Simultaneous coronary artery bypass grafting and carotid endarterectomy can be performed with low mortality rates

There is controversy over the best approach for patients with concomitant carotid and coronary artery disease.1 Therapeutic strategies include isolated coronary artery bypass grafting (CABG), staged carotid endarterectomy (CEA) and CABG, reversed staged CEA and CABG, and simultaneous procedures under single anaesthesia.2Although reported experiences over three decades are available, combining CEA with CABG remains to be elucidated.3 Furthermore, risk of cerebrovascular accident (CVA), which is one of the major predictors of prognosis of CABG, has been reported to increase up to 14% in patients with severe carotid artery stenosis (> 80%).4-9Peri-operative neurological events such as stroke after CABG are the major neurological complications, which increase with age.10 The incidence of peri-operative stroke has been well documented at approximately 2% of all cardiac surgeries.11 Despite reduced overall complication rates over the years after CABG, the incidence of stroke remains relatively unchanged.10The aetiology of peri-operative stroke is multi-factorial including hypotension or hypoperfusion-induced reduced brain flow, atherosclerosis due to micro- or macro-embolisation, and intra- or extra-cranial vascular diseases.5 In addition, carotid artery disease is a critical factor; however, it is considered unlikely to be the only culprit for peri-operative strokes.12Although no consensus on the optimal management of patients with concomitant carotid and coronary artery disease has been reached,13 simultaneous CEA and CABG surgery is often associated with low rates of mortality and morbidity.14-17 In this study, we report our experience with simultaneous CEA and CABG surgery in our clinic in the light of data in the literature.     

Hybrid技术治疗冠心病合并严重颈动脉狭窄的临床疗效及安全性研究

目的回顾性分析颈动脉支架术(CAS)和冠状动脉旁路移植术(CABG)同期或分期Hybrid技术治疗冠心病合并严重颈动脉狭窄的临床疗效及安全性。方法入选2008年7月至2014年9月期间中国医学科学院阜外医院成人心脏外科收治的同期或分期实施CAS和CABG的冠心病合并严重颈动脉狭窄患者274例,依据两种手术是否同期实施分为两组:同期手术组(间隔≤7 d,n=35)和分期手术组(间隔7 d,n=239)。对两组患者的临床资料及预后进行比较分析。结果与同期手术组相比,分期手术组患者的搭桥数量、颈动脉支架植入个数以及肾动脉支架植入个数显著增加,而呼吸机辅助时间显著减少,差异均具有统计学意义(P0.05)。中位随访时间为45.6(28.1~65.4)个月,随访期间仅1例患者发生脑卒中而死亡。两组患者围手术期不良事件发生率间差异无统计学意义(P0.05)。截至随访终期,Cox模型分析结果显示,是否同期手术与患者复合终点事件发生率无明显相关性(OR=0.679,95%CI:0.12~3.72;P=0.66)。结论 CAS联合CABG是治疗冠心病合并严重颈动脉狭窄的一种安全、有效的微创策略。     

风心病患者瓣膜置换术前颈动脉超声检查的临床意义

目的探讨颈动脉粥样硬化与冠状动脉粥样硬化的相关性以及颈动脉内膜—中膜厚度(IMT)对风心病患者是否合并冠心病的预测价值。方法117例风心病患者根据冠状动脉造影结果分为冠心病组和对照组,用B超检测颈动脉病变情况。结果颈动脉IMT增厚和斑块检出率对冠心病预测的敏感性为81.82%(9/11),特异性为75.47%(80/106),阳性预测值为25.71%(9/35),阴性预测值为97.56%(80/82)。IMT异常与冠状动脉硬化程度积分呈显著正相关(r=0.55,P<0.01)。结论B超检测颈动脉粥样硬化对风心病患者是否合并冠心病具有预测价值。     

