冠状动脉旁路移植术后旁路血管狭窄影响因素分析

目的总结冠状动脉旁路移植术(CABG)后旁路血管造影特点,分析相关因素对旁路血管通畅率的影响,并探讨提高旁路血管通畅率的方法。方法2004年4月至2006年4月间CABG术后平均间隔(46.4±39.1)个月,因心绞痛复发再入院行冠状动脉造影(CAG)病人149例,男120例;平均年龄(61.0±10.1)岁。共444支旁路血管,其中左乳内动脉(LIMA)131支,大隐静脉(SV)295支,左桡动脉(RA)15支,右乳内动脉(RIMA)3支。旁路血管造影完全闭塞或狭窄≥75%视为旁路血管病变。结果本组65.1%(97/149例)病人有旁路血管病变。31.1%(138/444支)旁路血管发生病变。LIMA闭塞5.3%(7/131支),狭窄(≥75%)6.9%(9/131支);SV旁路血管闭塞31.9%(94/295支),狭窄7.5%(22/295支);RA旁路血管闭塞33.3%(5/15支);RIMA旁路血管闭塞33.3%(1/3支)。LIMA旁路血管的通畅率明显优于SV。不同靶血管的SV旁路血管通畅率有明显差别。吻合口以远冠状动脉口径(runoff)≥2.0 mm的旁路血管通畅率明显高于<2.0mm者,尤其是SV旁路血管。近端冠状动脉狭窄程度对LIMA-前降支的通畅率影响明显,而对主动脉-SV-后降支通畅率影响不明显。序贯吻合及非体外循环CABG对旁路血管通畅率无明显影响。结论CABG术后旁路血管病变比较常见,是造成术后心绞痛复发的重要原因。不同旁路血管、不同靶血管、runoff大小、近端冠状动脉狭窄程度均明显影响旁路血管通畅率。手术技术不当是术后早期旁路血管病变的主要原因。改进手术技术,术后早期足量抗血小板药物及强化降脂治疗是提高旁路血管通畅率的关键。     

非体外循环心脏跳动下冠状动脉旁路移植术桥血流的研究

目的　术中测量非体外循环心脏跳动下冠状动脉旁路移植术 (OPCAB)桥血管的血流量和搏动指数 (PI)及血流波形 ,以探讨血管桥通畅率及其与波形的关系。方法　 2 34例病人接受OPCAB手术 ,采用左乳内动脉 (LIMA)全部与左前降支 (LAD)吻合 ,大隐静脉 (SV)吻合口在 2个以上采用序贯式吻合。术中用超声血流检测仪 (medi stimbutterflyflowmeter)测量旁路血管桥的血流量、PI值及其波形 ,根据结果判断桥路通畅情况 ,并且对比LIMA和SV旁路血管桥的血流量和LIMA中LAD近段狭窄大于 90 %与小于 90 %者的血流量。结果　LIMA使用率 10 0 % ,LIMA和SV桥通畅率 10 0 % ,LIMA平均血流量(19 99± 1 93)ml/min ,SV血流量 (38 17± 2 85 )ml/min ,两者差异显著 (P <0 0 1)。LIMA组中LAD近段狭窄大于 90 %者血流量 (32 0 0± 3.4 0 )ml/min ,小于 90 %者血流量 (15 2 9± 1 6 6 )ml/min ,两者差异显著(P <0 0 1)。PI平均值LIMA为 3 2 9± 0 2 2 ,SV为 3 4 1± 0 37。术后病人无并发症 ,心绞痛消失 ,全部治愈出院 ,平均住院 (7 0± 1.5 )d。随访无死亡。结论　OPCAB术吻合口的通畅率令人满意 ,静脉桥血流量高于LIMA ;LAD近段狭窄大于 90 %时LIMA血流量较高。反映桥通畅的最可靠指标是桥血流的搏动指数 ,而舒张期血流的波     

乳内动脉桡动脉大隐静脉的内皮型一氧化氮合酶表达

目的 应用免疫组织化学方法，探讨内皮型一氧化氮合酶(eNOS)在冠状动脉旁路移植术中常用的3种血管材料乳内动脉(LIMA)、桡动脉(RA)及大隐静脉(SV)中的定位及表达。方法取20例行冠状动脉旁移植术((LMIG)的冠心病病人的LIMA、RA及SV的废弃血管标本，行光镜观察及eNOS的免疫组织化学染色进行半定量观察。并行计算机图像分析，比较灰度值。结果eNOS在3种血管材料的内膜均有明显表达，LIMA灰度值明显高于RA及SV，RA灰度值高于SV；LIMA、RA的肌性中层可见eNOS的表达而SV无表达，LIMA灰度值明显高于RA。结论各种血管材料中eNOS的不同表达，可能是CABG术后的远期效果不同的原因之一。     

