解剖外途径动脉转流术治疗锁骨下动脉闭塞症

为提高锁骨下动脉闭塞症的治疗效果,作者报告了１９８９年～１９９６年采用非经胸解剖外途径治疗２０例锁骨下动脉闭塞症的经验。本组男９例,女１１例。１７例有上肢缺血表现,１１例有脑部缺血症状。１７例行颈动脉－锁骨下／腋动脉转流,３例行腋动脉－腋动脉转流术。除１例大动脉炎因远端流出道差转流血管阻塞疗效不理想外,其余患者患肢及脑缺血表现均明显改善或消除。无手术死亡。作者认为采用解剖外途径治疗锁骨下动脉闭塞症,无需开胸,创伤小,操作简便安全,并发症少,通畅率高,尤其适合于手术耐受性差的患者,值得进一步推广使用。     

Comparison of carbon-impregnated and standard ePTFE prostheses in extra-anatomical anterior tibial artery bypass: a prospective randomized multicenter study.

OBJECTIVES: The aim of this study was to find out whether carbon impregnated ePTFE vascular grafts have better long-term patency or limb salvage rates than Standard ePTFE vascular grafts in crural revascularization in patients with chronic critical ischemia. DESIGN: Prospective randomized multicenter trial. Study endpoints were 36 months follow-up, major amputation or death. MATERIALS: We used 6mm carbon ePTFE (Carboflo) and 6mm standard ePTFE vascular grafts (both C.R. BARD Inc./IMPRA). METHODS: From June 1995 to November 1998, 283 patients were randomly assigned either to carbon (C) (n=140) or to standard (St) ePTFE (n=143) vascular grafts at 19 centres. A standard protocol was used with lateral extra-anatomic course of the graft to the anterior tibial artery and of a distal vein patch or cuff. More than 90% of the patients had rest pain or gangrene. RESULTS: Two hundred and sixty-five (C=130; St=135) patients could be analysed in the intention-to-treat (ITT) group. Primary patency, secondary patency and limb salvage rates after 36 months were 33, 43 and 67% in the carbon- and 30, 38 and 58% in the standard PTFE group, respectively, (log-rank test: p=0.20, 0.12 and 0.16). Additional analyses were made per protocol (PP) and as-treated (AT). The retrospective power of the study was calculated as 79 and 83%. CONCLUSION: The ITT, PP and AT analysis, showed no statistically significant advantage of the carbon ePTFE vascular graft in terms of patency or limb salvage over the standard ePTFE vascular graft at 36 months.     

Coronary artery revascularization concomitant with vascular surgery

Patients with vascular disease and coronary disease are usually treated initially by coronary artery bypass grafting (CABG), and vascular surgery is generally performed later. In this study we assessed the feasibility of combined CABG and vascular surgery in a single operation. Between 1988 and 1995, 16 patients received combined operations for vascular and cardiac lesions and the clinical results were assessed. There were no operative or hospital deaths. The mean time for operation was 421 min and the duration of the stay in the intensive care unit (ICU) was a mean of 3.6 days. In one patient with an ischemic left leg, the left internal thoracic artery (ITA) had become a collateral source of the ischemic leg, and the need for preoperative angiography of the ITA in such patients was indicated. The combined operation clearly takes longer than either vascular surgery of CABG alone, but the length of the postoperative intensive care unit stay was essentially the same as that after a single operation and the patient was still managed safely after the combined operation. In patients requiring both operations, the combined procedure therefore appears to be safe and to have a good clinical outcome.     

