冠状动脉旁路术中不同旁路材料的应用体会

目的：总结冠状动脉旁路移植术中目前几种常用旁路材料的临床应用。方法：2000年1月-2002年3月连续56例行冠状动脉旁路移植术，旁路材料包括左乳内动脉（56根）、游离右乳内动脉（21根）、桡动脉（32根）和大隐静脉（43根）。回顾分析不同旁路材料的手术结果。结果：桡动脉移植后旁路血管“线样征“1例；无胸骨、前臂并发症；下肢切口感染2例，均为糖尿病、大体重患者，治疗后痊愈；死亡3例，与旁路材料无关（非体外循环手术因循环状态下不稳死亡1例，鱼精蛋白过敏1例，顽固性心律失常1例）。结论：注意旁路材料的取制技巧，针对不同病变冠脉血管选取应用不同旁路血管，以及术后及时监护处理是保证良好手术结果的关键。     

非体外循环下左侧乳内动脉及桡动脉Y型桥的冠状动脉旁路移植术近期疗效观察——附36例报告

目的:探讨非体外循环下左侧乳内动脉及桡动脉Y型桥的冠状动脉旁路移植术的疗效及安全性.方法:对36例冠状动脉粥样硬化性心脏病(冠心病)患者行非体外循环下冠状动脉旁路移植术,采用左侧乳内动脉及桡动脉作为移植物.术后利用Medi-stim Butterfly流量计进行桥血管流量测定,并记录血流量及搏动指数.结果:全组36例共行冠状动脉旁路血管移植149支,平均4.1支/例.桥血管流量测定均通畅,左乳内动脉干的流量为(31±6)mL/min,搏动指数为2.0±0.5,桡动脉的流量为(45±12) mL/min,搏动指数为1.9±0.7.36例中,无手术死亡病例,术后因胸骨后出血而开胸止血1例,术后4例诉手背外侧感觉异常、麻木,无发生围手术期心肌梗死、脑部并发症,无胸骨、纵隔感染.结论:非体外循环下左侧乳内动脉及桡动脉Y型桥的冠状动脉旁路移植术是安全、有效的手术方式,可以达到完全心肌血运重建目的,手术近期效果满意.     

自体桡动脉行冠状动脉旁路移植术156例分析

目的：探讨桡动脉用于冠状动脉旁路移植术的近期手术效果。方法：回顾分析156例桡动脉作为移植物应用于冠状动脉旁路移植术的手术技术和手术结果。采用改良Allefts试验筛选桡动脉,采用“无接触”技术提取桡动脉,术中术后应用合贝爽预防动脉痉挛。结果：共提取桡动脉156根,平均搭桥3．3支。术后死于恶性心律失常和严重低心排量1例,再次开胸止血1例,切口血肿2例,无切口感染,有暂时性拇指皮肤感觉减退6例,无前臂和手的运动功能障碍。结论：自体桡动脉是较理想的冠状动脉移植材料,应用“无接触”技术和合贝爽可有效防止桡动脉痉挛,近期临床结果满意。     

70例冠状动脉旁路移植术临床分析

目的 比较分析体外循环冠状动脉旁路移植术和非体外循环冠状动脉旁路移植术的临床效果.方法 回顾2002年1月-2009年2月间我院行冠状动脉旁路移植术70例的临床资料,依据术中采用不同的手术方式分为体外循环组和非体外循环组.并对两组患者的术后临床资料、术后并发症发生情况进行分析.结果 术后非体外循环组发生并发症1例,体外循环组6例;非体外循环组住院死亡1例,体外循环组死亡3例.结论 在多支病变中,非体外循环冠状动脉旁路移植术和体外循环冠状动脉旁路移植术在再血管化的应用上无差别;非体外循环冠状动脉旁路移植术后的死亡率和并发症发生率比体外循环冠状动脉旁路移植术患者低,但是合并瓣膜病或严重的3支血管病变、左主干病变、室壁瘤形成的患者更适宜行体外循环冠状动脉旁路移植术,非体外循环冠状动脉旁路移植术不能取代体外循环冠状动脉旁路移植术.     