乳内动脉-大隐静脉复合桥血管在老年人非体外循环冠状动脉旁路移植术中的应用及中期随访结果

目的探讨乳内动脉-大隐静脉复合桥血管在老年患者非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass surgery,OPCAB)中的应用及治疗效果。方法 2006年3月至2012年10月,新华医院心胸外科在OPCAB中应用左乳内动脉(left internal mammary artery,LIMA)-动脉或静脉复合桥血管治疗老年(70岁以上)冠心病患者共59例,其中男37例、女22例,平均年龄(72.71±1.95)岁。其中动脉-大隐静脉(SV)复合桥血管(LIMA-SV)组21例,动脉-桡动脉(RA)复合桥血管(LIMA-RA)组38例。结果所有患者均顺利应用LIMA-SV或LIMA-RA复合桥血管行OPCAB术。术后早期,LIMA-RA组死亡1例,其余58例均顺利康复出院,两组患者术后早期恢复情况差异无统计学意义(P0.05)。术后随访12~91个月,无冠状动脉再血管化病例。两组术后1年、3年、5年的累积生存率差异无统计学意义(P0.05)。全组患者LIMA通畅率为100%;术后1年、3年、5年SV桥血管通畅率与RA桥血管通畅率差异无统计学意义(P0.05)。结论尽管全动脉化是最佳的桥血管选择方案,但对于右乳内动脉或桡动脉桥无法使用,或获取后并发症风险较高的老年患者,LIMA-SV复合桥血管方案仍是一种良好的选择。     

再次冠状动脉旁路移植术的临床应用

目的总结再次冠状动脉旁路移植术(CABG)治疗冠心病的临床经验和手术效果。方法2001年6月～2006年12月,对18例冠心病患者行再次CABG。术前心绞痛(CCS分级)级7例,级11例;冠状动脉造影显示:16例均有原移植静脉狭窄/闭塞,2例左乳内动脉(LIMA)-左前降支(LAD)桥狭窄/闭塞,6例自体冠状动脉出现新的病变。全组均经原胸骨正中切口径路手术,常规体外循环(CPB)下CABG15例,非体外循环冠状动脉旁路移植术(OPCAB)3例;同期行室壁瘤切除、左心室成形1例,二尖瓣成形术3例,主动脉瓣和二尖瓣双瓣膜置换联合右颈动脉内膜剥脱术1例。应用LIMA12例次、双侧IMA4例次、桡动脉3例次,其余为大隐静脉或小隐静脉。结果15例常规CABG患者主动脉阻断时间45～112min(57±26min),CPB时间66～140min(78±24min)。再次CABG每例移植血管1～5支,平均每例远端吻合口3.11个。手术结束用血流仪测定移植血管血流量均满意(血流量27.0±12.5ml/min),搏动指数均<4.2。手术后因低心排血量需主动脉内球囊反搏辅助1例,术后6d发生肾功能衰竭死亡。其余17例患者术后呼吸机辅助呼吸时间5～15h,心绞痛均消失,围手术期无心肌梗死发生,胸腔引流量为290～1040ml,顺利恢复,均出院。术后随访17例,随访时间6.0个月～4.5年,均无心绞痛发作,4例复查冠状动脉造影,显示移植血管均通畅。结论再次CABG难度大于首次CABG,但只要手术中能正确找到靶血管,移植血管的血流可靠、完全再血管化和有良好的围术期管理,再次CABG可达到与首次手术同样的效果。     

