH using this technique. The back-approach technique is as follows: (a) insert the C-ring near the target branch, (b) push the C-ring over the proximal aspect of the target branch, (c) twist the C-ring forward to capture the target branch, and (d) cut the target branch by bipolar electrocautery.MethodsWe investigated 169 patients, including 35 women (mean age 70.1 ± 8.9 years), who underwent CABG at our hospital, using a novel EVH technique. The patients were categorized as those who underwent EVH (EVH group, n = 44) or open vein harvesting (OVH) (OVH group, n = 125). This method involves the creation of a small incision (2 cm), sufficient saphenous vein dissection near the skin incision, adequate dissection to separate the vein from the surrounding tissues, and the back-approach technique with C-ring to divide the side branch of the saphenous vein. The primary endpoint was the graft patency rate, and the secondary endpoints were leg wound complications and length of hospitalization.ResultsNo significant intergroup difference was observed in early patency of saphenous vein graft patency (OVH vs. EVH = 94.7 vs. 95.6%, p = 0.763). The incidence of lower extremity wound lymphorrhea was significantly lesser (OVH: EVH = 16.0: 0.0%, p = 0.005) and the length of hospitalization was also significantly shorter in the EVH group (OVH vs. EVH = 24.2 ± 9.8 vs. 19.0 ± 5.3 days, p = 0.001).ConclusionsEVH, using the back-approach technique, showed satisfactory short-term results; therefore, this technique performed with C-ring might be effective for vein harvesting during EVH.     

Early experience of endoscopic vein harvesting for CABG

Objectives As the traditional method of saphenous vein harvesting is associated with nagging leg wound problems, we tried to incorporate this relatively new technique of endoscopic vein harvesting (EVH) in to our regular coronary artery bypass grafting (CABG) Programme. Methods Selected patients (based on affordability, obesity, availability of operator and vein quality on inspection) were offered endoscopic vein harvesting (EVH) for CABG. Vasoview 6 (Guidant, U.S.A) Endoscopic dissector was used with carbon dioxide insufflation. As this was our initial experience, only thigh veins were tried. If additional veins were required or the endoscopically harvested veins were of unacceptable quality, additional vein was harvested by open method. Impacts on cost and operative time, discard rate and leg wound complications were noted. Results We have so far attempted EVH on 86 patients. In one (first), the whole vein had to be discarded and in two others, parts of the vein were not used. Additional vein harvesting was done in 4 patients. EVH was converted to Vein stripping in one patient due to bleeding while branch division and poor visibility. No leg wound complications occurred in any of these patients. Additional time spent was approximately 45–50mts in the first few patients. Of late this has reduced to 25–30 mts. Additional material cost was Rs.3000 per patient. Conclusion With experience, EVH can be a valuable additional tool in the CABG set up with the advantage of reduced leg incision and consequent reduction in leg wound problems with minimal increase in the operative time and cost.     

Nitric oxide expression by interleukin-10 in the endoscopic and open methods of vein harvesting in coronary artery bypass surgery.

OBJECTIVE: Interleukin-10 (IL-10) is an anti-inflammatory cytokine that suppresses lymphocyte functions, regulates production of proinflammatory cytokines, and suppresses nitric oxide production by activated macrophages. We examined IL-10 expression and its value as a surrogate index for nitric oxide (NO) production in endothelial cultures obtained from saphenous vein samples. METHODS: Using 2 different techniques (the open and endoscopic), we harvested samples of human saphenous veins from 90 randomly selected patients undergoing coronary artery bypass surgery (CABG). Endothelial cells collected from the vein samples retrieved through both techniques were cultured for 72 hours. Using a solid phase enzyme linked-immuno-sorbent assay (ELISA), we analyzed pre- and postoperative sera, in addition to the supernatants from the cultures, for IL-10. RESULTS: Mean preoperative levels of IL-10 (0.09 +/- 0.04 pg/mL) did not differ significantly from that for postoperative sera (0.14 +/- 0.17 pg/mL) (P = 0.54). Mean IL-10 levels for endothelial cell culture supernatants did not differ significantly between the endoscopic (0.32 +/- 0.39 pg/mL) and the open method (0.46 +/- 0.80 pg/mL) (P= 0.30). CONCLUSION: Our findings indicate that endoscopic and open saphenectomies are technically comparable with respect to their effects on IL-10 release during saphenous vein harvesting for CABG. We recommend the endoscopic method for its low morbidity and earlier hospital discharge.     

Extrinsic arterial supply of the great saphenous vein: an anatomic study

The extrinsic arterial supply to the great saphenous vein was studied by dissection following latex injection, diaphanisation and contrast roentgenograms. Arterial supply arises from the external pudendal, superficial femoral, superior genicular and posterior tibial arteries.These branches ensure the irrigation of the vasa vasorum. The role they play in the outcome of bypass with the great saphenous vein is a further argument pleading in favor of the in situ technique.     