冠脉旁路移植术对冠心病三支病变患者近期生活质量的影响

目的 观察冠脉旁路移植术(CABC)对冠心病三支病变患者生活质量的影响.方法 将69例患者按其意愿分为两组,CABG组行CABG术治疗,药物组行标准药物治疗.两组在确诊后于治疗前及治疗后1 a分别填写西雅图心绞痛调查量表(SAQ),观察躯体活动受限程度(PL)、心绞痛稳定程度(AS)、心绞痛发作程度(AF)、治疗满意程度(TS)、疾病认识程度(DP)6个维度积分.结果 两组治疗前后整体生活质量有明显提高(P<0.01),CABG组术后各项指标改善程度较药物组显著(P<0.01);CABG组术前TS、DP低于药物组(P<0.05),术后和药物组无明显差异(P>0.05).结论 CABG术可明显改善冠心病三支病变患者生活质量;尽量减少手术创伤,减少术后并发症,术前及术后加强心理干预是进一步提高患者生活质量的重要措施.     

Early ostial saphenous vein graft stenosis associated with the use of Symmetry sutureless aortic proximal anastomosis device: successful percutaneous revascularization.

A recent advance in technology permits the creation of sutureless proximal aortic anastomosis during coronary artery bypass graft surgery. This new tool has significant potential benefit by minimizing aortic manipulation with subsequent reduction in neuroembolization. Implantation of a nitinol-based proximal aortic connector (Symmetry) has a potential to elicit intimal hyperplastic reaction analogous to restenosis after coronary stent placement. We report cases of early vein graft stenosis in association with the use of the Symmetry device. Three patients suffered from severe ostial stenosis within 6 months of bypass surgery with symptomatic presentation. Of these three patients, two underwent successful percutaneous revascularization. Fluoroscopic star-shaped appearance of the metallic Symmetry allows device recognition during angiography. We review current data regarding graft patency with the use of Symmetry device and discuss technical issues to address specific problems during percutaneous revascularization.     

Screening for subclavian artery stenosis in patients who are candidates for coronary bypass surgery.

We prospectively evaluated 59 patients who were deemed candidates for coronary bypass surgery after coronary artery angiography for subclavian artery narrowing, which could compromise the ipsilateral internal thoracic artery graft. Bilateral arm blood pressure (BP) measurements, auscultation for supraclavicular or cervical bruits, and questioning about cerebrovascular ischemic symptoms were compared to brachiocephalic-subclavian arteriography. One neurologic complication occurred during arteriography. An upper extremity BP difference of > or = 15 mm Hg identified all patients with > or = 50% subclavian artery narrowing. We recommend brachiocephalic-subclavian arteriography only in patients with abnormal noninvasive screening for subclavian stenosis, not routinely.     

Aortic valve replacement for patients with mild to moderate aortic stenosis undergoing coronary artery bypass surgery

Aortic valve replacement (AVR) is not normally recommended in asymptomatic patients, even if aortic stenosis is severe. However, as the population ages, an increasing number of patients with mild or moderate aortic stenosis will require coronary artery bypass grafting (CABG). In these cases, risk of "prophylactic" AVR needs to be weighed against risks of subsequent worsening of the mildly or moderately diseased aortic valve. If unoperated, aortic stenosis will worsen at an average of 6-8 mmHg per year (-0.1 cm2/year valve area), and one-quarter of such patients will require late AVR with a high operative mortality (14-24%). If AVR is performed at the time of CABG, operative risk is increased only slightly (from 1-3% to 2-6%), as are late mortality (1-2% per year) and morbidity (1-2% per year), mainly from hemorrhagic complications. Intrinsic gradients of most prosthetic valves are sufficiently low that even patients with low aortic valve gradients are likely to derive hemodynamic benefit from AVR. Thus, if there is a measurable (>20-25 mmHg) gradient across the aortic valve in a patient who requires CABG, the patient is at considerable risk for developing symptomatic aortic stenosis prior to reaching the end of expected benefit from CABG; in this case AVR should be considered. It may be reasonable in patients with very mild gradients (<25 mmHg) to defer aortic valve surgery; however, it should be noted that aortic stenosis progression is generally more rapid when the initial gradient is small.     

