冠状动脉旁路移植术中升主动脉粥样硬化的诊断与处理

冠状动脉旁路移植术（coronary artery bypass grafting，CABG）后脑卒中的发生率为2％-5％。虽然引起CABG后脑卒中的原因较多，如体外循环、房颤等，但诸多研究认为，升主动脉粥样硬化（ascending aortic atherosclerosis．AAA）可能是脑卒中重要原因。升主动脉插管、阻断、钳夹或近端吻合使AAA斑块或碎片脱落，引起脑栓塞进而导致CABG术后脑卒中。AAA的诊断以及如何在CABG中减少或避免粥样硬化斑块或碎片脱落是临床上亟待解决的问题，我们就近年来的国内外相关文献对此予以综述。     

升主动脉疾病者的冠状动脉旁路移植术

老年人升主动脉粥样硬化发生率高 ,常与冠状动脉粥样硬化同时存在。严重时主动脉插管、阻断、部分阻断或冠状动脉旁路近端吻合都可造成致命的主动脉损伤、破裂出血和体循环包括冠状动脉本身栓塞〔1,2〕。临床资料　 2 0 0 1年 4月至 2 0 0 2年 3月我们在行冠状动脉旁路移植术 (CABG)中遇严重升主动脉粥样硬化 4例 ,其中 1例呈DeBakeyIII型夹层动脉瘤样改变。术前诊断不稳定型心绞痛 2例 ,急性心肌梗死 2例。 3例有陈旧性心肌梗死。冠状动脉造影均显示三支病变 ,左室射血分数 0 32～ 0 5 5。除 1例III型夹层动脉瘤者术前诊断明确外 ,其…     

非体外循环冠状动脉旁路移植术中升主动脉粥样硬化的处理(附35例报告)

目的总结非体外循环冠状动脉旁路移植术中升主动脉粥样硬化(ascending aortic athero-sclerosis,AAA)的临床处理经验。方法合并AAA行非体外循环冠脉搭桥术患者35例,5例联合应用左前外侧小切口不停跳冠脉搭桥和经皮腔内冠状动脉成形术(杂交技术);30例采用胸骨正中切口,其中9例行双侧乳内动脉原位移植,1例将大隐静脉桥近端吻合到无名动脉,12例以左乳内动脉为唯一的供血来源,其静脉桥或桡动脉桥吻合到左乳内动脉,8例应用"易扣"近端吻合辅助装置完成静脉桥的近端吻合。所有患者均未应用主动脉侧壁钳。结果35例手术均顺利完成,无死亡。术后主要并发症:二次开胸止血1例,肺部感染2例,切口感染1例,无围术期心肌梗死,无严重神经系统并发症。结论对于AAA患者,采用非体外循环冠脉搭桥结合杂交技术、主动脉不接触技术或近端吻合装置可以有效减少术后神经系统并发症,临床效果满意。     

合并升主动脉钙化的冠心病人冠状动脉多支搭桥的策略

目的探讨冠状动脉粥样硬化性心脏病（冠心病）合并升主动脉钙化行冠状动脉多支搭桥的策略。方法2002年6月-2007年12月对36例合并升主动脉钙化的冠心病不使用主动脉侧壁钳行非体外循环冠状动脉搭桥术。常规取左乳内动脉（left internal mammary artery,LIMA）,19例同时取右乳内动脉（right internal mammary,RIMA）。15例以LIMA为唯一的桥血流来源（in-flow）,其余的静脉桥吻合到LIMA;14例使用Enclose或Heartstring近端吻合装置行静脉桥在主动脉上的吻合。术中用血流仪（Medi-Stim Butterfly Flow Meter,Oslo,Norway）行桥血流定量测定。结果36例共行远端吻合116个[2-5个,（3.2±0.9）个]。术后2-22 h病人完全清醒。手术中实时桥血流测定满意,15例以LIMA为唯一in-flow的患者,LIMA主干的总血流量基本是各分支桥血流量的数学和。无围手术期心肌梗死及脑卒中。8例（26.7%）手术后一过性心房颤动;肺部感染2例;胸腔积液4例;下肢切口感染1例,均治愈。死亡1例,死亡原因为多脏器功能衰竭。30例随访6-60个月,（33.8±11.2）月,11例造影显示37支桥中,LIMA-LAD均通畅,2支到对角支的静脉桥闭塞,余静脉桥均通畅。结论对升主动脉有明显钙化的冠心病患者,采用非体外循环冠状动脉搭桥结合主动脉No-touch技术或主动脉近端吻合装置,可有效避免因在病变主动脉上操作引起的术后脑卒中发生。     

