64排螺旋CT冠状动脉造影在心瓣膜置换术前的应用

目的探讨无创64排螺旋CT冠状动脉造影(CTA)在心瓣膜置换术前诊断冠状动脉病变的敏感性、特异性。方法50岁以上的心脏瓣膜疾病患者152例,其中单纯二尖瓣病变78例,单纯主动脉瓣病变49例,联合瓣膜病变25例,合并心房颤动93例。所有患者均行CTA和有创冠状动脉造影(CAG)检查,根据两者的检查结果计算CTA诊断冠状动脉病变的敏感性、特异性。结果直径>1mm的冠状动脉、窦性心律、心率≤70次/分患者的CTA显像清晰,诊断冠状动脉病变的敏感性和特异性均为100%;合并心房颤动或心率控制不佳患者的CTA显像诊断冠状动脉病变的敏感性和特异性明显降低,且因冠状动脉病变的部位不同,其诊断的敏感性和特异性亦不相同,对左主干、左前降支、对角支病变诊断的敏感性和特异性分别为87%、89%,右冠状动脉、后降支为80%、76%,回旋支、钝缘支为67%、71%。对直径≤1mm的冠状动脉,CTA尚难成像。结论CTA作为无创、快速和价廉的检查方法,在心脏瓣膜置换术前对冠状动脉病变有一定的诊断价值,但目前尚不能完全替代有创CAG检查。     

多排螺旋CT冠脉成像与冠脉造影对冠心病诊断的对比研究

目的:初步评价MSCT在冠状动脉成像中的临床应用价值。方法:18例疑诊冠状动脉狭窄患者行MSCT扫描,利用影像曲面重建,3D重建,了解冠状动脉病变情况,并与冠状动脉造影对比。结果:18例76支血管同时经MSCT和CAG成像。冠状动脉造影发现狭窄27支,其中左前降支(LAD)病变11支,回旋支(LCA)病变3支,左主干(LMA)2支,右冠(RCA)病变9支,桥支病变2支。MSCT发现狭窄23支,其中左前降支病变11支,回旋支病变3支,左主干病变1支,右冠病变9支,桥支病变2支。MSCT成像的敏感性为81．5％(22／27),特异性100％,阳性推测值91．7％,阴性推测值94．2％。结论:在控制心率的情况下,MSCT可作为冠状动脉狭窄的一种无创筛选检查方法。     

非体外循环下冠状动脉旁路移植术治疗左冠状动脉主干合并3支血管病变

目的总结非体外循环冠状动脉旁路移植术(OPCAB)对左冠状动脉主干合并3支血管病变患者的治疗经验及体会。方法对33例左冠状动脉主干合并3支血管病变患者施行了OPCAB,用左乳内动脉作为移植血管与左前降支进行吻合,大隐静脉作为移植血管分别与回旋支、右冠状动脉/后降支、对角支和钝缘支进行吻合。结果每例患者行旁路血管移植2～5支,平均3.4支。无手术死亡,无围手术期心肌梗死、呼吸衰竭、肝肾功能衰竭等严重并发症,术后心绞痛均消失。结论OPCAB治疗左冠状动脉主干合并3支血管病变的高危冠心病患者是可行、有效的,手术损伤小;而积极的术前准备、主动脉内球囊反搏的应用、正确的手术方法和配合、建立一支熟练快速的应急队伍是确保手术成功的关键。     

冠状动脉CT成像技术在诊断不同程度冠状动脉狭窄中的敏感性和特异性分析

目的评估320排冠状动脉CT成像(CT angiography,CTA)诊断冠状动脉粥样硬化性心脏病(coronary artery disease,CAD)的价值。方法收集55例未确诊CAD的患者,在7 d内先后接受了320排冠状动脉CTA及冠状动脉造影(coronary angiography,CAG)的数据进行比较。结果 55例患者4个主要冠状动脉包括左主干、左前降支、左回旋支及右冠状动脉共220支在检查中显影良好。CAG结果显示冠状动脉病变者94例,显示无病变者126例。冠状动脉CTA结果显示冠状动脉病变共94例,显示无病变者126例。冠状动脉CTA与CAG均发现病变者68例,均未发现冠脉病变者100例。冠状动脉CTA的敏感性和特异性分别为0.72、0.79。结论 320排CT冠状动脉CTA是CAD患者无创检查诊断的重要手段,可为CAD患者诊断提供依据,虽然尚不能替代目前的金标准检查CAG,但由于CTA对于重度狭窄有高度特异性,因此对于那些拒绝CAG检查的患者(特别是存在严重狭窄的患者)是一个便捷的检查手段。     