Anatomic eligibility for transcarotid artery revascularization and transfemoral carotid artery stenting

ObjectiveTranscarotid artery revascularization (TCAR) has emerged as an alternative to transfemoral carotid artery stenting (tfCAS). We investigated the proportion of carotid arteries undergoing revascularization procedures that would be eligible for TCAR based on anatomic criteria and how many arteries at high anatomic risk for tfCAS would be amenable to TCAR.MethodsWe performed a retrospective review of consecutive patients who underwent carotid endarterectomy or carotid stenting between 2012 and 2015. Patients were excluded if computed tomography angiography of the neck was not performed within 6 months of the procedure. We assessed TCAR eligibility on the basis of the instructions for use of the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif) and high anatomic risk for tfCAS on the basis of anatomic factors known to make carotid cannulation more difficult or hazardous.ResultsOf the 118 patients and 236 carotid arteries identified, 12 carotid arteries were excluded for presence of an occluded internal carotid artery (ICA). Of the remaining 224 carotid arteries, 72% were eligible for TCAR on the basis of the instructions for use criteria; 100% had 4- to 9-mm ICA diameters, 100% had ≥6-mm common carotid artery (CCA) diameter, 75% had ≥5-cm clavicle to carotid bifurcation distance, and 96% lacked significant CCA puncture site plaque. In addition, 7% of carotid arteries had bifurcation anatomy unfavorable for stenting; thus, of the entire cohort of arteries examined, 68% were eligible for TCAR. Hyperlipidemia (odds ratio [OR], 6.7; 95% confidence interval [CI], 1.7-26; P < .01), chronic obstructive pulmonary disease (OR, 3.5; 95% CI, 1.5-8.3; P < .01), and older age (OR, 1.1; 95% CI, 1.0-1.1; P < .01) were independently associated with TCAR ineligibility, whereas white race (OR, 0.2; 95% CI, 0.0-1.0; P = .048) and beta-blocker use (OR, 0.3; 95% CI, 0.1-0.7; P < .01) were independently associated with TCAR eligibility. In addition, 24% of carotid arteries were considered to be at high risk for tfCAS for the presence of a type III aortic arch (7.6%), severe aortic calcification (3.3%), tandem CCA lesions (7.1%), moderate to severe stenosis at the carotid ostium (8.9%), and tortuous distal ICA precluding embolic filter placement (4.5%). Active smoking (OR, 4.4; 95% CI, 1.9-10; P < .01), hyperlipidemia (OR, 4.0; 95% CI, 1.2-14; P = .03), and older age (OR, 1.1; 95% CI, 1.0-1.1; P = .02) were independently associated with tfCAS ineligibility, whereas preoperative aspirin (OR, 0.1; 95% CI, 0.0-0.4; P < .001) or clopidogrel (OR, 0.3; 95% CI, 0.1-0.8; P = .01) use was associated with tfCAS eligibility. Of the arteries that were considered to be at high risk for tfCAS, 69% were eligible for TCAR.ConclusionsThe majority of carotid arteries in individuals selected for revascularization meet TCAR eligibility, making TCAR a viable treatment option for many patients.     

激光血运重建术治疗冠心病的临床研究

目的:总结分析了99年9月至99年11月激光血运重建术治疗冠心病3例的临床经验。资料及方法:3例冠心病患者均为不稳定性心绞痛,有阵旧性心肌梗塞1例,3例均合并Ⅱ期高血压病。超声心动图左室射血分数在0.57～0.62之间,FS 0.28～0.30。经心肌核素扫描99~M(Ti—MiBi)及心电图检查均提示前壁及下壁缺血。在全麻下经左胸前外侧第5肋间进胸,显露左心室壁,采用高功率二氧化碳激光打孔器(梅曼公司HL-100型)在左室缺血区域打孔8～14个。结果:3例病人术后2周全部康复出院,术后无心律失常,无心衰及心肌梗塞,术后心绞痛症状均全部缓解,一般体力活动不受限制。结论:激光血运重建术治疗冠心病是安全、有效的,对于国人由于冠状动脉血管纤细,激光血远重建术适应证可适当放宽。     

Endovascular versus open revascularization for chronic mesenteric ischemia: a comparative study