升主动脉不接触技术在非体外循环冠状动脉旁路移植术中的应用

目的总结升主动脉不接触技术在非体外循环冠状动脉旁路移植术(off-pump CABG)中的应用经验,以减少术后脑卒中的发生。方法回顾分析31例合并升主动脉粥样硬化冠心病患者的临床资料,男25例,女6例;年龄58～78岁,平均年龄71.3岁。5例联合应用off-pump CABG和经皮腔内冠状动脉成形术(PTCA)杂交技术治疗,其余26例均采用常规胸骨正中切口径路行off-pump CABG。9例双侧乳内动脉原位移植;16例以左乳内动脉为惟一的供血来源,大隐静脉或桡动脉近端与左乳内动脉端侧吻合;1例大隐静脉近端吻合到无名动脉。所有患者主动脉根部均无吻合口。结果5例"杂交"手术患者共经PTCA植入支架6枚,26例胸骨正中开胸患者移植血管74支(2～4支/例),全组患者手术均顺利完成,痊愈出院,无院内死亡。术后心绞痛消失24例,明显缓解7例。发生心房颤动2例,行二次开胸手术1例,肺部感染2例,切口感染1例,无围术期心肌梗死和神经系统并发症发生。随访29例,随访3个月～3年,失访2例。随访期间无死亡,1例行"杂交"手术患者术后1年心绞痛再发,其余28例患者生活质量良好,无神经、精神系统并发症发生。结论对合并升主动脉粥样硬化的冠心病患者,采用off-pump CABG结合升主动脉不接触技术治疗,可有效地减少术后神经系统并发症的发生,临床效果满意。     

停循环技术应用于升主动脉-胸降主动脉人工血管旁路移植治疗主动脉缩窄

目的总结经单一胸部正中切口采用低温停循环技术行解剖外升主动脉-胸降主动脉人工血管旁路移植术治疗主动脉缩窄的经验。方法回顾性分析2009年12月至2018年5月我院连续12例主动脉缩窄患者的临床资料。其中男女各6例,年龄13～42岁,均有高血压症状,上下肢动脉收缩压差46～85(57.1±16.8)mm Hg。手术经胸部正中切口,采用体外循环及深低温停循环技术,行升主动脉-心包后胸降主动脉人工血管旁路移植术。结果人工血管平均直径14～20(17.2±1.8)mm,体外循环时间69～197(115.9±40.6)min,主动脉阻断时间41～142(69.8±30.7)min,深低温停循环时间9～27(16.8±4.1)min。所有患者均未输血,无严重并发症。术后上下肢动脉收缩压差值为–12～22(14.3±4.8)mm Hg,较术前显著下降(P0.01)。所有患者均康复出院,平均随访3～91(41.9±21.5)个月,随访期间仅1例患者术后需要服用1种降压药物,其余患者均正常。结论深低温停循环下经胸部切口行解剖外人工血管旁路移植术治疗主动脉缩窄安全有效,未来需要更多病例进一步验证。     

