主动脉手术并同期冠状动脉旁路移植术的临床总结

目的总结行主动脉手术同期行冠状动脉旁路移植术的临床经验。方法回顾分析1997年11月至2004年8月,36例同期行主动脉手术和冠状动脉旁路移植术患者的临床资料。36例中,主动脉夹层19例,主动脉瘤17例。年龄(57±12)岁。其中急性A型主动脉夹层10例,术中探查见冠状动脉开口受累7例,冠状动脉为索条状2例,1例在外院行冠状动脉造影检查发现;慢性A型主动脉夹层7例,术中发现冠状动脉开口受累2例,冠状动脉呈索条状3例,术前造影检查发现冠状动脉病变2例;B型主动脉夹层2例;真性主动脉瘤均为术前冠状动脉造影检查发现冠状动脉病变。移植血管共57支,其中动脉6支,静脉51支。结果平均体外循环时间(157±54)m in,心肌阻断时间(98±31)m in。围手术期死亡5例(均为A型主动脉夹层),分别为低心排血量综合征、心源性休克并发多脏器功能衰竭3例,脑疝1例,内脏缺血坏死1例。术后发生并发症2例,发生率为6%,分别为二次开胸止血和呼吸功能衰竭气管切开。结论主动脉夹层累及冠状动脉和冠状动脉本身的病变严重影响预后。对年龄>50岁的主动脉瘤患者,于术前常规行冠状动脉造影检查,行单纯主动脉瘤手术并同期行冠状动脉旁路移植手术安全、可靠。     

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…     

冠状动脉支架植入术后Stanford A型主动脉夹层的外科治疗

目的 分析冠状动脉支架植入术后Stanford A型主动脉夹层患者的外科治疗方式,探讨其手术技术及手术时机。方法 回顾性分析2016年4月—2019年7月首都医科大学附属北京安贞医院连续收治的1 246例Stanford A型主动脉夹层患者的临床资料。纳入冠状动脉支架植入术后Stanford A型主动脉夹层患者。结果 最终纳入患者19例,其中男16例、女3例,年龄35～66(54±7)岁。19例患者中急性主动脉夹层11例。AC型（DeBakeyⅠ型）主动脉夹层15例,AS型（DeBakeyⅡ型）4例。AC型患者中行孙氏手术（全弓置换+支架象鼻手术）10例,部分弓置换5例;19例患者中同期行冠状动脉旁路移植术7例,二尖瓣置换术1例;4例患者术中取出位于右冠开口的支架。本组住院死亡1例,主因术前合并脏器灌注不良,术后死于多脏器功能衰竭。18例患者经治疗后痊愈出院,平均随访30(18～56)个月,其中1例因冠状动脉吻合口漏行二次漏修补术,1例因远端夹层新发破口行胸主动脉腔内修复,1例因左主干支架闭塞急诊行经皮冠状动脉介入治疗,1例因髂动脉闭塞行股股转流。结论 冠状动脉支架植入术后Stanfo...     

孙氏手术治疗急性Stanford A型主动脉夹层

目的 总结急性Stanford A型主动脉夹层采用孙氏手术(主动脉弓部替换加支架象鼻手术)的临床经验与随访结果.方法 2004年8月至2012年3月,73例急性A型夹层患者施行了孙氏手术,其中男60例、女13例,平均年龄49.6(26 ～79)岁.手术均采用深低温停循环、低流量选择性脑灌注技术.单纯行升主动脉替换加孙氏手术30例;主动脉根部替换(Bentall术)加孙氏手术10例,主动脉瓣及升主动脉替换加孙氏手术12例,主动脉瓣成形加孙氏手术21例(同时行主动脉窦重建16例),同期行冠状动脉旁路移植术( CABG)9例,术后通过CTA评价胸腹主动脉塑形及假腔愈合情况.结果 体外循环平均(248.1±69.8)min,选择性脑灌注(38.2±10.5)min.手术死亡5例(6.85％,5/73例).术后60例随访2个月～7.6年,术后3个月CTA复查显示,91.7％的患者主动脉夹层的假腔在膈肌水平形成血栓,患者术后1、5和7年的生存率分别是97％、87％和81％.结论 孙氏手术治疗急性A型主动脉夹层安全有效且远期效果令人满意.     