自体桡动脉在冠状动脉旁路术中应用的护理28例

用乳内动脉 (IMA)行冠状动脉旁路移植术(CABG) ,桥血管的远期通畅率 (10年通畅率 >90 % )明显优于大隐静脉 (SV)桥 (10年通畅率 5 0 %～ 60 % ) [1] ,已被公认。但有限的IMA不能满足多支病变时动脉化的需要 ,桡动脉 (radialartery ,RA )作为第 2种理想的替代动脉 ,逐渐被多数学者重新应用 ,且远期通畅率与IMA相当[2 ] 。 2 0 0 2年 1～11月我科共应用桡动脉为移植物行CABG 2 8例 ,早期临床效果满意 ,现将护理体会介绍如下。1　临床资料1 1　一般资料2 0 0 2年 1～ 11月 ,我院自体桡动脉 (RA)应用于冠状动脉旁路移植术 2 8例 ,男 2…     

非体外循环下冠状动脉旁路移植术20例报道

目的 :总结非体外循环下冠状动脉旁路移植术 (Off -pumpcoronaryarterybypassgrafting ,OPCAB)的临床经验和效果。方法 :2 0例冠心病人术前均有心绞痛发作史 ,左室射血分数 3 0 %～ 69%。取胸骨正中切口 ,采用Octopus心表稳定器显露固定目标血管拟吻合部位 ,使用血管内分流管 (Shunt)维持冠脉血流和改善术野显露。应用左乳内动脉 2 0例 (其中双侧乳内动脉 3例 )、桡动脉 2例。结果 :无手术死亡 ,无围术期心肌梗死。平均ICU住留时间 1 5d。术后平均 7 5d出院。平均随访 9个月 ,所有患者心绞痛症状消失 ,活动量改善。ECT检查示心肌血供显著改善 ,超声心动图示左室射血分数明显增加。结论 :OPCAB技术安全、经济、有效 ,对于体外循环高危患者尤其有意义。     

非体外循环冠状动脉旁路移植术的围手术期治疗特点分析

目的 :总结非体外循环冠状动脉旁路移植术 (OPCAB)及围术期治疗特点。方法 :应用OPCAB方法手术治疗冠心病 3 0例 ,男性 2 6例 ,女性 4例 ;年龄 48～ 76岁 ,平均 (65 .7± 6.4)岁 ,移植旁路血管数目 3～ 4根 ,平均 (3 .4± 1.4)根。结果 :术中血流动力学稳定 ,术后随访 0 .5～ 2年 ,所有病例心绞痛症状均消失。结论 :正确选择手术适应症 ,合理设计手术方案 ,治疗效果肯定 ,并发症少 ,恢复快。     

乳内动脉在冠状动脉旁路移植术中的应用

目的 :总结应用乳内动脉行冠状动脉旁路移植术 (CABG)早期效果和经验。方法 :71例 (男 5 6例 ,女 15例 )冠心病患者 ,年龄 3 2～ 71岁 ,平均 5 2 5岁。心绞痛Ⅲ～Ⅳ级者 69例。多支血管病变占 92 % ,左心室射血分数 <5 0 %者 2 1例 ( 2 9% )。全部病人均在体外循环下施术 ,共移植血管 2 0 6支 ,平均 2 9支 /例。其中左乳内动脉移植血管 75支 ,游离右乳内动脉移植血管 43支 ,大隐静脉移植血管 88支。旁路移植材料包括 :左乳内动脉 71支 ,游离右乳内动脉 3 7支 ,大隐静脉 69支。 1例使用主动脉内球囊反搏支持。结果 :71例病人痊愈出院 ,出院时无心绞痛主诉 ,心电图示心肌缺血明显改善。结论 :应用乳内动脉行CABG术 ,安全、有效 ;游离右乳内动脉的使用扩展了全动脉化CABG术的可能性 ,早期结果令人鼓舞。     