冠心病合并颈动脉狭窄患者冠状动脉旁路移植术后远期结果

目的：分析不同术式（心脏停跳或不停跳）对行冠状动脉旁路移植术（CABG）后患者脑卒中发生率和生存率的影响。方法解放军总医院心血管外科2003年6月至2013年6月冠心病合并颈动脉狭窄的159例患者,其中男118例,女41例,年龄为（67.0±7.5）岁,根据心脏是否停跳分为停跳（on-pump）组及不停跳（off-pump）组,并对两组患者行CABG后的脑卒中发生率和生存率进行回顾性分析。结果随访146例,随访率93.6%,随访时间6～120（46.3±25.3）个月,10例术后出现神经系统症状,其中2例脑出血,8例脑梗死。17例死亡（4例脑部并发症,1例食管癌,1例肺癌,11例为心源性）,平均死亡时间为术后41（4～72）个月。停跳组患者术后脑卒中发生率及生存率与不停跳组相比差异无统计学意义（P＞0.05）。结论心脏是否停跳对冠心病合并颈动脉狭窄患者术后脑卒中发生率和生存率无明显影响。     

Coronary artery bypass graft surgery in dialysis patients

Objective—To examine the short term results and long term survival of patients on long term dialysis undergoing coronary artery bypass graft surgery.
Methods—A retrospective analysis of 19 patients on established dialysis who underwent coronary revascularisation between 1983 and 1995; 14 patients (73%) had class IV angina and five (25%) had unstable angina requiring heparin and nitrate infusions before surgery.
Results—The 30 day mortality was 5%. Follow up was completed in the remaining 18 patients. The mean follow up time was 34 months (range eight to 61). During the follow up period four patients died of cardiac causes. The actuarial survival at one, two, and three years was 87%, 78%, and 59%, respectively. The overall functional status was significantly improved compared to preoperative levels, with a mean Karnofsky score of 76% (p < 0.01) at three years.
Conclusions—Coronary artery bypass graft surgery can be performed with increased but acceptable morbidity and mortality in chronic dialysis patients. It results in considerable improvement in symptoms and functional status. However, long term survival is limited and this requires further investigation.

     

严重冠心病患者合并颈动脉重度狭窄应用AngioguardTM 远端保护装置行颈动脉支架术--附7例报告

目的评价远端保护装置(DPD)AngioguardTM血栓捕获导丝在严重冠心病多支病变患者颈动脉支架置入术(CAS)中应用的安全性和疗效.方法2002年8月至2003年7月,7例冠心病多支病变患者在冠状动脉造影同时行颈动脉造影提示存在严重颈动脉狭窄(＞75%),在于预冠状动脉病变前后行CAS治疗,术中均应用AngioguardTM DPD.7例患者均为男性,平均年龄(60.9±10.1)岁(46～72岁).4例有陈旧脑梗死史,1例有短暂性脑缺血发作史.结果2例患者于CAS前1周行经皮冠状动脉介入治疗(PCI),其余5例于CAS术后1～2周体外循环下行心脏冠状动脉旁路移植术(CABG)治疗.AngioguardTMDPD均顺利通过所有病变并回收,均成功置入支架,技术成功率100%.干预单侧颈动脉4例,其余3例同时干预双侧病变.3例双侧病变者于球囊扩张或支架释放过程中出现短暂窦缓、窦停,伴血压下降,经对症处理后恢复.围术期无新发脑血管意外及其他严重并发症.2例PCI和5例CABG治疗患者术后恢复良好,无神经系统并发症.结论在严重冠心病多支病变患者CAS中应用AngioguardTMDPD行远端保护是安全有效的.     

Robotic‐assisted balloon angioplasty and stent placement with distal embolic protection device for severe carotid artery stenosis in a high‐risk surgical patient

The use of robotic assistance in endovascular interventions may facilitate smoother procedures with fewer device manipulations, improve precision and accuracy of device deployment, and reduce exposure to fluoroscopic radiation. We used the CorPath GRX Robotic System for carotid balloon angioplasty and stent placement in a patient with limited surgical options.     

