冠状动脉旁路移植术后行PCI患者特点分析

目的:探讨冠状动脉旁路移植术后行经皮介入治疗(PCI)患者的临床及造影特点,为冠脉旁路移植术后患者治疗策略的选择提供参考. 方法:分析150例搭桥术后行PCI患者的临床及造影特点. 结果:患者平均年龄(62.3±9.3)岁,左室射血分数(59.1±6.6)％.150例患者均为冠状动脉多支血管病变,共处理罪犯病变197处,其中自身血管153处,动脉桥血管2处,静脉桥血管42处.所有患者均行PCI治疗,无再流发生率为12.7％,其中16例为桥血管病变,3例自身冠状动脉病变,桥血管介入治疗较自身血管介入治疗后其心肌标志物升高明显,无术中死亡病例. 结论:PCI是冠状动脉搭桥术后心肌缺血患者的有效治疗手段,心功能和血管病变造影特点是成功治疗的关键.     

冠状动脉旁路移植术后桥血管造影特点分析

目的总结冠状动脉旁路移植术(CABG)后桥血管造影特点,分析相关因素对桥血管通畅率的影响。方法选择2004年4月至2006年4月我院CABG术后因心绞痛复发再入院行冠状动脉造影(CAG)的256例患者,男性218例,平均年龄(61.2±9.7)岁。CABG到复查CAG的间隔时间(50.9±40.1)个月。共722支桥血管,其中左乳内动脉(LIMA)桥215支,大隐静脉(SV)桥485支,左桡动脉(RA)桥19支,右乳内动脉(RIMA)桥3支。桥血管造影完全闭塞或狭窄≥75%视为桥血管病变。结果31.6%(228/722)的桥血管发生病变。LIMA桥病变率13.5%(29/215),SV桥病变率39.2%(190/485),RA桥病变率42.1%(8/19),RIMA桥病变率33.3(%1/3)。术后1年内LIMA桥和SV桥病变率分别达14.6%和32.9%,之后随时间缓慢增加。不同靶血管的SV桥通畅率有明显差别。手术年龄<50岁者桥血管病变率增加。性别、序贯吻合及综合危险因素对桥血管通畅率无明显影响。结论CABG术后桥血管病变较常见,是造成术后心绞痛复发的重要原因。LIMA桥的通畅率明显优于SV桥。不同桥血管、不同靶血管、手术年龄均明显影响桥血管通畅率。     

不同手术策略对冠状动脉搭桥术后桥血管病变的影响

目的：分析冠状动脉搭桥术（coronary artery bypass grafting,CABG）后桥血管病变特点并探讨不同手术策略对桥血管病变的影响。方法：收集我院CABG术后因再发心肌缺血于2014年10月至2016年10月再次入院行冠状动脉造影（coronary angiography,CAG）共126例患者的临床资料,其中桥血管病变（桥血管造影显示狭窄≥75%或出现“线样征”）80例,自体冠状动脉病变加重（未搭桥冠状动脉狭窄从＜75%加重到≥75%）46例,对80例桥血管病变患者的259支桥血管及其吻合口进行评估,单支桥140支,序贯桥119支,平均3.2支/人,其中左乳内动脉桥72支,左桡动脉桥8支,右桡动脉桥3支,大隐静脉桥176支。结果：（1）桥血管病变患者80例,构成比63.5%,自体冠状动脉病变加重患者46例,构成比36.5%;（2）靶血管直径≥1.5mm与直径＜1.5mm的桥血管病变率分别为22.9%,42.9%,差异有统计学意义（P＜0.05）;（3）单支桥、序贯桥病变率分别为25.0%,28.6%,差异无统计学意义（P＞0.05）。结论：桥血管病变是CABG术后患者再发心肌缺血的主要原因,术中尽可能选择直径1.5mm以上的靶血管吻合,采用序贯吻合技术不增加桥血管病变率。     