非体外循环冠状动脉旁路移植术38例早期临床分析

目的总结分析非体外循环冠状动脉旁路移植术的早期临床结果和经验.方法2001年至今本科完成非体外循环冠状动脉旁路移植术38例,男33例,女5例;年龄44～78岁;左主干病变6例,单支病变2例,双支病变9例,3支病变27例;左心室射血分数平均(0.52±0.16).结果常规正中胸骨切口共行冠状动脉搭桥90支,其中单支6例,双支15例,3支14例,4支3例,乳内动脉桥数为27支,大隐静脉桥数为63支.2例术后使用了主动脉内球囊反搏,住院死亡1例,37例痊愈出院.结论非体外循环冠状动脉旁路移植术安全可行,手术和术后并发症少,早期临床效果满意,远期效果有待于进一步随访观察.     

冠状动脉旁路移植术后复发心绞痛患者临床研究

目的:探讨冠状动脉旁路移植术术后再次发作心肌缺血事件的原因.方法:回顾性分析545例行冠状动脉旁路移植术术后复发心绞痛接受冠状动脉造影检查患者的临床资料.结果:545例冠状动脉旁路移植术术后复查冠状动脉造影的患者,糖尿病患者为156例(28.6%),较非糖尿病患者搭桥术后心绞痛复发时间短(P<0.05).266例患者药物治疗(48.8%).247例接受再次介入治疗(45.3%),32例行二次冠状动脉旁路移植术.冠状动脉旁路移植术术后1个月内复发症状者冠状动脉造影显示左乳内动脉闭塞37.5%,1～12个月大隐静脉桥狭窄16.3%,闭塞15.2%,左乳内动脉狭窄15.3%.>1年后症状复发桥血管闭塞以静脉桥为主.结论:冠状动脉粥样硬化的危险因素及搭桥血管的类型影响再次冠状动脉治疗的必要性和倾向性.     

胃网膜右动脉应用于非体外循环冠状动脉旁路移植术患者的临床护理

目的总结胃网膜右动脉(RGEA)应用于非体外循环冠状动脉旁路移植术(OPCABG)患者围手术期的护理,探讨RGEA应用于OPCABG的护理特点。方法 38例应用常规移植血管(左乳内动脉、桡动脉、大隐静脉)外加REGA的OPCABG患者,围手术期进行全面严密监护,突出胃肠道和抗痉挛护理的特点,总结经验。结果 38患者手术顺利,恢复良好,无严重并发症。结论 RGEA是OPCABG良好的移植血管,高质量护理可减少并发症,降低死亡率,提高手术效果,是OPCABG治疗不可缺少的部分。     

Comparison of fatty acid profiles of aorta and internal mammary arteries in patients with coronary artery disease

BACKGROUND: Atherosclerosis represents the principal cause of death in the many societies. Since few data have been published about the composition of fatty acids in atherosclerotic arteries such as the aorta comparing to the non affected internal mammary artery which is used for aortocoronary bypass grafting, we compared the fatty acid profiles of atherosclerotic aorta and internal mammary arteries in human individuals. METHODS: Twenty-one angiographically documented coronary artery disease (CAD) patients who were admitted to the open heart surgery division enrolled in this study. They were operated electively for coronary artery bypass grafting surgery (CABG). Small segments of ascending aorta and internal mammary arteries were sampled during open heart surgery. The samples were subjected to lipid extraction and fatty acid analysis by high performance liquid chromatography. RESULTS: The results showed that different fatty acid profiles were seen in the aorta and internal mammary arteries. The atherosclerotic aorta contained lower amounts of unsaturated fatty acids (including trans isomer of oleic acid) and higher proportions of saturated fats comparing to the internal mammary. In the aorta also, the amounts of omega6 series of fatty acids were more and levels of omega3 fats were less than the internal mammary. CONCLUSION: This study suggests that modification of fatty acids may play a role during atherogenesis.     