70岁以上患者的冠状动脉旁路移植术

目的介绍70岁以上高龄患者行冠状动脉旁路移植术(CABG)的结果和围术期处理策略. 方法对70岁以上患者行CABG 121例,119例(98.3%)为不稳定型心绞痛,113例(93.4%)合并其他疾病.80例(66.1%)采用非体外循环心脏不停跳CABG(OPCAB),41例(33.9%)选择常规体外循环CABG(CCABG);胸膜外技术游离左乳内动脉(LIMA),保持胸膜腔完整,常规将LIMA与左前降支(LAD)吻合,其余桥用大隐静脉(SV).术中使用即时超声血流仪(TTFM)测量移植血管血流,保证吻合口通畅.术后加强物理治疗和营养支持,严格控制血糖于6～10 mmol/L.结果行CCABG患者移植血管3.08±0.75支, OPCAB患者2.24±0.82支,110例(90.9%)使用LIMA.全组死亡1例(急诊手术),死亡率0.8%,死于多器官功能衰竭;发生并发症4例(3.3%).术后呼吸机使用时间OPCAB患者10.04±5.68小时,CCABG患者21.46±14.54小时;住ICU 时间2.65±1.45天,术后12.22±5.56天出院. 结论充分评估手术风险,选择恰当的手术方案,经过缜密的围术期处理,高龄患者亦可取得良好的手术效果.     

冠状动脉旁路移植术中应用骨骼化与带蒂左乳内动脉的随机对照试验

目的探讨冠状动脉旁路移植术(CABG)中应用骨骼化左乳内动脉(LIMA)移植的临床经验。方法选取2013年1~4月于中国医科大学附属第一医院行单纯CABG的冠状动脉粥样硬化性心脏病患者122例,其中男77例、女45例,年龄41~76(62.8±10.5)岁。将患者采用随机数字表法分为两组:A组,60例,使用骨骼化LIMA;B组,62例,使用带蒂LIMA,LIMA均吻合到前降支上。结果术中获取LIMA过程中,A、B组各有1例失败而改为大隐静脉移植,被排除在外。术后A组和B组的其余病例分别发生围手术期心肌梗死2例(3.4%)和3例(4.9%),两组差异无统计学意义(P0.05);院内各死亡1例,死亡率分别为1.7%和1.6%,两组差异无统计学意义(P0.05)。A组无纵隔感染,B组有1例纵隔感染,两组差异无统计学意义(P0.05)。A组游离LIMA时间长于B组[(30.7±7.2)min vs(17.2±5.6)min,P0.05],差异有统计学意义。术后随访6~10个月,术后6个月冠状动脉CT显示A、B两组LIMA血管通畅率分别为96.8%和100.0%,差异无统计学意义(P0.05)。结论利用合适的技术获取骨骼化LIMA作为血管材料进行CABG的近期临床效果满意。     

微创左胸小切口多支冠状动脉旁路移植术的应用及效果评价

目的探讨左乳内动脉-桡动脉或大隐静脉(LIMA-RA或LIMA-SV)复合桥血管在微创左胸小切口多支冠状动脉旁路移植术的应用及效果。方法 2009年1月至2015年5月,上海交通大学医学院附属新华医院心胸外科在微创冠状动脉旁路移植术中应用LIMA-RA或LIMA-SV复合桥血管治疗冠心病患者56例,男36例、女20例,平均年龄(65.41±7.73)岁。其中,LIMA-RA复合桥血管(动脉-动脉复合桥血管)34例,LIMA-SV复合桥血管(动脉-静脉复合桥血管)22例。患者均经左胸前侧第4肋间切口,在非体外循环下行微创直视冠状动脉旁路移植术(MIDCAB)术。结果全部患者均顺利完成MIDCAB术,无术中转为正中开胸。靶血管再血管化数目:2支12例,3支41例,4支3例。术后机械通气时间为(27.14±31.35)h,术后住ICU时间为(3.16±2.53)d,术后住院时间(11.89±3.91)d。围术期死亡1例(1.79%),该例系LIMA-SV组患者,术后因多脏器功能衰竭死亡。术后随访1~77(22.70±17.56)个月,全组无冠状动脉再血管化病例。LIMA-RA组术后2年的累积生存率为94.4%±5.4%,LIMA-SV组术后2年的累积生存率为86.8%±9.2%,两组差异无统计学意义(P=0.299)。全组患者LIMA通畅率为100.0%,LIMA-RA组术后2年的累积RA桥血管通畅率为90.3%±5.3%,LIMA-SV组术后2年的累积SV桥血管通畅率为86.7%±6.3%,两组差异无统计学意义(P=0.265)。结论 LIMA-RA或LIMA-SV复合桥血管可安全应用于MIDCAB术中,早、中期治疗效果满意。对于桡动脉桥无法使用或获取后并发症风险较高的患者,LIMA-SV复合桥血管方案仍是一种良好的选择。     