同期杂交手术治疗复杂Stanford B型主动脉夹层

目的回顾性分析同期杂交手术治疗复杂Stanford B型主动脉夹层的手术方法及疗效,探讨基层医院施行该手术的可行性。方法2010年12月至2013年3月襄阳市中心医院胸心外科对7例复杂Stanford B型急性主动脉夹层患者施行同期杂交手术治疗。男2例、女5例,年龄45～64（50．0±8.3）岁。术前主动脉CT血管造影（CTA）示主动脉夹层破口距左锁骨下动脉开口〈15mm 4例,累及左锁骨下动脉开口3例,其中1例合并胸主动脉壁多部位钙化,冠状动脉CTA示前降支近中段狭窄约70％。采用气管内插管静脉复合麻醉,手术室先期行颈部切口完成主动脉弓分支旁路手术,术毕转送导管室行股动脉切口完成主动脉腔内修复术,冠状动脉粥样硬化性心脏病患者同期完成前降支支架植入术。结果所有患者均成功完成手术,并植入覆膜支架。1例术后发生少量Ⅰ型内漏。围术期无死亡和严重并发症发生。术中CTA证实主动脉夹层真腔血流恢复正常,旁路血管血流通畅,支架植入定位准确,支架无明显移位。随访7例,随访时间3～24（12．0±3．6）个月,所有患者均生存,恢复正常生活。6例术后3个月及术后1年或2年复查主动脉增强CT示支架无移位和内漏,支架内及人工血管旁路血流通畅;1例少量Ⅰ型内漏患者术后3个月复查假腔内仍有造影剂显示,但部分血栓形成,假腔程度及范围较术前变小,真腔明显增大,术后6个月复查内漏消失。所有患者未见脑部和肢体缺血征象。结论复杂Stanford B型主动脉夹层采用同期杂交手术治疗安全、有效,扩大了介入覆膜支架腔内治疗的适应证,在基层医院值得推广应用。     

血管旁路移植术联合腔内隔绝术治疗主动脉扩张疾病的临床研究

目的总结采用血管旁路移植术联合腔内隔绝术(endovascular aortic repair,EVAR)治疗主动脉扩张疾病的临床经验。方法 2008年1月-2011年8月,采用血管旁路移植术联合EVAR治疗12例主动脉扩张疾病患者。其中男11例,女1例;年龄47～81岁,平均65.9岁。均经主动脉血管造影(computed tomography angiography,CTA)确诊,其中Stanford A型夹层1例,Stanford B型夹层5例,主动脉弓部动脉瘤4例,腹主动脉瘤2例。8例患者先行颈部血管旁路移植术,再行EVAR;4例患者先行EVAR,再行股动脉血管旁路移植术。结果术后肺部感染3例,肾功能不全2例,脑梗死1例,血红蛋白和血小板降低7例,腹股沟切口愈合不良1例。11例患者获随访3～42个月,平均18.6个月。1例行胸、腹主动脉EVAR患者,术后6个月复查发现移植物远端有新的动脉瘤形成,再次行EVAR,3个月后复查恢复良好。其余患者术后3、6及12个月复查,主动脉CTA均提示假腔明显缩小以及假腔内血栓形成,未发现内漏,支架无迟发变形或移位,人工血管吻合口通畅。结论血管旁路移植术联合EVAR扩大了腔内修复术的适应证,既提供了足够的锚定区,又保证了重要脏器血供,简化了手术操作过程,降低了腔内治疗难度。     

胸主动脉瘤合并冠心病同期外科治疗(附15例报告)