Background  The aim of our study was to evaluate and compare short- and long-term outcomes of percutaneous angioplasty and open revascularization for chronic intestinal ischemia. Materials and methods  Twenty-nine consecutive patients undergoing percutaneous angioplasty (n = 14) or open revascularization (n = 15) for chronic intestinal ischemia were prospectively studied from 2000 to 2006. All patients were symptomatic with at least thrombosis or 80% stenosis of superior mesenteric artery. Results  No patient was lost to follow-up. Patients were older in percutaneous angioplasty than in the open revascularization group (p = 0.0009). Open revascularization allowed to revascularize more vessels (1.4 versus 1, p = 0.01). There was no difference between groups regarding major complications, mortality, hospital length of stay, and symptomatic recurrence. Primary re-stenosis was only observed in three patients (21.4%) in the percutaneous angioplasty group. Survival at 2 years estimated by the Kaplan–Meier method was 58% in the percutaneous angioplasty group and 70% in the open revascularization group (p = NS). Conclusion  Percutaneous angioplasty should be preferentially offered to older patients and those unable to undergo open revascularization.     

Brachiocephalic revascularization: a comparison between carotid-subclavian artery bypass and axilloaxillary artery bypass.

Sixty-seven patients who underwent carotid-subclavian bypass (CSBP) (28 CSBPs only and eight with carotid endarterectomy) or axilloaxillary artery bypass (n = 31) with polytetrafluoroethylene grafts were followed up for a mean of 69.2 and 71.9 months, respectively. Indications for surgery in the CSBP group included hemispheric transient ischemic attack (TIA)/cerebrovascular accident in five, nonhemispheric TIA in seven, upper extremity ischemia in 15, and combined TIA and arm ischemia in nine patients. In the axilloaxillary artery group, two patients had hemispheric TIA, five had nonhemispheric TIA, 12 had upper extremity ischemia, and 12 had combined TIA and arm ischemia. Graft patency was determined clinically and confirmed by segmental Doppler pressures, duplex ultrasonography, or angiography. The 30-day mortality rate was approximately 3% in both groups. The 30-day complication rate was 3% for the axilloaxillary artery group and 8% for the CSBP group (not statistically significant). Relief of symptoms was achieved in 100% of patients in both groups; however, 20% of the patients in the axilloaxillary artery group had a recurrence of symptoms, in contrast to 5.6% in the CSBP group. The cumulative 10-year primary and secondary patency rates, calculated by life-table analysis, were 66% and 84.6% for the axilloaxillary artery procedures and 93.8% and 93.8% for the CSBP procedures, respectively (statistically significant). Concomitant carotid endarterectomy with CSBP did not influence graft patency. In conclusion, both bypasses have comparable morbidity and mortality rates; however, the CSBP has a statistically significantly better primary patency rate than the axilloaxillary artery bypass. Therefore CSBP should be the procedure of choice and the axilloaxillary artery bypass should be restricted to high-risk patients.     

Sequential bypass using the right gastroepiploic artery for coronary artery bypass grafting

Objective: Since 1989, we have applied the right gastroepiploic artery (RGEA) as a third arterial conduit for coronary artery bypass grafting (CABG) and started to use sequential RGEA in 1992. We evaluated the feasibility and efficacy of sequential RGEA grafting in CABG.Methods: From December 1990 to January 2000, 46 patients underwent CABG with sequential RGEA. There were 42 male and 4 female patients with a mean age of 59±8.1 years. Mean postoperative follow-up period was 70 months.Results: The mean number of anastomoses was 3.7 per patient. Mean luminal diameter of the RGEA was 2.2±0.4 mm by preoperative angiography and 2.3±0.6 mm by intraoperative measurement. Patency of the sequential RGEA was 92%; proximal anastomosis 100%, distal anastomosis 86% (p=0.01). The 5-year actuarial survival and cardiac event-free rate were 91% and 93%, respectively.Conclusions: Sequential bypass using the RGEA is feasible, with excellent early and long-term results. The indication for sequential RGEA, however, needs careful anatomical consideration of both the luminal diameter of the RGEA and proximal stenosis of the target coronary arteries.     