升主动脉隔离装置在升主动脉近端钙化患者非体外循环冠状动脉旁路移植术中的应用

目的 评价升主动脉近端隔离装置(Heartstring和Enclose近端吻合装置)在非体外循环冠状动脉旁路移植术(OPCAB)中的应用效果. 方法 2006年1月至2008年2月收治了150例合并升主动脉近端钙化的冠心病患者,其中男102例,女48例;年龄55～78岁,平均年龄69岁.所有患者在冠状动脉旁路移植术中应用升主动脉近端隔离装置,大隐静脉与升主动脉近端共完成251个吻合口,升主动脉近端吻合口1～3个/例,大隐静脉桥血管完成后应用流量仪进行流量测定.术后观察神经系统并发症的发生情况. 结果 术后死于低心排血量综合征1例(0.67%);二次开胸止血2例,其中1例为乳内动脉床渗血,1例为胸骨后出血;其余患者术后24 h胸腔引流量为100～200 ml.所有患者均于术后24～48 h内顺利拔除气管内插管;术后均未出现明确的昏迷、肢体偏瘫、语言障碍及运动不协调等神经系统并发症;大隐静脉桥血流量为28.5～70.1 L/min(53.7± 23.9 L/min).术后随访145例,随访率97.32%,随访时间3个月～1年;4例失访.随访期间患者未发生迟发性脑出血或脑梗死等神经系统并发症.结论 在OPCAB术中应用Heartstring和Enclose升主动脉近端隔离装置,安全、有效,能有效地降低脑卒中的发生率.     

冠状动脉硬化性心脏病合并左锁骨下动脉严重狭窄非体外循环下同期手术的临床经验

目的探讨非体外循环冠状动脉旁路移植同时主动脉-锁骨下动脉旁路治疗冠状动脉硬化性心脏病(冠心病)合并锁骨下动脉重度狭窄的手术方法及效果.方法2003年1月～2004年5月,我院治疗须行冠状动脉旁路移植术同时合并左锁骨下动脉近端重度狭窄3例,术中先行主动脉-锁骨下动脉旁路,左乳内动脉获得满意的流量后,再行非体外循环冠状动脉旁路移植.结果手术时间210～340 min,平均283 min,出血量570～1 630 ml,平均963 ml.游离左乳内动脉后量杯测流量均＜5 ml/min,主动脉-锁骨下动脉旁路后量杯测流量均＞50 ml/min,乳内动脉远端与前降支吻合后流量仪测流量12～27 ml/min,平均20 ml/min.术后临床症状缓解,未发现冠脉-锁骨下动脉窃血综合征.3例随访3～6个月,平均5个月,无心绞痛发作.结论非体外循环冠状动脉旁路移植同时主动脉-锁骨下动脉旁路手术是治疗冠心病合并锁骨下动脉重度狭窄简单而有效的方法.     

非体外循环冠状动脉旁路移植术的心肌保护

目的　比较非体外循环心脏跳动下冠状动脉旁路移植术 (OPCAB)与常规体外循环下冠状动脉旁路移植术 (CABG)的心肌保护效果。方法　将 70例冠状动脉粥样硬化病人分成 2组 ,行非体外循环冠状动脉旁路移植术组 (非体外循环组 35例 ) ,间断冷氧合血心脏停搏液冠状动脉旁路移植术组 (冷血停跳组 35例 )。 2组病人术前心功能、年龄、性别、体质量差异无统计学意义 ;各组于围术期不同时点分别抽血测定肌酸激酶同工酶 (CK MB)、心肌肌钙蛋白T(cTnT)。关胸前每组各随机取 2例病人心尖区心肌 ,行心肌超微结构观察。结果　非体外循环组术中、术后各时间点CK MB、cTnT与冷血停跳组比较差异有显著性 (P <0 0 5 ) ;非体外循环组心肌超微结构表明心肌保护效果明显优于后者。结论　非体外循环组心肌保护效果优于冷血停跳组。与CK MB相比 ,cTnT是评价心肌损害的更特异、更敏感的指标。     