内窥镜采集大隐静脉行冠状动脉旁路移植术1年随访

目的 总结应用内窥镜采集静脉(endoscopic vein harvesting,EVH)技术获取大隐静脉(greater saphenous vein,GSV)进行冠状动脉旁路移植手术(coronary artery bypass grafting,CABG)后1年随访结果,评估采用EVH技术的手术效果.方法 2009年5月至2010年5月,136例患者应用EVH取GSV进行的非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass grafting,OPCABG),112例开放静脉获取术(open vein harvesting,OVH)取GSV进行的OPCABG.评估71例应用EVH和64例传统手术切口取GSV行OPCABG患者1年随访结果,比较两组患者手术情况、下肢切口并发症、1年后移植血管通畅率以及心理状况.结果 EVH组与OVH组比较,在创面大小、伤口恢复及美观化、伤口感染率、神经功能影响、二次清创缝合率以及下肢切口总体并发症发生率等方面具有明显优势.比较两组患者术后1年移植血管通畅率,EVH组动脉移植血管通畅率96.8％,静脉移植血管通畅率85.7％;OVH组动脉移植血管通畅率94.9％,静脉移植血管通畅率86.4％.两组随访结果中心绞痛再发率、动脉移植通畅率、静脉移植通畅率差异均无统计学意义.EVH组患者心理状况调查结果优于OVH组.结论 与常规OVH方法相比较,EVH技术对获取移植静脉具有更多优势,通过在采集前对患者进行部分肝素化等更具保护移植静脉材料的方法,EVH组也保持了满意的移植血管1年期通畅率.     

冠状动脉旁路移植术后移植血管通畅率的影响因素分析

目的分析冠状动脉旁路移植术(CABG)后1年移植血管通畅率及危险因素。方法前瞻性连续纳入哈尔滨医科大学附属第一医院2010年6～12月行CABG患者71例,其中男37例,女34例;年龄(59.8±7.7)岁,由同一术者主刀完成手术,术后用标准药物治疗。术后1年行冠状动脉256排多层螺旋CT检查,根据移植血管通畅与否,将患者分为闭塞组(n=16)和通畅组(n=55)。收集术前、术中和术后随访资料,通过单因素分析和logistic多因素回归分析筛选导致移植血管病变的危险因素。结果术后1年移植血管通畅率为91.0%(172/189)。单因素分析结果显示,术前胆固醇水平(t=-2.389,P=0.017)、血管弥漫性病变(χ2=4.449,P=0.042)、靶血管直径(t=5.064,P=0.000)、术后未规范服用抗血小板药物(χ2=10.175,P=0.008)是移植血管病变的潜在危险因素。logistic多因素回归分析结果显示,靶血管狭窄[RR=0.014,95%CI(0.001,0.228),P=0.003]和术后未规范服用抗血小板药物[RR=13.375,95%CI(1.075,175.536),P=0.044]是移植血管病变危险因素。结论 CABG患者术后1年移植血管通畅率较高,移植血管通畅率与靶血管狭窄及术后抗血小板药物的规范服用相关。     

Sixteen-slice multidetector computed tomography for graft patency evaluation after coronary artery bypass surgery

OBJECTIVE: To investigate the ability of 16-slice multidetector computed tomography (MDCT) to assess coronary artery bypass graft patency and to detect bypass stenosis by comparison with coronary angiography. METHODS: Thirty patients underwent both conventional coronary bypass angiography and retrospective ECG gated 16-slice multidetector computed tomography after surgery using 0.4 seconds rotation time and 1.25 mm slice thickness. RESULTS: Among a total of 107 bypass grafts, 101 grafts (94.4%) were evaluable by MDCT. Thirteen patients were taking oral beta blockers. Mean heart rate was 73.6 (52-105). Of the 40 internal mammary arteries and two radial arteries examined, only one was occluded by coronary bypass angiography and MDCT, resulting in a sensitivity of 100% and a specificity of 100%. MDCT correctly diagnosed all patent venous grafts and missed two of the 14 venous grafts shown occluded by conventional angiography resulting in a sensitivity of 85.7% and specificity of 100%. When occluded grafts were excluded, MDCT did not detect two out of two anastomotic arterial graft stenosis >50% and resulted in one false positive result for a sensitivity and specificity of 0% and 97.4%, respectively. MDCT correctly diagnosed one out of three venous stenosis >50% and falsely diagnosed one venous graft stenosis >50% yielding a 33.3% and 97.6% sensitivity and specificity, respectively. CONCLUSION: Sixteen-slice MDCT allows for noninvasive evaluation of coronary bypass grafts patency with high diagnostic accuracy. Assessment of distal anastomotic stenosis was deficient, particularly for arterial grafts, still limited by low resolution or artifacts. Improved accuracy may be obtained by more aggressive heart rate reduction.     