冠状动脉旁路移植术中经静脉桥血管注射尼卡地平后桥血管流量的影响研究

目的探讨冠状动脉(冠脉)旁路移植术中经静脉桥血管注射尼卡地平后桥血管流量的影响。方法回顾性分析2017年5月至2017年8月于阜外医院心外科一个病区行冠脉旁路移植术中经静脉桥注射尼卡地平后患者桥血管流量的变化。结果经静脉桥血管注射尼卡地平患者共计87例,其中男性76例,女性11例,年龄在39～83岁之间,平均年龄为(63.4±10.0)岁。尼卡地平经静脉桥注射前、后静脉桥血管平均流量分别为(33.7±8.7)ml/min、(56.2±15.3)ml/min(n=195,P0.05);左胸廓内动脉桥血管平均流量前后分别为(24.8±6.8)ml/min、(34.6±7.6)ml/min(n=85,P0.05)。体外循环与非体外循环分组经静脉桥血管注射尼卡地平后桥血管流量变化无明显差异(P0.05)。冠脉非弥漫病变组与弥漫病变组分组经静脉桥血管注射尼卡地平后桥血管流量变化无明显差异(P0.05)。结论冠脉旁路移植术中经静脉桥注射尼卡地平后患者桥血管流量明显增加。经桥血管注射尼卡地平是一种冠脉旁路移植术中改善桥血管流量简易、安全、有效的治疗方法。     

一站式复合血管重建技术治疗无保护左主干病变

目的 评价一站式复合血管重建技术治疗无保护左主干病变的可行性和安全性.方法 2007年6月至2009年4月共有14例左主干病变患者接受一站式复合血管重建技术再血管化.其中男性13例,女性1例,平均年龄(60.4±15.4)岁,冠状动脉造影显示左主干开口或体部病变5例,远端或分叉病变11例.手术在一站式复合手术室内进行.通过胸骨下段小切口在心脏不停跳状态下行微创冠状动脉旁路移植术(左乳内动脉至前降支旁路移植),同期对左主干病变和(或)其他非前降支病变行经皮冠状动脉介入治疗.结果 14例患者均顺利进行一站式复合手术.即刻冠状动脉造影显示左乳内动脉桥均通畅.共有25处非前降支病变接受经皮冠状动脉介入治疗,其中23处病变置入支架(药物洗脱支架27枚,金属裸支架2枚),其余2处病变仅行冠状动脉球囊扩张术.围术期及随访期间无死亡、围术期心肌梗死、脑卒中或再次再血管化等发生.平均随访7.9个月(1～15个月),所有患者均存活且无再发心绞痛.5例患者术后1年再次接受冠状动脉造影,证实左乳内动脉桥及支架均通畅.结论 一站式复合血管重建技术治疗经选择的无保护左主干病变尤其是合并高危因素者安全可行.     

冠状动脉旁路移植术后再次急性冠状动脉综合征患者的冠状动脉造影分析

目的分析接受冠状动脉旁路移植术(CABG)后的患者再次发作急性冠状动脉综合征(ACS)的时间与相关血管的关系.方法从本院1997～2001年间因CABG术后再次发作ACS而入院的168例患者中,选出行再次冠状动脉造影的患者43例,男38例,女5例,平均年龄(57.9±10.2)岁,再次发作ACS时间在术后次日至11年间.分析术后再次发作ACS的时间与罪犯血管之间的关系.结果 (1)由原自身冠状动脉血管病变加重导致的ACS共19例,占44.2%,由移植血管病变导致的共24例,占55.8%,其中12例移植血管病变发生在术后半年内,占移植血管病例的50%,且大部为吻合口病变.(2)从发作时间上划分,在术后次日至半年内发作ACS的为14例,占所有分析病例的32.6%.其中12例为移植血管病变所致,占整组病例的27.9%.随时间的延长,引起ACS的相关血管既有移植血管,也有原自身冠状动脉血管远端病变加重的血管,但术后3年内发作的ACS大多数由移植血管病变引起,检出率为75%,特异度为63%(P<0.01),3年后发生的ACS主要为未移植血管的原自身冠状动脉或移植血管远端的原自身冠状动脉血管病变加重所致.(3)所分析的43例患者共置入静脉血管桥99支,病变37支,总病变率37.4%,动脉桥31支,病变9支,总病变率29.0%.两者间差异有显著性(P<0.01).(4)桥病变的发生与患者综合危险因素间无明确相关性.结论 CABG术后3年内发作的ACS,其相关移植血管病变检出率为75%,特异度为63%,尤其半年内发生ACS的患者,移植血管病变检出特异度达89%,而且大部分为吻合口病变.移植血管病变的发生率与综合危险因素之间无明确相关性,但静脉移植血管的闭塞率要高于动脉移植血管.     