冠状动脉搭桥内镜大隐静脉获取术136例

目的探讨内镜辅助小切口获取大隐静脉进行冠状动脉搭桥手术的价值。方法411例冠状动脉搭桥手术,依据患者意愿采用微创小切口手术及传统开放大切口手术获取大隐静脉,其中136例应用内镜静脉获取术(endoscop icve in harvesting,EVH),275例应用开放静脉获取术(open ve in harvesting,OVH),比较2组患者手术情况以及下肢切口并发症发生率。结果EVH组下肢切口并发症总发生率为18.4%(25/136),显著低于OVH组36.7%(101/275)(2χ=14.406,P=0.000),其中下肢浮肿、感觉异常、血肿和液化发生率EVH组均低于OVH组,分别为1.5%(2/136)vs.35.3%(97/275)(2χ=56.861,P=0.000)、7.4%(10/136)vs.33.8%(93/275)(2χ=33.937,P=0.000)、16.2%(22/136)vs.27.3%(75/275)(2χ=6.214,P=0.013)和0.7%(1/136)vs.8.7%(24/275)(2χ=10.174,P=0.001)。总手术时间EVH组为(226.3±28.5)m in,OVH组为(224.7±19.2)m in,2组比较差异无显著性(t=0.673,P=0.502)。血管桥早期失功EVH组和OVH组各发生1例,2组比较差异无显著性(2χ=0.000,P=1.000)。远端吻合口数目EVH组(3.6±0.8)个,OVH组(3.3±1.0)个,2组比较差异有显著性(t=3.049,P=0.002),但临床意义不明显。结论内镜大隐静脉获取术可以显著降低高危患者的切口相关并发症,并不增加手术时间和血管桥早期失功发生率,亦不会减少远端吻合口数量而影响冠状动脉的完全再血管化治疗。     

2型糖尿病对冠心病患者大隐静脉旁路血管内皮细胞的影响

目的 探讨2型糖尿病对冠心病患者大隐静脉血管内皮细胞的影响。方法 选取预行冠状动脉旁路移植术40例患者,其中冠心病合并2型糖尿病20例(试验组)及无糖尿病20例(对照组)。每例均取其大隐静脉旁路血管的远心端1 cm长的血管环,切成3段。分别观察血管内皮形态学的变化及采用器官管槽法,在37℃有氧条件下,检测苯肾上腺素(10-5 mol/L)引起的血管收缩反应、以及不同浓度(10-9～10-5 mol/L)的硝酸甘油、乙酰胆碱引起的血管舒张反应。结果 试验组大隐静脉超微结构受损程度较对照组严重。苯肾上腺素引发的预收缩强度和硝酸甘油引发的非内皮依赖性舒张反应两组差异无统计学意义(P＞0.05),但乙酰胆碱引发的内皮依赖性最大舒张反应,试验组明显低于对照组(P＜0.05)。结论 2型糖尿病会加重冠心病患者大隐静脉旁路血管内皮细胞的损害。     

桡动脉桥血管应用于冠状动脉旁路移植术的围术期疗效分析

摘要：目的探讨桡动脉作为第二动脉桥血管对冠状动脉旁路移植术围术期手术疗效的影响。方法回顾性分析2011年8月至2012年4月沈阳军区总医院连续接受非体外循环冠状动脉旁路移植术175例患者的临床资料,175例患者随机分为两组,组1：75例,男49例,女26例;年龄（56．8±8．2）岁;应用桡动脉作为桥血管材料;组2：100例,男66例,女34例;年龄（57．7±8．1）岁;使用大隐静脉作为桥血管材料,不用桡动脉作为桥血管材料;两组患者左乳内动脉使用率均为100％。比较两组患者围术期心血管事件发生率及其它临床参数。结果所有患者术后30d内均存活。两组患者手术时间、术后24h胸腔引流量、术后住院时间比较差异无统计学意义（P〉0．05）。术后重症监护时间、机械辅助通气时间虽然两组间差异无统计学意义,但组1较组2有减少趋势。术后因心功能不佳需较长时间心血管活性药物支持方面,两组间差异虽无统计学意义,但组2患者的比率高于组1[16％（16／100）VS．12％（9／75）]。组1患者术后无新发心肌缺血和因血流动力学不稳定而行主动脉内球囊反搏（IABP）辅助;组2有3例患者出现新发心肌缺血,新增2例IABP辅助。结论桡动脉作为桥血管取代部分大隐静脉,不仅并未增加围术期心血管事件的风险,反而在一定程度上有利于患者的恢复。桡动脉可更加广泛地应用于冠状动脉旁路移植术。