The comparison of the graft patency after coronary artery bypass grafting using coronary angiography and multi-slice computed tomography.

OBJECTIVE: Coronary angiography (CAG) is the gold standard method in evaluating graft patency following coronary artery bypass grafting (CABG), even though there are several kinds of non-invasive methods. Recently developed multi-slice CT (m-CT), having effective scan times up to 0.25 s and multi-row detector array systems, enable rapid imaging of cardiac structures, including coronary arteries during one breath-hold. We compared m-CT with CAG for the evaluation of graft patency following CABG. METHODS: Forty-two patients having undergone m-CT and CAG within 3 months of CABG were studied. Twenty-three patients underwent conventional CABG and 19 off-pump CABG. A total of 125 grafts were used, including 42 left internal mammary arteries (LIMA), 25 radial arteries (RA), 3 right internal mammary arteries (RIMA) and 55 vein grafts. RESULTS: CAG showed a 96% (120/125) patency rate (1 LIMA, 2 RA and 2 vein grafts were occluded). m-CT showed a 98% (122/125) correct positive ratio with a sensitivity and specificity of 98 and 100%, respectively. The sensitivity in LIMA, RA, RIMA and vein grafts was 98, 91, 100 and 100%, respectively, with 100% specificity for all. There was an equivocal result in the competitive grafts with native coronary artery that were patent in the CAG, but faint opacification with no significant flow in the m-CT. CONCLUSIONS: This study showed that m-CT was very simple, useful and accurate in evaluating graft patency during the early post-operative period following CABG, even though there was an equivocal result in the competitive grafts with a native coronary artery.     

再次冠状动脉旁路移植术术前静脉桥通畅率的造影分析

目的　比较单一静脉桥与序贯静脉桥在冠状动脉旁路移植 (CABG)术后的通畅率和寿命。方法　收集 30 0例再次CABG病人术前的冠状动脉造影资料。其中 10 6例既有单一桥 (15 9条 ) ,又有序贯桥 (118条 )。结果　 10 6例病人单一桥对序贯桥的堵塞率和狭窄率 (≥ 5 0 % )为 :1年 ,1%和 1%对 2 %和 0 ;5年 ,1%和 0对 2 %和 1% ;10年 ,8%和 7%对 7%和 9% ;15年 ,2 4%和 18%对 2 3%和 2 5 % ;2 3年 ,45 %和 31%对 39%和 42 %。结论　序贯吻合本身不影响静脉桥的通畅率     

Serial angiographic follow-up of grafts one year and five years after coronary artery bypass surgery.

OBJECTIVE: We studied retrospectively the patency of grafts after coronary artery bypass grafting (CABG) using serial angiographies performed one year and five years after surgery. METHODS: One hundred and nine patients who had available coronary angiographies at both one year and five years after CABG were included. Morphologic changes of anastomotic sites and grafts were traced in the same group of patients using the FitzGibbon grading system. RESULTS: The arterial graft patency rate (FitzGibbon grade A+B) was significantly higher than the saphenous vein grafts at both one year (98.0% vs 82.4%, p<0.001) and five years (90.7% vs 80.2%, p=0.006) after surgery, respectively. The arterial graft patency rate was superior to vein grafts in the left anterior descending coronary artery territory at both one year (97.5% vs 82.0%, p=0.001) and five years (90.9% vs 78.0%, p=0.042) postoperatively. Other territories showed similar patency rates between arterial and vein grafts. The vein graft patency rate at five years postoperatively was lowest in the right coronary territory when compared with other territories. When the patency pattern was compared between postoperative years 1 and 5, the proportion of FitzGibbon grade B grafts increased significantly in the vein grafts (3.1% vs 7.5%, p=0.002), while that of arterial grafts remained stable (8.6% vs 7.3%, p=0.774). When the graft patency at postoperative year 5 was compared between patients with recurrent angina and those without, the patients with recurrent angina showed a higher proportion of FitzGibbon grade B grafts (19.2% vs 4.8% in arterial grafts, p=0.023; 20.5% vs 4.8% in vein grafts, p=0.003) and lower grade A grafts (65.4% vs 86.4% in arterial grafts, p=0.019; 43.6% vs 78.2% in vein grafts, p<0.001), and a lower vein graft patency rate (64.1% vs 83.0%, p=0.014). CONCLUSIONS: The arterial graft patency rate was significantly higher than that of saphenous vein grafts, especially in the left anterior descending coronary artery territory, at one year and five years postoperatively. The decreased patency rate of the vein grafts, along with insulin-dependent diabetes mellitus, were associated with angina recurrence.     