Coronary artery bypass grafting for coronary artery anomalies in infants and young children

Open in a separate window OBJECTIVESCoronary artery bypass grafting (CABG) has been reported for coronary artery diseases in patients with Kawasaki disease and coronary artery complications after arterial switch operations for transposition of the great arteries. However, only a few studies have explored this modality for congenital coronary artery anomalies. As congenital coronary artery anomalies, particularly left coronary artery atresia and stenosis, are one of the reasons for sudden death, coronary revascularization is often required in infants and young children. Therefore, we aimed to investigate the outcome of CABG for such anomalies in infants and young children.METHODSFrom 2014 to 2018, 3 infants and 2 children (median age: 10 months; range: 6–40 months) with coronary artery anomalies underwent CABG at our hospital. The indications for the procedure included left main coronary artery atresia and stenosis in 2 and 3 patients, respectively. Graft patency was evaluated postoperatively by contrast-enhanced computed tomography or coronary angiography, and postoperative outcomes (including death and cardiac events) were assessed during the follow-up period.RESULTSNo 30-day or in-hospital mortalities were noted. Postoperative examinations revealed patent grafts in all patients. They were discharged without any cardiac complications. Regarding the outcomes at the follow-up period, the graft patency rate was 80.0% (4/5 grafts), with no deaths or cardiac events.CONCLUSIONSCABG is a useful strategy for coronary revascularization in infants and young children with coronary artery anomalies. Although the mid-term outcomes and patency are satisfactory, careful follow-up is necessary because the long-term outcomes remain unknown.     

Sequential bypass using the right gastroepiploic artery for coronary artery bypass grafting

OBJECTIVE: Since 1989, we have applied the right gastroepiploic artery (RGEA) as a third arterial conduit for coronary artery bypass grafting (CABG) and started to use sequential RGEA in 1992. We evaluated the feasibility and efficacy of sequential RGEA grafting in CABG. METHODS: From December 1990 to January 2000, 46 patients underwent CABG with sequential RGEA. There were 42 male and 4 female patients with a mean age of 59 +/- 8.1 years. Mean postoperative follow-up period was 70 months. RESULTS: The mean number of anastomoses was 3.7 per patient. Mean luminal diameter of the RGEA was 2.2 +/- 0.4 mm by preoperative angiography and 2.3 +/- 0.6 mm by intraoperative measurement. Patency of the sequential RGEA was 92%; proximal anastomosis 100%, distal anastomosis 86% (p = 0.01). The 5-year actuarial survival and cardiac event-free rate were 91% and 93%, respectively. CONCLUSIONS: Sequential bypass using the RGEA is feasible, with excellent early and long-term results. The indication for sequential RGEA, however, needs careful anatomical consideration of both the luminal diameter of the RGEA and proximal stenosis of the target coronary arteries.     

Descending thoracic aortobifemoral bypass: an alternative approach for difficult aortic revascularization

Descending thoracic aortobifemoral bypass is an alternative inflow operation in cases in which standard aortobifemoral or axillobifemoral bypass is not an option. We performed descending thoracic aortobifemoral bypass for failed inflow operations in four patients, prior abdominal/pelvic radiation in two patients, poor quality distal aorta (extensive atherosclerotic disease or poor tissue quality) in two patients, and abdominal sepsis in two patients. Eight have had excellent results with patency at a mean follow-up of 38 months. There was no limb loss. One patient died of organ failure, and one patient with hypercoagulability developed a graft clot. A literature review disclosed that a descending thoracic aortobifemoral bypass was reported to have been performed in 203 patients, with most cases reported in the last decade. This procedure was the primary inflow operation in 42 per cent of cases. Indications for the operation included failed aortic grafts (38%), "hostile" abdomen (21%), infected aortic grafts (18%), and other (23%). The patency rate was 95 per cent at 6 months. Few long-term results are known, but the results appear to be durable. Descending thoracic aortobifemoral bypass is a useful operation in highly selected circumstances in which conventional methods of aortic reconstruction are not available.     