64层螺旋CT对冠状动脉狭窄病变诊断准确性的对比研究

目的比较64层螺旋CT(64-MSCT)冠状动脉显像和选择性冠状动脉造影(SCA)诊断冠状动脉狭窄的准确性。方法华西医院2004年4月至2010年12月行SCA检查并同期行64-MSCT检查患者共93例,其中男74例,女19例;年龄(58.2±8.5)岁,全部患者为窦性心律,心率≥90次/分患者使用倍他乐克控制心律,选取管腔内径≥2 mm的可显像冠状动脉节段,管腔内径狭窄≥50%确定为冠状动脉节段狭窄。根据节段显示情况及是否存在伪影将图像质量分为Ⅰ～Ⅳ级,Ⅰ～Ⅲ级符合影像学评价要求。以SCA造影检查结果为金标准,评价64-MSCT显像成象质量及检测冠状动脉节段狭窄病变的准确性。结果 SCA能清晰显像的冠状动脉节段(100%,1 238/1 238),造影图象质量均符合冠状动脉成像质量评价方法中可评价图象要求(Ⅰ～Ⅲ级);64-MSCT评价冠状动脉有无狭窄的总体敏感度、特异度、阳性及阴性预测值分别为88.8%(427/481)、91.7%(694/757)、87.1%(427/490)和92.8%(694/748)。64-MSCT造影对左回旋支近段和第一钝缘支病变的诊断准确率较其他节段低:左回旋支近段的敏感度68.3%(41/60),特异度60.6%(20/33),阳性预测值75.9%(41/54),阴性预测值51.3%(20/39);第一钝缘支的敏感度58.8%(10/17),特异度93.5%(58/62),阳性预测值71.4%(10/14),阴性预测值89.2%(58/65)。影响冠状动脉狭窄判断和图象质量的主要因素是冠状动脉钙化和心脏活动伪影。结论 64-MSCT诊断冠状动脉狭窄具有较高的准确性,具体评价与病变检测受解剖部位和血管大小的影响,对左回旋支近段及第一钝缘支病变的诊断准确率较低。     

终末期肝病/肝移植术后合并冠状动脉粥样硬化性心脏病患者不停跳冠状动脉旁路移植术三例

正临床资料患者1,男,47岁,主因"间断后背疼痛2年余"入院。入院后行冠状动脉造影提示:冠状动脉左主干合并三支血管病变,其中左冠状动脉主干(LMd)病变40%～50%节段性狭窄,左前降支(LAD)o-m 70%～90%弥漫性狭窄,LADd 70%～80%节段狭窄,左旋支(LCX)o-d70%～90%弥漫性狭窄,右冠状动脉右旋支(RCA)p-d90%～99%节段狭窄,右冠状动脉后降支(PDA)o-m80%～90%弥漫狭窄。患者既往"乙型病毒性肝炎,肝硬     

急诊冠状动脉旁路移植术一例

患者男,63岁.因持续心绞痛入院,心电图诊断急性前壁心肌梗死,临床上血流动力学不稳定.急行冠状动脉造影示冠状动脉3支病变,即左前降支(LAD)狭窄95%,左回旋支主干(LCX)90%,对角支(Diag)95%以及右冠状动脉(RCA)两处狭窄均大于90%.心尖部心肌运动减弱.直接送入手术室,术中见心尖部心肌颜色变暗,心肌运动消失.手术在全身麻醉低温体外循环及间断灌注4∶1冷血心脏停搏液下进行.建立低温体外循环后,用大隐静脉行LCX,Diag和RCA血管移植,左胸乳内动脉与LAD吻合.开放升主动脉后,心脏自动复跳,顺利停机.术后心绞痛症状消失,心电图示心肌缺血改善.术后10天恢复出院.     