冠状动脉旁路移植术后再发心绞痛的介入治疗分析

目的分析冠状动脉（冠脉）旁路移植术（CABG）后再发心绞痛的原因及进行介入治疗的有效性和安全性。方法再发缺血症状的CABG术后老年患者78例，进行冠脉和桥血管造影，并同时对53例进行介入治疗。结果78例均进行冠脉和桥血管造影，其中8例桥血管通畅，原冠脉病变无或有轻微发展；17例桥血管严重狭窄或全部闭塞，同时，原冠脉3支弥漫严重病变；53例原冠脉血管病变有明显进展或桥血管出现严重病变或闭塞。78例共移植桥血管226支（其中大隐静脉桥血管153支，乳内动脉桥69支，桡动脉桥4支）。大隐静脉桥血管153支中，110支发生病变（71．9％，其中长段弥漫性病变或完全闭塞77支，吻合口狭窄14支，体部狭窄19支）。乳内动脉桥共69支，27支发生病变，占39．1％（其中全程弥漫性病变和完全闭塞12支，吻合口狭窄15支）。桡动脉桥共4支，通畅3支，吻合口狭窄1支。226支桥血管发生病变共有138支（包括大隐静脉桥血管110支，乳内动脉桥27支，桡动脉桥1支），桥血管吻合口狭窄30支，体部病变19支，弥漫病变或完全闭塞89支。在吻合口狭窄的桥血管中，术后0～3个月发生21支（70.0％），术后3～12个月发生9支（30．0％），术后1年以上无吻合口狭窄。在体部病变的桥血管中术后0～3个月未发生病变，术后3～12个月发生10支（52．6％），术后1年以上发生9支（47．7％）。桥血管弥漫病变或完全闭塞术后0～3个月发生28支（31．5％），术后3～12个月发生14支（15．7％），术后1年以上发生47支（52．8％）。53例患者进行原发血管和（或）桥血管介入治疗，50例介入治疗成功（94、3％）。所有病变介入治疗后均即刻获得良好结果，30d随访，未出现严重心脏事件。结论CABG术后再发心绞痛介入治疗成功率、有效性、安全性均较高，介入治疗可作为CABG术后再发缺血的主要治疗手段之一。     

冠状动脉旁路移植术后移植血管的转归及影响因素分析

目的:探讨冠状动脉旁路移植术(CABG)后移植血管包括大隐静脉桥(SVG)和左乳内动脉桥(LIMAG)的转归及相关的影响因素。方法:对自2010年至2015年92例行CABG后症状复发而复查冠状动脉(冠脉)自体血管造影和移植血管造影的结果和临床特征进行分析。92例患者中男性83例,女性9例,平均年龄(62.6±10.8)岁。52支LIMAG中,19支发生病变为LIMAG病变组,33支未发生病变为LIMAG无病变组;60支大隐静脉单独桥中,38支有病变的大隐静脉单独桥为大隐静脉单独桥病变组,22支无病变的大隐静脉单独桥为大隐静脉单独桥无病变组。统计分析SVG、LIMAG病变与传统动脉粥样硬化危险因素如年龄、性别、高血压、高脂血症、糖尿病、吸烟、冠心病家族史以及其他临床特点如心绞痛复发时间、冠脉造影距离CABG时间等、大隐静脉桥血管移植方式(序贯桥和单独桥)、自身靶血管搭桥前病变特点的相关性。结果:平均症状复发时间(35.10±24.7)个月。共有移植血管146支,其中LIMAG 52支,SVG 94支(单独桥60支,序贯桥34支),LIMAG通畅率显著高于SVG(63.5%vs 44.7%,P=0.030)。SVG病变发生与CABG后症状复发时间呈正相关(OR=1.119,95%CI:1.002~1.249,P=0.046),与女性患者有相关倾向(P=0.065),与其他临床因素均不相关,而LIMA病变发生与各项临床因素均不相关。大隐静脉序贯桥通畅率明显高于单独桥(58.9%vs 36.7%,P=0.038)。大隐静脉单独桥病变组(术前自体靶血管完全闭塞/狭窄=24支/14支)与无病变组(术前自体靶血管完全闭塞/狭窄者=17支/5支)的自体靶血管病变之间比较无差异(P=0.388);而LIMAG病变组中自体血管狭窄病变者明显多于LIMAG无病变组(LIMAG病变组:狭窄/闭塞=7支/12支;LIMAG无病变组:狭窄/闭塞=23支/10支),差异有统计学意义(P=0.04)。结论:CABG后桥血管发生病变与冠心病传统的危险因素无明显相关性,术后SVG发生病变与CABG后心绞痛复发时间呈正相关。SVG序贯桥中远期通畅率高于单独桥。单独桥中CABG前自体靶血管血流状况将影响术后LIMAG的转归,而对SVG无明显影响。     