目的 总结胸主动脉手术同期行冠状动脉旁路移植术的经验。方法1999年6月至2002年7月，胸主动脉瘤手术同期行冠状动脉旁路移植术15例，均为男性；年龄40～66岁，平均57．2岁；体重60～89kg，平均70．2kg。病种包括主动脉根部瘤5例、升主动脉瘤2例、弓部瘤3例、主动脉夹层5例。经胸骨正中切口在全麻低温体外循环下手术14例；左外侧切口非体外循环下冠状动脉旁路移植同期股股转流降主动脉置换术1例。结果术后早期30d内死亡1例，随访1～36个月，无远期死亡，无再次手术及冠心病相关事件发生。结论胸主动脉置换术与冠状动脉旁路移植术能够安全同期进行，同期冠心病的再血管化对预防冠心病相关事件的发生有积极作用。     

3D打印辅助腔内治疗复杂主动脉疾病的临床疗效

目的 探讨3D打印辅助腔内治疗复杂主动脉疾病的可行性。方法 纳入中山市中医院血管介入科2019年12月至2021年10月收治的5例复杂主动脉疾病患者。术前行CT血管造影（CTA）后进行主动脉三维重建,在3D打印机打印成1∶1主动脉模型,并辅助手术方案制定及进行手术模拟。结果 1例肾上型腹主动脉穿透性溃疡,1例近肾型腹主动脉假性动脉瘤,2例累及弓上分支的胸主动脉瘤,1例累及弓上分支的主动脉夹层,所有患者在术前完成主动脉病变段3D模型打印,根据结果辅助制定手术方案,手术技术成功率为100%,无内漏、支架移位或闭塞、内脏动脉丢失等严重并发症出现。结论 3D打印辅助腔内治疗能使复杂主动脉疾病腔内治疗直观化、精准化,具有良好的可行性。     

50岁以上Stanford B型主动脉夹层患者中冠心病的患病分析及其对预后的影响

目的 探讨高龄Stanford B型主动脉夹层(aortic dissection,AD)患者中冠心病(coronary artery disease,CAD)的发病情况及其对预后的影响.方法 连续人选2008年1月至2011年12月,200例50岁以上Stanford B型AD患者行胸主动脉腔内修复治疗(thoracic aortic repair,TEVAR),主动脉造影及腔内修复术前常规行冠状动脉造影(coronary angiography,CAG)判断冠状动脉病变程度.所有患者随访1年,比较AD患者中有CAD与无CAD患者不良事件发生率.结果 CAG提示,200例AD患者中53例(26.5％)有CAD.多元回归分析发现,男性(OR=4.415,95％ CI:1.131～ 17.237,P=0.033)和年龄(OR=1.061,95％ CI:1.017～1.108,P=0.006)是共患CAD的独立预测因素,年龄是多支病变/左主干病变的独立预测因素(OR=1.096,95％ CI:1.009～1.191,P=0.023).并发CAD患者与非CAD患者不良事件发生率差异无统计学意义,CAD患者与非CAD患者相比,1年心肌梗死[3例(5.66％)对0例(0),P=0.018]和卒中[4例(7.55％)对1例(0.68％),P=0.018]发生率显著高.结论 高龄Stanford B型主动脉夹层患者并发CAD比例较高,并发CAD患者心脑血管缺血事件风险高于非CAD患者,但并未增加主动脉相关不良事件风险.     

胸主动脉真性、假性和夹层动脉瘤行主动脉腔内修复术的临床和影像学研究

目的 总结胸主动脉真性、假性和夹层动脉瘤的术前诊断和腔内修复的要点,对术前、术后的主动脉CT血管造影(CTA)影像进行评估和比较,以探讨用统一的影像学指标在术前、术中、术后和随访中对病变演变和疗效进行系统评价和动态观察. 方法 48例胸主动脉瘤和夹层动脉瘤患者在术前CTA图象指导下行主动脉腔内修复术(EVR),植入覆膜支架,植入前、后做数字减影血管造影(DSA),术后定期多次做CTA随访评价疗效.所有CTA和DSA图象输入e-FilmTM软件中建立影像数据库,筛选关键层面,测量分析对比. 结果 48例共行EVR 49次,准确植入长、短支架54枚,夹层内膜破口封闭42例,胸主动脉真性动脉瘤完全隔绝2例,假性动脉瘤颈口封闭4例.术后发生不同程度的内漏9例,经相应的处理消除;因导入动脉出血抢救成功,但发生弥漫性血管内凝血、多器官功能衰竭死亡1例.随访47例,随访时间6～51个月.所有患者恢复良好,临床效果满意. 结论 EVR治疗胸降主动脉真、假性和夹层动脉瘤效果良好;夹层动脉瘤的早期诊断要点为胸痛和CTA扫描;CTA特定层面和左前斜位图象是术前评估和术后疗效评定的重要参考.     