连续静脉-静脉血液透析治疗冠状动脉旁路移植术后慢性肾功能衰竭一例

患者男,53岁。胸闷、气促8个月,加重15d ,以冠状动脉粥样硬化性心脏病(冠心病),不稳定型心绞痛,心功能Ⅲ级,高血压Ⅲ级,糖尿病,糖尿病肾病,慢性肾功能不全失代偿期,乙型肝炎收入院。入院后冠状动脉造影显示3支血管病变,右冠状动脉及回旋支100%闭塞,左冠状动脉主干狭窄达管径的60%,左前降支狭窄70%;术前尿量为20m l/h,血尿素氮(BUN )22.13mm o l/L,血肌酐(C r)511μm o l/L,动脉血氧分压(PaO2)为47mmHg (1kPa=7.5mmHg)。患者因出现呼吸衰竭经气管内插管后急诊行冠状动脉旁路移植术,术中用左乳内动脉与左前降支吻合,大隐静脉行钝缘支-对…     

非体外循环下冠状动脉内膜剥脱后搭桥治疗弥漫性冠状动脉病变

目的探讨非体外循环心脏跳动下冠状动脉内膜剥脱后搭桥治疗弥漫性冠状动脉病变的早期临床结果和经验。方法2003年5月—2005年5月,对53例弥漫性冠状动脉病变患者行非体外循环下冠状动脉内膜剥脱后搭桥手术治疗。53例中,男性41例、女性12例,年龄55～79(64±7)岁。加拿大心脏病协会心绞痛分级：Ⅰ～Ⅱ级15例,Ⅲ级6例,Ⅳ级32例。有心肌梗死史26例(49%)。冠状动脉造影：双支病变3例,3支病变50例,其中合并左主于病变9例。左心室射血分数0．26～0．65(0．52±0．17)。53例共行70支冠状动脉内膜剥脱：左前降支系统38支,其中5例内膜剥脱后先用大隐静脉片行前降支成形,再在补片上用乳内动脉搭桥;回旋支的钝缘支8支;右冠状动脉系统24支。应用左乳内动脉53支,桡动脉2支,余均为大隐静脉桥,人均搭桥(3．8±1．1)支,再血管化指数1．03±0．07。结果术中桥血流测定显示63支桥血流满意,7支欠满意。术后2例发生围手术期心肌梗死,但对血流动力学无明显影响。53例皆痊愈出院。44例随访6～29个月,无心绞痛发作;9例失访。6例在手术后3～27个月复查冠状动脉造影,显示桥血管均通畅。结论非体外循环下冠状动脉内膜剥脱后搭桥,安全可行,再血管化程度高,是治疗弥漫性冠状动脉病变的有效方法。     

弥漫性冠状动脉病变的外科治疗

目的总结非体外循环心脏跳动下冠状动脉内膜剥脱后行非体外循环冠状动脉旁路移植术（off—pump CABG）治疗弥漫性冠状动脉病变的早期临床结果和经验，以提高手术疗效。方法2003年5月～2006年11月，对83例弥漫性冠状动脉病变患者在非体外循环下做冠状动脉内膜剥脱后行off—pump CABG，其中男61例，女22例；年龄55-80岁（65±7岁）；加拿大心脏病协会（CCS）心绞痛分级：Ⅱ级7例，Ⅲ级20例，Ⅳ级56例。有心肌梗死史36例（43．4％）。冠状动脉造影显示：双支血管病变5例，3支病变78例，其中合并左主干病变16例。左心室射血分数25％～65％（51％±16％）。83例共行110支冠状动脉内膜剥脱，其中左前降支系统67支，回旋支、钝缘支9支，右冠状动脉系统34支。20例内膜剥脱后先用大隐静脉片行左前降支成形，再在补片上用乳内动脉行旁路血管移植；应用左乳内动脉83支，桡动脉2支，余均为大隐静脉，每例移植血管3．9±1．2支。结果无手术死亡。术中移植血管血流满意101支（92％），血流量为22±16ml／min。术后发生心肌梗死4例，梗死面积小，无血流动力学改变，未给予特殊治疗。83例患者皆痊愈出院。随访75例（90．4％），8例失访，随访时间8～50个月，无心绞痛发作。8例患者在手术后3～29个月复查冠状动脉造影显示：冠状动脉内膜剥脱后行off—pump CABG的移植血管均通畅。结论非体外循环下冠状动脉内膜剥脱后行off—pump CABG，安全可行，再血管化程度高，是治疗弥漫性冠状动脉病变的有效方法。     

Haemangioblastoma with multiple dural arterial supply

Summary A case of primary haemangioblastoma with a marked blood supply from multiple meningeal branches of the internal and external carotid arteries is reported, and the clinical implication of detailed angiographic study of unusual feeders in this highly vascular tumour is discussed.     