冠状动脉搭桥术前常规超声检查相关血管的临床价值

目的 评价冠状动脉搭桥术前常规超声检查进行桥血管筛查的价值。方法 总结140例拟行冠状动脉搭桥术患者胸廓内动脉、颈动脉(其中74例患者同时检查双侧桡尺动脉)的彩色多普勒超声检查结果并进行分析。结果 140例患者中，11例胸廓内动脉纤细或狭窄，28例存在不同程度颈内动脉狭窄。74例患者桡尺动脉的超声检查中，14例左桡动脉存在低血流动力学状态，管径纤细，存在斑块、迂曲或尺动脉狭窄。结论 冠状动脉搭桥术前常规超声检查进行桥血管的筛查，对协助临床医师选择桥血管，减少手术风险，提高手术效果有着重要意义。     

Use of the internal mammary artery for myocardial revascularization in a patient with radiation-induced coronary artery disease.

A 9-year-old boy with clinical stage IIA Hodgkin's disease underwent radiotherapy to the neck and mediastinum. Twenty-two years later, he sought medical attention because of angina pectoris. Cardiac catheterization revealed proximally located high-grade stenoses of the left main, left anterior descending, circumflex, and right coronary arteries. He underwent coronary artery bypass grafting with use of the left internal mammary artery to the left anterior descending coronary artery and reversed saphenous vein grafts to the circumflex and right coronary arteries. The postoperative course was uncomplicated. Previous radiotherapy to the mediastinum should be considered a risk factor for the development of premature coronary artery disease. Surgical revascularization is the preferred method of management. A combination of an internal mammary artery graft and a saphenous vein graft should be used in young patients.     

Technical considerations in aortocoronary bypass grafting

Since the inception of aortocoronary bypass surgery, many technical advances have been rapidly achieved. Early experience was limited to reversed saphenous vein grafting of single vessel coronary artery disease. Multiple grafts to several vessels soon became commonplace and sequential grafting techniques were developed. Expanded use of the internal mammary artery resulted after analysis of superior patency rates achieved with this conduit. Use of alternative conduits such as upper extremity veins, allogenic veins, synthetic graft material (polytetrafluorethylene), radial artery, splenic artery, and gastroepiploic artery have been explored. Apart from the gastroepiploic vessel, none of these alternative conduits have been suitable. A grat deal of effort has been directed at the mechanisms of saphenous vein occlusion including technical considerations, early thrombosis, intimal hyperplasia and graft atherosclerosis. Platelet inhibition and lipid reduction have shown promise in improving patency rates. Further work in these areas should lead to even better results.     

Left Internal Mammary Artery as an Endocrine Organ: Insights Into Graft Biology and Long-term Impact Following Coronary Artery Bypass Grafting

The left internal mammary artery (LIMA) is considered the criterion standard vessel for use in coronary artery bypass grafting. In recent decades, countless studies have documented its superiority over other arterial and venous coronary artery bypass grafting conduits, although the full mechanisms for this superiority remain unknown. A growing body of literature has unveiled the importance of extracellular vesicles known as exosomes in cardiovascular signaling and various pathologic states. In this review, we briefly compare the clinical longevity of the LIMA relative to other conduits, explore the effects of varying grafting techniques on clinical and angiographic outcomes, and provide physiologic insights into graft function on a cellular and molecular level. Finally, we explore exosome signaling as it pertains to atherosclerosis in support of the LIMA as an “endocrine organ.”     

非体外循环冠状动脉旁路移植术治疗心肌桥13例分析

目的:探讨非体外循环冠状动脉旁路移植术治疗心肌桥的临床效果.方法:2004年4月-2009年1月狭窄程度Noble分级在3级以上的13例心肌桥患者,均接受非体外循环冠状动脉旁路移植术治疗.采用Genzyme心脏血管稳定器,心脏不停跳下切开心肌桥远端(冠状动脉钻出心肌处)心肌表面脂肪组织,取左内乳动脉搭桥至心肌桥远端.结果:13例患者均顺利完成手术.术后随访6～50个月,均无心绞痛发作,患者生活质量满意.结论:非体外循环冠状动脉旁路移植术是治疗Noble3级以上心肌桥的有效方法.     

Intraoperative assessment of coronary grafts by novel digital epivascular imaging.