冠状动脉旁路术同期瓣膜手术的体会

目的 介绍冠状动脉旁路术(CABG)同时行心脏瓣膜手术的体会。方法 45例患者,平均年龄59岁(42～75岁);心功能(NYHA)Ⅱ级7例、Ⅲ级30例、Ⅳ级8例;二尖瓣病变30例、主动脉病变7例、联合瓣膜病变8例,均伴有单支或多支冠状动脉病变。手术在中度低温体外循环下完成。心脏停跳后,先作静脉桥的远端吻合,然后置换瓣膜。心脏复苏后完成大隐静脉与升主动脉的吻合,或在升主动脉1次阻断下完成。乳内动脉的吻合在换瓣后心脏复苏前完成。本组6例行二尖瓣成形,31例行机械瓣置换,8例行进口生物瓣置换。结果 本组患者无手术死亡。术后呼吸机使用时间平均18．7h,ICU监护1．8d。住院时间平均9．2d。随访6个月～4年患者无死亡,心功能Ⅰ级35例、Ⅱ级10例。结论 冠状动脉旁路移植术同时行瓣膜手术是安全、有效的。     

An evaluation of coronary artery bypass grafting without aortic cross-clamping due to severely atherosclerotic ascending aorta

OBJECTIVES: We evaluated coronary artery bypass grafting (CABG) in which aortic cross-clamping is not done due to severe atherosclerosis of the ascending aorta. METHODS: Subjects were 51 patients undergoing CABG without aortic cross-clamping during cardiopulmonary bypass under moderately hypothermic ventricular fibrillation in the 12 years from June 1988 to October 1999 (Group N). In some cases, empty beating or moderate hypothermic circulatory arrest was used. We compared these 51 with 1104 subjects undergoing conventional CABG with aortic cross-clamping and cardioplegic cardiac arrest in the 9 years from June 1988 to December 1997 (Group A). RESULTS: In all 6 cases with neurologic deficits, moderately hypothermic circulatory arrest was used during proximal anastomosis of saphenous vein grafts. Postoperative computed tomography scan showed them to have suffered infarction due to embolization. Multivariate analysis identified proximal saphenous vein grafting under moderately hypothermic circulatory arrest as a predictor of neurologic deficit. Complete revascularization was significantly lower in Group N. Actual survival and freedom from cardiac death were significantly lower in Group N. CONCLUSION: Manipulation of the atherosclerotic ascending aorta under moderately hypothermic circulatory arrest or ventricular fibrillation generates the highest risk of perioperative neurologic deficit and should thus be avoided. In-situ arterial grafting should be conducted with utmost care.     

Extra-anatomic coronary artery bypass graftings in patients with porcelain aorta

AIM: Severely atherosclerotic (porcelain) ascending aorta is associated with increased morbidity and mortality during coronary artery bypass grafting (CABG) due to the increased risk of perioperative atheroembolism. Three maneuvers during CABG can cause atheromatous embolism from the diseased ascending aorta: 1) cannulation of the ascending aorta; 2) cross- clamping; 3) partial clamping for the construction of the proximal anastomosis. METHODS: In our hospital, extra-anatomic CABG was performed in 8 patients with heavily calcified ascending aorta: 6 patients were men and 2 women. Operations were performed on the beating heart in 5 patients, 2 patients operated on beating heart and another patient on fibrillating heart with supportive cardiopulmonary bypass (CPB). Arterial cannulation was done through the right femoral artery on these patients. Apart from internal mammary artery (IMA) grafts, proximal anastomotic sites were the right axillary, right subclavian and innominate arteries. RESULTS: One patient who preoperatively had dialysis dependent chronic renal failure, died as a result of dialysis complication on the 5th day. The postoperative course was uneventful in the other patients and no patient experienced either any cerebrovascular or visceral organ injury as a result of atheroemboli. CONCLUSION: We think that extra-anatomic CABG procedures are safe and reliable in patients with severely atherosclerotic (porcelain) ascending aorta to minimize the prevalence of perioperative stroke and systemic embolization.     

Does routine use of aortic ultrasonography decrease the stroke rate in coronary artery bypass surgery?