Coronary ostial stenosis after aortic valvuloplasty (comprehensive aortic root and valve repair)

Comprehensive aortic root and valve repair (CARVAR) surgery using specially designed aortic rings was introduced as a new surgical technique for aortic valve disease. We present five consecutive cases of iatrogenic coronary ostial stenosis after CARVAR surgery in patients with aortic stenosis. The preoperative coronary angiography confirmed that all the patients had normal coronary arteries. They underwent aortic valvuloplasty by aortic leaflet extension and insertion of specially designed inner and outer rings at the level of the sinotubular junction. Within 6 months after surgery, all the patients complained of resting chest pain and dyspnea with changes of electrocardiography. Repeated coronary angiography demonstrated right coronary artery (RCA) ostial stenosis in one patient and left main (LM) ostial stenosis in the other four patients. Intravascular ultrasonography demonstrated severe ostial stenosis and extensive echogenic tissue in the extravascular area. Four patients with LM ostial disease successfully underwent coronary bypass graft surgery, and percutaneous coronary intervention with stenting was performed in one case of RCA ostial stenosis. Because the mechanism of this complication is not fully confirmed, more clinical study is required to confirm the safety issues of CARVAR surgery.     

Late acute aortic dissection after coronary artery bypass

Introduction  Late ascending aortic dissection after coronary artery bypass grafting (CABG) is an uncommon phenomenon, and treatment presents a complex clinical dilemma. Materials and methods  Between 1995 and 2005, eight patients were diagnosed with post-CABG late acute aortic dissection. Mean age was 61.7 (range 52–76), and mean period between CABG and late acute aortic dissection was 45.3 months (range 5 to 122 months). Three patients underwent surgical replacement of the ascending aorta. One patient died after surgery, and the other two had an uneventful recovery, with a successful mean 6.5-year follow-up. Five patients were treated conservatively, with a mean follow-up of 81.2 months (range 50–112 months). Results and discussion  Periodic computed tomography (CT) scans showed minor or no change in aortic diameter and satisfactory general condition. Late acute aortic dissection after CABG is rare. Only a few reports have been published, and no standard treatment guidelines exist. Conclusion  We assume that postoperative pericardial scarring and adhesions provide some protection against progression of the dissection and therefore suggest that preferred treatment in non-stable patients should be surgical. In stable patients, close follow-up and blood pressure control are beneficial. Condensed abstract  Late ascending aortic dissection after CABG is rare, and treatment presents a clinical dilemma. We treated eight patients with post-CABG late acute aortic dissection. Three underwent surgical replacement of the ascending aorta. One died after surgery, and the other two had an uneventful recovery. Five patients were treated conservatively. No standard treatment guidelines exist for late acute aortic dissection after CABG. We assume that postoperative pericardial scarring and adhesions provide some protection against progression of the dissection, and suggest that preferred treatment in non-stable patients should be surgical. In stable patients, close follow-up and blood pressure control are beneficial.     