非体外循环冠状动脉旁路移植术的总结(附105例分析)

目的:总结105例非体外循环下(off—pump)冠状动脉旁路移植术的经验。方法:105例患者中男87例,女18例。年龄48～74(平均59.l±9.06)岁。手术在全麻常温下进行,正中切口。单支病变18例,双支病变20例,三支病变62例,左主干病变15例;急性心梗1例,陈旧性心梗3例。搭1支桥8例,搭2支桥26例,搭3支桥43例,搭4支桥22例,搭5支桥6例,内膜剥脱1例。平均每例搭桥2.9支。结果:全组无手术死亡,平均带气管插管时间10.9±10.78小时,平均在ICU45.9小时。术后平均胸腔引流量394 ml,术后1例1年内经冠脉造影提示血管桥堵塞。结论:非体外循环下的冠状动脉旁路移植术是安全可行的;适用于左主干病变,三支病变及心梗患者;可以做到完全再血管化,对于冠心病患者应为首选。     

静脉桥病变的介入治疗及临床预后观察

目的:本文针对不同部位桥血管病变的介入特点及临床预后进行比较探讨。方法:入选2005年12月至2011年12月,行静脉桥血管(SVG)介入治疗的患者68例。共73处SVG病变,其中位于主动脉-静脉桥开口14处,体部病变39处,远端病变20处。随访联合终点事件包括:急性心肌梗死,靶血管闭塞及再狭窄(TVF),心源性死亡。结果:平均桥血管病变发生时间为冠状动脉搭桥术后(6.72±4)年。1年以内的发生的桥血管病变大部分为远端吻合口病变(54.5%)。经皮冠状动脉介入术的介入成功率为94.5%,以体部病变成功率最高达100%,主动脉-静脉桥开口的成功率最低为85.7%。远端保护器应用在体部病变中应用比率最高(30.8%,P<0.01),远端吻合口病变所需支架直径最小(3.26±0.57)mm,P<0.05。主动脉-静脉桥开口病变所需支架的后扩张压力最大(17.8±2.3)atm(1atm=101.325 kPa),P<0.05。平均随访24.37个月,共发生终点事件17例(23.3%)。以主动脉-静脉桥开口最为多见6例(42.9%)。结论:SVG的经皮介入治疗可行,主动脉-静脉桥开口病变的介入成功率较低,远期预后较差。     

Proximal internal mammary in situ graft and distal coronary-coronary graft

When a left anterior descending coronary artery passes over the cardiac apex and presents with 2 stenoses, 1 proximal and 1 distal, the available bypass conduit often is too short to enable both the anastomosis below the distal stenosis and the sequential anastomosis on the arterial segment between the 2 stenoses. In this circumstance, we graft the internal mammary artery in situ onto the proximal segment of the left anterior descending coronary artery, then use a short residual segment of the internal mammary to perform a coronary-coronary bypass of the distal stenosis. This technique also spares segments of the internal mammary for other purposes. We present our experience, together with angiographic evidence of long-term patency.     