Purpose: The purpose of this study is to determine whether the routine use of intraoperative surface aortic ultrasonography decreases the stroke rate in coronary artery bypass graft surgery (CABG).Methods: One hundred ninety-five consecutive patients undergoing CABG between July 1, 1992, and June 30, 1993 (study group), were evaluated by intraoperative surface aortic ultrasonography. Based on information obtained, changes in the operative technique were made in an effort to decrease the incidence of embolic stroke from unsuspected atherosclerotic disease of the ascending aorta. The outcome of these patients was compared with that of 164 consecutive patients who underwent CABG between July 1, 1991, and June 30, 1992 (control group), in whom the ascending aorta was assessed by inspection and palpation only.Results: Significant disease was detected in three (2.0%) of 164 patients in the control group. Modifications in their operative technique consisted of hypothermic fibrillatory arrest with no cross-clamping of the aorta and left ventricular venting in two patients and single cross-clamping in one patient. There were five strokes overall in this group (3.0%), and six patients died (3.6%), one in whom the stroke contributed directly to the cause of death. In the study group the ultrasonic findings were normal to mild in 168 patients, moderate in 20 patients, and severe in seven patients. These results led to a modification of the technique in 19 patients, (10%): hypothermic fibrillatory arrest with no cross-clamping of the aorta and left ventricular venting in 14 patients, modification in the aortic cannulation site or single cross-clamping in three patients, and modification in placement of proximal anastomoses or all arterial grafts in two patients. No strokes occurred in this group ( p < 0.02, Fisher's exact test). Five patients died, for an operative mortality rate of 2.6%.Conclusion: These data indicate that intraoperative ultrasonography of the ascending aorta with simple modifications in operative technique reduces the stroke rate in CABG. (J V ASC S URG 1995;21:98-109.)     

Patency of saphenous vein coronary artery bypass grafts from the vascular prosthesis of the ascending aorta.

BACKGROUND: Patients who have Stanford type A aortic dissection with impaired coronary arteries or who have aneurysms from the ascending aorta to the aortic arch with coronary artery disease need coronary artery bypass grafting (CABG) with tube graft replacement of the ascending aorta simultaneously. When vein grafts are used for CABG in these patients, the proximal anastomoses of vein grafts are attached to the prosthetic tube graft of the ascending aorta. However, the validity of proximal anastomoses of vein grafts to the prosthetic tube graft of the ascending aorta has not been confirmed. PATIENTS AND METHODS: We retrospectively analyzed patients who underwent venous coronary bypass grafting with prosthetic graft replacement of the ascending aorta. Between January 1984 and October 2002, 35 patients underwent CABG using saphenous vein grafts at the time of tube graft replacement of the ascending aorta, and the proximal anastomoses of the vein grafts were attached to the tube graft of the ascending aorta. Thirty-three venous bypass grafts were analyzed in 24 survivors. RESULTS: The postoperative catheterization showed only one early vein graft occlusion of 16 vein grafts anastomosed distally to the left anterior descending artery (LAD). All 14 venous grafts anastomosed to the right coronary artery (RCA) and 3 to the left circumflex artery (LCX) were patent. Therefore, the postoperative patency rate at discharge was 97.0% (32/33). Spiral computed tomography performed for long term follow-up revealed occlusion of two vein grafts (3.5 years and 9.7 years) anastomosed to the LAD. CONCLUSIONS: The patency rate of vein grafts anastomosed from prosthetic grafts of the ascending aorta to the native coronary arteries was similar to that of conventional CABG using saphenous vein grafts.     

A case report of coronary artery bypass grafting using hypothermic circulatory arrest technique for the severely calcified ascending aorta]

Severe calcification of the ascending aorta makes coronary artery bypass grafting (CABG) complicated since aortic cross-clamping may induce cerebral embolization of aortic debris or aortic dissection. Furthermore, there are problems that the distal aortic occlusion becomes incomplete and proximal anastomosis between the ascending aorta and saphenous veins becomes impossible. CABG for a 56 year-old male with severely calcified ascending aorta was successfully conducted using hypothermic circulatory arrest technique. His right internal thoracic artery was bypassed to LAD under fibrillatory arrest and then his right gastroepiploic artery was bypassed to the distal portion of RCA under hypothermic circulatory arrest. There was no complication and left ventricular ejection fraction improved from 16% to 38% postoperatively.     