OBJECTIVE: We sought to validate and evaluate 2 novel intraoperative ultrasound probes for epicoronary and epiaortic imaging. BACKGROUND: The noninvasive intraoperative assessment of successful coronary artery bypass grafting remains a challenge. METHODS: A total of 19 consecutive patients (4 female, 15 male; mean age 60.5 +/- 13.8 years SD, range 34-84) underwent coronary artery bypass grafting. The epivascular probes (GE Ultrasound) were validated in vitro and intraoperatively. Coronary arteries, grafts, and ascending aorta were imaged and quantified. RESULTS: Mean adjusted flow measured by flowmeter was 3.25 L, SE 0.47 (range: 1-5.5 L) and was 3.15 L, SE 0.46 (range: 1-5.0 L) by ultrasound, with r = 0.97, P <.0001. Intraoperatively, 56 native coronary vessels were bypassed using 15 left internal mammary artery grafts, 25 vein grafts, and 16 venous jump grafts. A total of 15 left internal mammary artery grafts (100%), 12 left internal mammary artery anastomoses (80%), 20 vein grafts (15 left anterior descending coronary arteries, left circumflex artery grafts, 5 right coronary artery grafts) (80%), 4 jump grafts (25%), and 15 ascending aortas (78%) were successfully imaged by inexperienced surgeons. Doppler flow measurements were possible in 50 vessels (89%). Mean lumen diameter for graft arteries (veins) was 2 mm (2.87 mm), maximal velocity was 72 cm/s (46 cm/s), and mean velocity was 29 cm/s (21 cm/s) with a mean flow rate of 70 mL/m (55 mL/m). CONCLUSIONS: We conclude that: (1) the novel intraoperative probes measure validated flow; (2) intraoperative hemodynamic assessment of graft patency is feasible without a learning curve; and (3) these findings should encourage the routine use of these intraoperative epivascular digital ultrasound probes.     

桡动脉作为冠状动脉旁路移植术桥血管的安全性评估

目的比较二维及多普勒超声和Allen试验2种方法筛选冠状动脉旁路移植术(CABG)移植血管的准确性。方法51例患者CABG术前联合Allen试验与超声检查评价尺(UA)、桡动脉(RA)间侧支循环状况。结果47例经超声检查证实UA、RA间存在完善的侧支循环的患者,无论Allen试验结果阴性或阳性,术后均未发生手部缺血。2例Allen试验阴性结果,但超声检查认为UA不能代偿供血的患者,发生了不同程度的手部缺血表现。2例因不符合条件被排除。结论超声检查与Allen试验比较,对手掌部UA、RA间侧支循环评估的准确性更高,是一项很有意义的前瞻性检查。     

Composite arterial grafting

The success of coronary artery bypass grafting, the gold standard for the treatment of multivessel coronary artery disease, is limited by poor long-term vein-graft patency. By contrast, the left internal mammary artery has been demonstrated to have a superior graft patency rate and has provided excellent clinical results. This suggests that the use of arterial conduits for coronary artery bypass grafting may be beneficial for long-term results. Recently, there has been an upsurge in the use of arterial grafts for myocardial revascularization based on the clinical advantage of the use of the left internal mammary artery as a bypass conduit. Many retrospective studies have supported the safety and the effectiveness of arterial grafting, and it has become apparent that the free arterial graft can be used as a branched or a lengthened conduit to the in situ arterial graft by adopting one or more of the several composite grafting techniques. Arterial composite grafts with or without sequential grafting techniques appear an attractive strategy as increased number of distal coronary anastomoses can be performed, with a limited number of grafts, avoiding proximal aortic anastomoses. However, concerns regarding the total dependence of the coronary bypass flow on the flow of one in situ arterial graft and technical error, resulting in compromised flow in one or both limbs of the composite graft have prevented composite arterial grafting from being universally adopted. It is expected that in the near future a prospective, multi-institutional, randomized controlled trial, to compare the short- and long-term outcomes of exclusive arterial grafting using composite and conventional aortocoronary revascularization strategies, will be undertaken to validate the safety and efficacy of composite arterial grafting.