Morbidity and mortality following coronary artery bypass graft surgery in patients with cirrhosis: a population‐based study

Background: The risk of cardiac surgery in patients with cirrhosis is poorly defined. Our objective was to describe outcomes of coronary artery bypass graft (CABG) surgery in cirrhotic patients from a population‐based perspective. Methods: We analysed the 1998–2004 Nationwide In‐patient Sample to identify patients hospitalized for CABG surgery. The effect of cirrhosis on mortality, complications, length of stay (LOS) and charges was evaluated using logistic regression models. Results: Between 1998 and 2004, there were 403 094 CABG admissions; 711 patients (0.2%) had cirrhosis. The average annual number of surgeries increased 4.2% [95% confidence interval (CI) 0.7–7.8] in cirrhotic patients, but decreased 5.5% (3.4–7.5) in non‐cirrhotic patients. Patients with cirrhosis had an increased risk of mortality [17 vs. 3%; adjusted odds ratio (OR) 6.67; 95% CI 5.31–8.31], complications [43 vs. 28%; OR 1.99 (95% CI 1.72–2.30)] and greater LOS and charges (P<0.0001). Predictors of mortality included age over 60 (OR 2.21; 95% CI 1.31–3.73), female gender (OR 1.92; 95% CI 1.08–3.41), ascites (OR 3.80; 95% CI 1.95–7.39) and congestive heart failure (OR 1.75; 95% CI 1.08–2.84). Hospital volume and off‐pump CABG did not affect mortality. Conclusions: Patients with cirrhosis have an increased risk of morbidity and mortality following CABG surgery. Additional studies are necessary to refine risk stratification in this high‐risk patient population.     

冠状动脉粥样硬化性心脏病患者颈总动脉中内膜厚度与冠状动脉病变的关系

目的 探讨冠状动脉粥样硬化性心脏病（冠心病）患者颈总动脉中内膜厚度与冠状动脉狭窄程度与狭窄范围的关系.方法 将211例怀疑冠心病的患者,根据冠状动脉造影结果,依有无狭窄及狭窄程度分为3组：A组（60例）为轻度狭窄组,狭窄程度＜50％;B组（97例）为中重度病变组,狭窄程度＞50％;对照组为54例冠状动脉造影阴性者.157例冠状动脉狭窄患者又依狭窄程度分为单支病变亚组（49例）、双支病变亚组（37例）、三支病变亚组（71例）.采用彩色多普勒声像仪测取颈总动脉中内膜厚度,并比较分析各组颈总动脉中内膜厚度.结果 对照组、A组、B组比较,颈动脉总中内膜厚度依次增高,对照组、A组、B组两两比较差异有统计学意义[（0.812 5±0.118 6）mm vs.（0.893 6±0.133 1）mm vs.（1.038 9±0.141 1）mm,P＜0.05].在以病变范围为基础的分组中,各亚组与对照组比较,颈动脉中内膜明显增厚,且两两比较差异有统计学意义（P＜0.05）;单支病变亚组与双支病变亚组比较,差异有统计学意义[（0.920 4±0.141 5）mm vs.（0.990 6±0.144 3）mm,P＜0.05],但双支病变组与三支病变组比较,差异无统计学意义[（0.990 6±0.144 3）mm vs.（1.031 7±0.149 6）mm,P＞0.05].结论 颈总动脉中内膜厚度能很好地反映冠状动脉狭窄程度,但无法很好地反映病变范围.     

Early recognition of catheter‐induced left main coronary artery vasospasm: Implications for revascularization

Catheter‐induced left main coronary artery (LMCA) vasospasm is a rare complication of coronary angiography that confounds the decision for coronary artery bypass graft (CABG) surgery. We report two cases of catheter‐induced LMCA vasospasm. The first case was a 68‐year‐old woman who presented 6 years after CABG for presumed severe LMCA atherosclerotic disease. Coronary angiography demonstrated totally occluded CABGs and normal native coronary arteries, including a normal LMCA. The second case was a 56‐year‐old man with severe LMCA stenosis, who was scheduled for unprotected LM percutaneous coronary intervention (PCI). Repeat angiography 2 days later showed no stenosis. These cases emphasize the need for meticulous technique and a high index of suspicion of LMCA vasospasm. Intravascular ultrasound (IVUS) at the time of angiography may help to identify minimal atherosclerotic disease suggesting vasospasm. Alternatively, noninvasive testing, such as Computed Tomography (CT) angiography, may diagnose LM spasm in these patients prior to CABG surgery. © 2010 Wiley‐Liss, Inc.