Immediate and long-term results of coronary artery bypass operation in hemodialysis patients

This study evaluated the early and late results of coronary artery bypass grafting (CABG) in patients on long-term maintenance hemodialysis (chronic HD) at Teikyo University Ichihara Hospital between January 1996 and June 2000. Thirty-six patients on chronic HD underwent CABG. There were 26 males (72%) and 10 females (28%) ranging from 41 to 81 years (mean +/- SD, 61.8 +/- 9.2 years) of age. Twenty-one patients (58%) had unstable angina, 14 (39%) stable angina, and 1 acute myocardial infarction. Eleven patients (31%) had urgent or emergency CABG. The average graft number was 2.5 +/- 0.8 (arterial graft 1.3 +/- 0.7/patient). Six patients had concomitant cardiac operations. Three patients underwent re- or a second re-CABG. Five patients underwent off-pump CABG. Principally, HD was performed during cardiopulmonary bypass and was followed by continuous hemodiafiltration in the early postoperative period. The early mortality was 11%; 25% in emergency and urgent CABG and 4% in elective CABG. In the follow-up period between 1 and 53 months (mean +/- SD 21.9 +/- 15.1 months), 4 patients died, and 9 patients developed recurrence of angina pectoris (6, occlusion of saphenous vein graft and 3, native coronary progression). Six patients had coronary intervention. The postoperative angiogram showed that all arterial grafts were patent, but the patency of the vein grafts was only 61.5%. The early results of CABG in patients on chronic HD was satisfactory. The late recurrence of angina pectoris mostly was caused by occlusion of the saphenous vein graft. In conclusion, the aggressive use of arterial grafts is crucial in CABG for patients on chronic HD.     

Saphenous vein graft angioplasty pseudoaneurysm: A surgical challenge

A 73-years-male, hypertensive, non-smoker and nondiabetic underwent coronary artery bypass grafting (CABG) in 1986. Three years earlier he had undergone angioplasty for anastomotic lesion in left anterior descending (LAD) and right coronary artery (RCA). Patient again developed unstable angina in august 2006. Angiogram revealed patent stents with discrete lesion in proximal saphenous venous graft(SVG) to LAD, Graft angioplasty was done and a drug eluting stent was deployed. He presented with low grade fever and pain left shoulder two days following intervention. Serial computed tomography (CT) angiograms revealed expanding pseudoanaeurysm at the distal end of stent. Redo CABG with excision of Pseudoanaeurysm done. Psuedoaneurysm with a patent graft is a surgical challenge.     

冠状动脉内膜剥脱联合旁路移植治疗弥漫性冠状动脉狭窄病变的近中期效果

目的探讨冠状动脉内膜剥脱术(CE)联合冠状动脉旁路移植术(CABG)治疗弥漫性冠状动脉狭窄病变的近中期效果。方法回顾性分析2010年1月至2019年1月在南京市第一医院心胸血管外科接受CE+CABG的248例弥漫性冠状动脉狭窄病变患者的临床资料。男性201例,女性47例;年龄(65.6±8.5)岁(范围:43~79岁)。体外循环手术156例,非体外循环手术92例。共对269根病变血管完成CE,包括前降支108根,右冠状动脉140根,钝缘支21根。共完成旁路移植872支,包括左胸廓内动脉248支,桡动脉48支,大隐静脉576支,每例患者移植(3.5±0.8)支(范围:2~6支)。CE后平均血流量为(26±8)ml/min(范围:13~59 ml/min),血流指数为3.1±0.8(范围:2.0~6.7)。采用t检验或χ²检验比较体外循环和非体外循环患者的手术结果及术后通畅率。结果全组围手术期病死率为1.2%(3/248),2例死于肾功能衰竭,1例死于术后顽固性低心排血量。9例发生围手术期心肌梗死。随访(41.8±21.4)个月(范围:1~68个月)。旁路血管术后1年通畅率为78.4%(182/232),3年通畅率为69.8%(162/232)。左冠状动脉系统通畅率明显高于右冠状动脉系统(1年:87.4%比73.1%,χ²=6.533,P=0.011;3年:78.2%比64.8%,χ²=4.588,P=0.032)。体外循环组和非体外循环组旁路血管通畅率无差异(1年:80.0%比76.9%,χ²=0.277,P=0.599;3年:71.5%比67.9%,χ²=0.300,P=0.584)。结论CE+CABG治疗弥漫性冠状动脉狭窄病变可以获得较满意的完全再血管化,有较好的早、中期效果和旁路血管通畅率。体外循环和非体外循环手术具有相似的早中期结果。     