MYCOTIC CERVICAL CAROTID ANEURYSM

Mycotic aneurysms of the extracranial carotid arteries are rare. with only 27 cases reported in the English literature.¹ The causative organism is most frequently Staphylococus but infections due to Streptococcus, Salmonella and Klebsiella have been reported.²Escherichia coli has been reported as the causative organism in three cases. Mycotic aneurysms usually present in the setting of generalized sepsis such as postoperative infection, septicaemia. dental sepsis, drug addiction or bacterial endocarditis. We report a patient who presented with a mycotic aneurysm of the internal carotid artery 2 months after undergoing a laparotoiny for perineal sepsis.     

Accessory left hepatic artery arising from common hepatic artery

The knowledge of anatomical variations in hepatic artery are of importance to surgeons and radiologists while performing complicated procedures like liver transplantation and transarterial chemo-embolization for hepatic tumors. The incidence of accessory left hepatic artery is less common than the right accessory hepatic artery. Here we report an anomalous accessory left hepatic artery arising from common hepatic artery in a 55 year old male cadaver.     

暂时性体外胫后动脉旁路术的解剖学研究

目的 为暂时性体外胫后动脉旁路术提供解剖学依据.方法 对5例成人尸体10侧下肢标本的胫后动脉、胫前动脉、腓动脉及其分支进行解剖学观测.结果 本组研究未发现胫后动脉缺如,全长(291±31)mum,显露部下端外径(2.8±0.5) mm.胫后动脉在小腿内侧发出穿支皮动脉存在率100％,平均发出(4±2)支,动脉外径(1.5±0.5) mm,发自中上1/3的穿支皮动脉长度最长(6.5±3.5) cm.结论 胫后动脉及小腿内侧穿支皮动脉在小腿走行恒定,变异率小,管径粗大,易于操作,供区影响小,是暂时性体外胫后动脉旁路手术的理想选择.     

Pulmonary artery diameter: means and normal limits—assessment by computed tomography angiography

Open in a separate window OBJECTIVESNormal pulmonary artery (PA) diameter remains blurred and the definitions of PA aneurysm are heterogenous. We aimed to assess PA diameters, identify a threshold for normal diameters, define PA aneurysms, possible predictors of PA size and evaluate the correlation with mid-ascending aortic diameters.METHODSBetween April 2018 and August 2019, 497 consecutive patients who underwent whole-body computed tomographic angiography were reviewed. Clinical and imaging data were collected from our institutional database. Precise three-dimensional centreline measurements were taken. Linear regression analysis was performed to detect parameters associated with PA diameter. A two-stage model was created to identify potential predictors and the resulting statistically significant interactions were tested. Data were grouped and PA, standard deviation, and upper normal limits were calculated.RESULTSAmong 497 patients with an average age of 51.4 (20.2) (74.6% males), the mean PA diameter measured 32.0 (4.6) mm [female: 31.2 (4.7) mm vs male: 32.2 (4.5) mm; P = 0.032]. The mean PA length, left PA and right PA diameters were similar between male and female patients. We found a significant correlation (r = 0.352; P < 0.001) between the PAs and mid-ascending aortic diameters. Body surface area (P = 0.032, β =  4.52 [0.40; 8.64] 95% CI) was the only significant influencing variable for PA diameter.CONCLUSIONSThe normal mean PA diameter in a reference cohort is 32.0 (4.6) mm. Body surface area is the only influencing variable of PA diameter. The normal diameters measured and corresponding upper limits of normal revealed that a PA aneurysm should not be considered below a threshold of 45 mm.     