Redo-OPCAB via left thoracotomy using symmetry aortic connector system: a report of two cases

Left thoracotomy is an established approach for redo coronary artery bypass grafting (CABG). This approach has also been successfully used in off-pump coronary artery bypass (OPCAB). Traditionally, the grafts have been anastomosed proximally to the descending thoracic aorta or the left subclavian artery. Recently, proximal connectors have been introduced by various manufacturers for use on ascending aorta during primary CABG and OPCAB. One such device is the Symmetry aortic connector system (St. Jude Medical, Minneapolis, MN). These devices have obviated the need for partial occluding clamps for the construction of the proximal anastomoses and hence are extremely useful when the aorta is heavily calcified. We used this device successfully in two patients undergoing redo-OPCAB, where the proximal anastomosis was constructed on the descending aorta. In so doing, we also used the shortest possible length of vein graft since the descending aorta at that level was much closer than the left subclavian artery. This can be an additional factor in redo-operations where the availability of vein can be an issue.     

Transapical aortic cannulation via left lateral thoracotomy for descending thoracic and thoracoabdominal aortic surgery

Two patients underwent surgery for a chronic type B dissection using a total cardiopulmonary bypass (CPB) with transapical arterial cannulation. At surgery, a total CPB was established by cannulating the left femoral artery and the ascending aorta via the ventricular apex. The patients were cooled to 30°C. The proximal anastomosis was done after cross-clamping the aortic arch between the left carotid artery and the left subclavian artery in both cases. In the first case, the entire descending thoracic aorta was replaced, and two pairs of intercostal arteries were reconstructed. The other patient underwent replacement of the proximal descending thoracic aorta. Neither patient experienced any complications. Transapical aortic cannulation is a useful option during descending thoracic and thoracoabdominal aortic surgery. It can provide more stable circulation during the cross-clamping, more gentle manipulation of the aorta by nonpulsatile flow, and more liberty in temperature control.     

On-pump beating coronary artery bypass grafting for the post-thoracoplasty patient with porcelain aorta; report of a case

A 79-year-old post-thoracoplasty patient who had undergone coronary artery bypass grafting (CABG) 20 years before was admitted to our hospital because of chest pain. Coronary angiogram showed occlusion of the both saphenous vein grafts. And the computed tomography revealed severe calcification of the ascending aorta. We performed on-pump beating CABG cannulating his femoral vessels and anastomosed bilateral internal thoracic artery grafts without manipulation of the ascending aorta. On-pump beating CABG is useful for the patients with past medical history of CABG.     

Results with the Heartstring anastomotic device in patients with diseased ascending aorta

BACKGROUND: Avoidance of manipulation of diseased ascending aorta has been shown to be associated with a reduced risk of postoperative stroke after off-pump coronary artery bypass surgery (OPCAB). The use of the Heartstring device (Guidant, Indianapolis, USA) to accomplish a proximal aortic anastomosis without aortic clamping has been suggested in such patients. PATIENTS AND METHODS: From April 2004 to December 2005, proximal aortic anastomoses have been accomplished employing the Heartstring device in 19 patients with calcified ascending aorta who underwent OPCAB. The diagnosis of diseased ascending aorta was made intraoperatively by epiaortic ultrasound scanning. RESULTS: Eighteen vein grafts and three radial artery grafts have been successfully anastomosed to the ascending aorta by employing the Heartstring device. Breaking of eight seals occurred during insertion. One patient (5.2%) had stroke two days after urgent OPCAB. CONCLUSION: The use of the Heartstring anastomotic device should be considered in high-risk patients with diseased ascending aorta requiring a prompt myocardial revascularization, whenever there is a place to safely insert this device into the ascending aorta.