Concomitant coronary artery bypass grafting during surgical repair of acute type A aortic dissection affects operative mortality rather than midterm mortality

BackgroundIn this study, we investigated the impact of concomitant coronary artery bypass grafting (CABG) on operative and midterm mortality in patients with acute type A aortic dissection (ATAAD) undergoing surgical repair.MethodsFrom January 2012 to December 2014, among 489 patients (mean age: 47.6 ± 10.4 years, 77.1% male) with ATAAD who received surgical repair at our institute, 21 patients (4.3%) underwent concomitant CABG. Isolated aortic repair was performed in the remaining 468 cases (95.7%). Coronary dissection was indicated in 15 patients (Neri classification type B in 2, type C in 13), concomitant coronary artery disease in five and coronary artery compression in one. The follow-up time was 97.3% at 44.1 ± 13.9 months.ResultsA total of 44 patients (9%) died from surgery, and operative mortality in the concomitant CABG group was significantly higher than that in the isolated aortic repair group (47.6%, 10/21 vs. 7.3%, 34/468; P < 0.001). Among the 11 survivors in the concomitant CABG group, no deaths occurred during the follow-up. Cox regression indicated that concomitant CABG increased the operative mortality risk by 9.2 times (HR, 9.26; 95% CI, 4.31–19.89; P < 0.001). Although it predicted a 5.2-fold increase in overall mortality (HR, 5.20; 95% CI, 2.55–10.61; P < 0.001), concomitant CABG did not affect midterm death (P = 0.996).ConclusionsConcomitant CABG carries a significant operative risk in ATAAD patients undergoing surgical repair. However, survivors may benefit from concomitant CABG and had similar midterm mortality compared with the other cases.     

Coronary artery bypass grafting for left main disease and the risk of stroke: Incidence,aetiology and prevention

This review explores the association between left main disease and the increased risk of perioperative stroke following coronary artery bypass grafting, specifically addressing the potential underlying mechanisms and its potential prevention. In particular, this correlation appears stronger for patients with left main disease when compared to patients with isolated triple vessel disease. Even though evidence on this topic is limited and of modest quality, there appears to be a significant association between ascending aorta atherosclerosis and coronary artery disease. Furthermore, there seems to be a relationship between the severity and extent of carotid artery stenosis and coronary artery disease. Carotid artery disease is itself associated with atherosclerosis of the ascending aorta, a well-recognised risk factor for postoperative atheroembolic stroke. The association between left main disease, ascending aorta atherosclerosis and carotid artery stenosis may reflect an increased systemic atherosclerotic burden and hence explain, at least partially, the higher risk of perioperative cerebrovascular events. Potential pre-, intra- and post-operative strategies for stroke prevention are discussed.     

Aortic valve replacement and coronary bypass in a patient with homozygous familial hypercholesterolemia

Homozygous familial hypercholesterolemia is a rare defect of lipid metabolism characterized by markedly elevated levels of serum total cholesterol. The patients develop premature atherosclerosis and aortic stenosis. Surgical management is complicated by the dense calcification of the ascending aorta and the small aortic root. We present our experience with the management of such a patient with coronary artery disease and aortic valvular and supra-valvular stenosis. She underwent coronary bypass and aortic valve replacement with a root enlargement. The calcified and atheromatous ascending aorta resulted in her developing a stroke. The few reported cases are reviewed to suggest techniques to prevent this lethal complication.     

Warm blood cardioplegia in high risk patients

Objective: Despite overall good clinical results, cardiac surgery in high risk patients, such as those with poor left ventricular function or heavily hypertrophied myocardium, is still challenging. This study was designed to assess the efficacy of warm blood cardioplegia (WBC) in these two subgroups of patients. Methods: Fifty-two patients, with an ejection fraction less than 50%, who underwent surgical revascularization, and 36 patients, with marked left ventricular hypertrophy (LVH), who were operated on for aortic valve replacement (AVR), were consecutively studied. All of them received continuous retrograde ‘warm' blood cardioplegia. Results were assessed on clinical outcomes and compared with those predicted from a risk-stratifying index which has been previously validated in a large multicenter population-based study (Ontario score). Results: For cardiac revascularization, the rates of overall hospital mortality, Q-wave infarctions and inotropic use were respectively 5.8%, 9.6% and 21.1%, comparing favorably with those of the Ontario Group. For aortic valve replacement, the incidence of hospital mortality and Q-wave infarction was 2.8%. Conclusions: By virtue of the study design, these data cannot conclusively establish the superiority of warm blood cardioplegia over other methods of myocardial protection. However, they support the safety of this technique, and suggest that these subgroups of high risk patients might represent the elective indication for aerobic arrest.     