锁骨下动脉、腋动脉、肱动脉血管广泛血栓形成1例

1病例资料患者,男,44岁。右上肢肿胀刺痛1个月加重伴手指麻木发凉5d,于2007年12月13日18：00急诊入院。患者自述于1个月前出现右侧手指指尖麻木,近5d右上肢麻木、胀痛明显加重,自测不到脉搏,右上肢皮肤苍白,皮温低,呈持续性,伴胸闷、气短、大汗。心电图：窦性心率（正常心电图）;右上肢血管超声：右侧锁骨下动脉下段、腋动脉、肱动脉血管闭塞（完全性血栓形成）;血压16／10kPa;血糖正常。以“左上肢动脉栓塞”收住入院。患者既往有小儿麻痹症病史,右下肢发育短小、无力,长期扶双拐行走;常伴有右上肢苍白,皮肤发凉,肱动脉、桡动脉、尺动脉脉搏测不到。     

Successful surgical management for aneurysms of single coronary artery with a fistulous connection to the right ventricle

While a coronary artery fistula with aneurysmal formation is rare, a fistula/aneurysm combination occurring in single coronary artery is even rarer. Here, we report the successful surgical correction of a right ventricular fistula with a large aneurysm of 30 mm and a daughter aneurysm within a case of single coronary artery.     

非体外循环双侧乳内动脉完全心肌血运重建

目的 评估非体外循环双侧乳内动脉完全心肌血运重建治疗的效果。方法 2000年10月至2004年8月，共行双侧乳内动脉“Y”形吻合冠状动脉旁路移植（冠脉搭桥）52例，年龄33～78岁，平均56岁。3支病变者42例（80．8％），左主干病变者10例（19．2％）。心功能分级Ⅱ级46例，Ⅲ级4例。脑CT检查示陈旧性脑梗者11例（21．2％），颈动脉病变者21例（40．4％）。制备双侧乳内动脉，将游离的右侧乳内动脉吻合于左侧乳内动脉成“Y”形。均在心脏不停跳下进行冠脉搭桥，左侧乳内动脉序贯吻合对角支、左前降支，右侧乳内动脉序贯吻合于中间支、回旋支（钝缘支、左室后支）、后降支。并应用Tranortie H1311流量计进行桥血管的流量测定。结果 全组52例共行冠脉搭桥171支，平均3．3支/人。全组病人无死亡。围术期心梗2例，应用IABP 1例，开胸止血1例。全组无脑部并发症，无胸骨纵隔感染。结论 非体外循环下双侧乳内动脉“Y”形冠状动脉搭桥是安全、有效的手术方式，可以实现全动脉化的完全心肌血运重建，手术近期效果满意，远期效果有待进一步的随访观察。     

Safe evolution towards routine off-pump coronary artery bypass: negotiating the learning curve

Objective: Off-pump coronary artery bypass (OPCAB) hopes to avoid morbidity associated with cardiopulmonary bypass, improving clinical outcomes. Yet its technical difficulty and unfamiliarity raise concern that adoption of OPCAB might be associated with poorer outcomes during each surgeon's ‘learning curve’. We examined trends in patient selection over time as a single surgeon's practice evolved to routine OPCAB. Methods: Between 10-1-96 and 12-31-01, 1479 consecutive patients had isolated coronary artery bypass grafting (CABG). Clinical data were gathered prospectively and reviewed retrospectively. Trends in adoption of OPCAB and clinical outcomes were examined. Results: There were 756 OPCAB and 723 CABG/cardiopulmonary bypass patients. The practice evolved from 90% conventional CABG to 93% OPCAB. An abrupt transition coincided with evolution of techniques to expose the obtuse marginal arteries, and improvements in suction-based coronary stabilizers. Mortality was 1.0% for the off-pump group and 2.1% for the on-pump group. Careful patient selection helped maintain acceptable outcomes during the ‘learning curve’. Patients with depressed left ventricular ejection fraction, left main disease, and complex three vessel disease were excluded from OPCAB until significant experience (>200 cases) was attained. Presently, all isolated coronary bypass cases are candidates for OPCAB except patients with ischemic ventricular arrhythmias, those in cardiac arrest, and those for whom previous left pneumonectomy or deep pectus excavatum prevent rightward mobilization of heart. Conclusions: Despite a significant learning curve, evolution to routine OPCAB can be achieved while maintaining good patient outcomes. The development of specialized techniques, coronary stabilizers, and apical suction devices allows the application of OPCAB to virtually all coronary bypass patients, as surgeon experience matures.