Off-pump coronary artery bypass surgery technique for total arterial myocardial revascularization: a prospective randomized study

BACKGROUND: We investigated whether off-pump coronary artery bypass (OPCAB) surgery should be the procedure of choice in total arterial myocardial revascularization with composite grafts. METHODS: We prospectively enrolled 176 patients undergoing total arterial myocardial revascularization and assigned them at random to one of two groups: group 1 was composed of 88 patients undergoing coronary surgery with cardiopulmonary bypass (CPB); group 2 consisted of 88 patients receiving the OPCAB procedure. We excluded from this study patients with significant risk factors for CPB-related morbidity. Composite arterial grafts in Y-T shape were realized in three different configurations according to patients' characteristics, coronary anatomy, and target stenosis. RESULTS: There were no significant differences between the two groups in terms of preoperative characteristics and risk factors (Euroscore: group 1 = 6.1 +/- 3.5, group 2 = 6.6 +/- 3.8). Mean number of anastomoses was similar in both groups (group 1 = 2.8 +/- 0.8, group 2 = 2.7 +/- 0.5) whereas mean mechanical ventilation time (group 1 = 23 +/- 9 hours, group 2 = 9 +/- 4 hours), intensive care unit stay (group 1 = 43 +/- 6 hours, group 2 = 22 +/- 8 hours), and postoperative stay (group 1 = 7 +/- 3 days, group 2 = 5 +/- 2 days) were significantly reduced in group 2. Early mortality was 2.3% in group 1 and 3.4% in group 2 (p = not significant). Major postoperative complications occurred similarly in the two groups (atrial fibrillation: group 1 = 35.2%, group 2 = 21.6%; myocardial infarction: group 1 = 2.2%, group 2 = 1.1%; stroke: group 1 = 2.2%, group 2 = 0%; abdominal infarction: group 1 = 3.4%, group 2 = 0%). At follow-up (mean, 15 +/- 12 months) no significant differences were observed in terms of survival free of any cardiac-related event (group 1 = 94.3%, group 2 = 96.5%; p = not significant). CONCLUSIONS: Off-pump coronary artery surgery could be successfully used for total arterial grafting without compromising the completeness of revascularization. Avoidance of CPB significantly decreased mechanical ventilation support and length of intensive care unit and postoperative stay; however in the absence of risk factors for cardiopulmonary bypass, off-pump coronary artery surgery did not improve early and midterm clinical outcome.     

Unilateral iliac artery occlusive disease: A randomized multicenter trial examining direct revascularization versus crossover bypass

This randomized trial compared the patency of direct unilateral aorto- or iliofemoral prosthetic bypass with that of crossover femorofemoral or iliofemoral bypass in unilateral atheromatous occlusive disease of the iliac artery. Between May 1986 and March 1991, 143 patients were enrolled in this study (74 crossover and 69 direct revascularizations). Cardiovascular risk factors, preoperative symptoms, and atheromatous lesions were similar in both groups. Patients were followed by Duplex scanning with systolic pressure index measurements. Routine digital subtraction arteriograms were obtained postoperatively and separately, when hemodynamic anomalies developed. Mean follow-up was 22 months. One patient with direct revascularization died postoperatively. Primary patency of direct revascularizations was 89.8% at 48 months compared with 52% for crossover bypass. This difference was statistically significant. Secondary patency of direct and crossover revascularization at 48 months was 92.9% and 93.6%, respectively (not significant). Even though crossover bypasses seem attractive because of their technical simplicity and low morbidity, our results suggest that direct revascularizations are preferable in the young patient with no major operative risks, while crossover bypasses remain indicated in patients at risk.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, June 20–21 1991, Marseille, France.