Saphenous vein graft vs. radial artery graft searching for the best second coronary artery bypass graft

Coronary artery bypass grafting (CABG) was first used in the late 1960s. This revolutionary procedure created hope among ischemic heart disease patients. Multiple conduits are used and the golden standard is the left internal mammary artery to the left anterior descending artery. Although all approaches were advocated by doctors, the use of saphenous vein grafts became the leading approach used by the majority of cardiac surgeons in the 1970s. The radial artery graft was introduced at the same time but was not as prevalent due to complications. It was reintroduced into clinical practice in 1989. The procedure was not well received initially but it has since shown superiority in patency as well as long-term survival after CABG. This review provides a summary of characteristics, technical features and patency rates of the radial artery graft in comparison with venous conduits. Current studies and research into radial artery grafts and saphenous vein grafts for CABG are explored. However, more studies are required to verify the various findings of the positive effects of coronary artery bypass grafting with the help of radial arteries on mortality and long-lasting patency.     

Vascular graft infections

Prosthetic vascular grafting is a commonly performed procedure that is central to the management of arterial disease and renal failure. Though rare, vascular graft infections (VGI) are potentially devastating, and carry a high rate of mortality and amputation. Despite extensive research and clinical experience, VGI remain a daunting therapeutic challenge for surgeons and infectious disease specialists. This article reviews the pathogenesis of VGI, in particular the role of biofilms, as well as the current state of clinical management including diagnostic modalities, surgical options for treatment, antimicrobial therapy, and preventive measures.     

Primary graft dysfunction

Primary graft dysfunction (PGD) is the most important cause of early morbidity and mortality following lung transplantation. PGD affects up to 25% of all lung transplant procedures and currently has no proven preventive therapy. Lung transplant recipients who recover from PGD may have impaired long-term function and an increased risk of bronchiolitis obliterans syndrome. This article aims to provide a state-of-the-art review of PGD epidemiology, outcomes, and risk factors, and to summarize current efforts at biomarker development and novel strategies for prevention and treatment.     

Vascular graft infection

This article presents a discussion of the management of vascular prosthetic infections. The emphasis is on aortic graft infections, but other peripheral graft infections are also discussed.     

Saphenous graft angioplasty

In our daily practice the rate of saphenous graft angioplasty is less than 5%. This kind of angioplasty is more complex with a higher rate of complications in known fragile patients. Some technical trips and tricks are necessary to easily perform these angioplasties. Main difficulties are the extension of saphenous graft lesions, the risk of distal embolism, coronary slow or no flow and the high rate of restenosis. Pharmacological treatment is disappointing with no efficacy of the Gp IIb-IIa blockers. Otherwhise the use of protection devices is clearly effective and must be used when it is technically possible. With the use of bare metal stents in saphenous graft angioplasty the rate of restenosis is very high. There are some encouraging results with drug eluting stents. But we are still now not allowed to use them in this indication in our daily practice.     

T-shaped re-anastomosis of graft for outlet obstruction after free jejunal graft

We experienced three patients with persistent outlet obstruction after free jejunal graft and performed T-shaped re-anastomosis for relief of this symptom. Two patients underwent a laryngopharyngectomy for hypopharyngeal cancer and the other patient underwent a laryngopharyngectomy and total esophagectomy for concurrent hypopharyngeal cancer and esophageal cancer. We reconstructed alimentary conduit by a free jejunal reconstruction without using surgical microscopes. In brief, a graft vein and the internal jugular vein were anastomosed and a graft artery and the carotid artery were anastomosed. Then, the anastomosis of pharyngojejunostomy was carried out in a side-to- end fashion, followed by an end-to- end jejunesophagostomy. In a T-shaped re-anastomosis, the flexure of the transplanted jejunum was separated by GIA (US Surgical Corporation, Norwalk, CT, USA). In cases where the efferent part was redundant, the proximal or distal site was resected and straightened in order to avoid outlet stasis. After this, the end-to-side anastomosis between the efferent part and the bottom of proximal horizontal portion of the graft was performed by CDH (Ethicon, Somerville, NJ, USA) or Olsen's one layer method. These three patients received this operation and were relieved from persistent dysphagia. This method is a safe and easy procedure for relief from dysphagia and for recovery of quality of life for patients with this complication. However, it is of utmost importance to perform a reconstruction followed by profluent passage at the first operation.