继发性腹主动脉瘤肠瘘的诊治分析

目的总结继发性腹主动脉瘤肠瘘的诊治经验,提高治疗效果。 方法回顾性分析本院2000年1月至2014年12月接诊的6例腹主动脉瘤开放及腔内修复术后继发肠瘘患者的资料。2例初次手术方式为腹主动脉瘤切除+人工血管置换,4例为腹主动脉瘤腔内修复术。本次均以反复发热就诊,发热距初次手术中位时间11个月（1~27个月）,2例伴有"预兆性消化道出血"。再次手术前确诊3例,其中2例放弃治疗。4例患者经充分准备后施行腋动脉-双侧股动脉人工血管旁路、移植物取出及肠修补,其中1例伴有主动脉膀胱瘘的患者同时行膀胱修补。 结果肠瘘位于十二指肠水平段2例,空肠上中段4例。4例接受再次手术的患者均痊愈出院,随访3~48个月,1例人工血管旁路闭塞但无下肢严重缺血,无其他严重并发症。 结论继发性腹主动脉瘤肠瘘是腹主动脉瘤术后罕见的严重并发症,经充分的抗炎准备后建立解剖外旁路并及时移除植入物是有效的治疗手段。     

胸主动脉瘤合并冠心病的外科治疗

目的探讨行胸主动脉瘤置换同期行冠状动脉旁路移植术的安全性及其对预后的影响。方法1982年5月至2004年10月我院收治67例胸主动脉瘤患者,其中同时行冠状动脉旁路移植术者24例：行降主动脉置换+冠状动脉旁路移植术9例,升主动脉置换+冠状动脉旁路移植术15例。将其术后结果与同期仅行胸主动脉置换者进行对比。结果同期行冠状动脉旁路移植术者总病死率为13%(3/24),同期行降主动脉置换+冠状动脉旁路移植术者虽因心肺转流和选择性脑灌注使手术时间显著延长[(278±54)与(188±59)min,t=5．397,P＜0．05],但术后并发症发生率、3年生存率和3年无心脏意外率与单纯行胸主动脉置换术者比较,差异无统计学意义(P＞0．05)。结论同期胸主动脉瘤置换+冠状动脉旁路移植术安全可靠,有助于防止因冠心病而致术后远期发生心脏意外。     

Associations between mean arterial pressure during cardiopulmonary bypass and biomarkers of cerebral injury in patients undergoing cardiac surgery: secondary results from a randomized controlled trial

Open in a separate window OBJECTIVESCardiac surgery is associated with risk of cerebral injury and mean arterial pressure (MAP) during cardiopulmonary bypass (CPB) is suggested to be associated with cerebral injury. The ‘Perfusion Pressure Cerebral Infarcts’ (PPCI) trial randomized patients undergoing coronary artery bypass grafting (CABG) and/or aortic valve replacement to a MAP of 40–50 or 70–80 mmHg during CPB and found no difference in clinical or imaging outcomes between the groups. We here present PPCI trial predefined secondary end points, consisting of biomarkers of brain injury.METHODSBlood was collected from PPCI trial patients at baseline, 24 and 48 h after induction of anaesthesia and at discharge from the surgical ward. Blood was analysed for neuron-specific enolase, tau, neurofilament light and the glial marker glial fibrillary acidic protein. Linear mixed models were used to analyse differences in biomarker value changes from baseline between the 2 MAP allocation groups.RESULTSA total of 193 (98%) patients were included. We found no differences in biomarker levels over time from baseline to discharge between the 2 MAP allocation groups (P_NSE = 0.14, P_Tau = 0.46, P_NFL = 0.21, P_GFAP = 0.13) and the result did not change after adjustment for age, sex and type of surgery.CONCLUSIONSWe found no significant differences in levels of biomarkers of neurological injury in patients undergoing elective or subacute CABG and/or aortic valve replacement randomized to either a target MAP of 40–50 mmHg or a target MAP of 70–80 mmHg during CBP.