Initial clinical experience with a new end graft holder for anastomosis in coronary surgery

Objective We assessed the feasibility and effectiveness of a novel end graft holder for coronary artery bypass grafting (CABG) and evaluated anastomotic patency and early clinical results. Methods The end graft holder was applied to 45 consecutive patients. Operative characteristics were off-pump CABG in 22.2%, emergency in 28.9%, and concomitant cardiac surgery in 13.3%. Results The device was used safely without graft injury or inadequate gripping on grafts. Postoperative angiography showed that the patency rate of distal anastomosis was 96.7% (arterial, 100%; venous, 94%). All proximal aortic and composite graft anastomoses were patent without stenosis. The rate of 30-day major adverse cardiac and cerebrovascular events was 13.3% (operative deaths, 3; repeated CABG, 1; percutaneous coronary arterial intervention, 1; and cerebral infarction, 1). None of the elective patients died during hospitalization. Conclusion Our initial clinical experience demonstrated that the new end graft holder was safe, reliable, and effective during CABG. The excellent fixation and visualization of the graft with the device might be particularly beneficial for off-pump CABG or for teaching trainees. No financial support was received for this study, and the equipment used has not been donated for the purposes of this study. The authors had full control of the study design, the methods used, outcome parameters, analysis of the data, and production of this report.     

Multi-detector computed tomography in coronary artery bypass graft assessment: a meta-analysis

Multi-detector computed tomography (MDCT) has become an alternative to coronary angiography in diagnosis of graft occlusion and stenosis after coronary artery bypass. A literature search was performed for studies comparing angiography to 8-slice, 16-slice, and 64-slice MDCT in the assessment of coronary grafts. In assessing occlusion, 14 studies produced pooled sensitivity of 97.6%, specificity of 98.5%, diagnostic odds ratio of 934.2, area under the curve of 0.996, and Q* of 0.977. Ninety-six percent of all grafts were visualized for occlusion assessment. Beta blockers, symptomatic status, and postoperative period did not significantly affect diagnostic performance. Stenosis assessment produced sensitivity of 88.7% and specificity of 97.4%. Eighty-eight percent of patent grafts could be assessed for stenosis. The diagnostic accuracy of MDCT approaches angiography for diagnosing graft occlusion and stenosis in patients with venous and arterial coronary bypass grafts. Our findings show that cardiac surgeons will need to interpret MDCT images of both native and grafted vessels soon in preparation for primary or re-do coronary bypass grafting procedures.     

Off-pump coronary artery bypass grafting: comparison between standard CABG and off-pump CABG

We have performed 321 cases of coronary artery bypass grafting (CABG), between October 15 1995 and November 20 2000. We have evaluated the operative results of 142 cases (44.2%) of conventional CABG and 179 cases (55.8%) of off-pump CABG performed during this period. The average numbers of bypassed grafts was 3.53 for conventional CABG, and 1.62 for off-pump CABG. The total number of 369 grafts were anastomosed to 501 coronary arteries for conventional CABG, and 283 grafts were anastomosed to 290 coronary arteries for off-pump CABG. RESULTS: Although two saphenous veins were occluded, the early postoperative patency rate was 100% for conventional CABG using RITA, LITA, GEA and RA. Three site of stenosis in 18 LITAs and 2 in 16 RITAs were recognized in off-pump CABG without the use of stabilizers. One site of stenosis in 130 LITAs and 3 string signs in 44 GEA were recognized in off-pump CABG with the use of stabilizers. Postoperative angiography in 52 off-pump CABG cases at one year later showed no new lesion. CONCLUSION: The use of stabilizers and LIMA suture enables adaptation of the MIDCAB procedure to a wider range of coronary artery bypass procedures, and a higher graft patency can be expected.