颈动脉狭窄合并冠心病的分期介入治疗及随访研究

目的探讨分期介入治疗颈动脉狭窄合并冠心病患者的疗效,并发症及随访效果。方法回顾性分析了57例经冠状动脉及脑血管造影或CT血管成像(CTA)证实的颈动脉狭窄合并冠心病患者的临床资料,所有患者均先行经皮冠状动脉介入治疗(PCI),术后1周左右再行颈动脉支架术(CAS),手术前后均进行水化以保护肾功能,观察手术前后患者的神经功能评分(mRS)、肾功能,术中术后并发症等,对患者进行长期随访,观察有无心肌梗死、脑梗死并复查造影观察支架内情况。结果 57例患者均成功行分期介入手术,技术成功率100%,术中显示血管通畅,狭窄解除满意,手术前后患者mRS评分无明显变化,两次介入前后估算的肾小球滤过率无明显变化,1例患者PCI术后3d出现原脑梗症状加重,紧急行CAS术,预后良好。虽有16例患者存在颈动脉窦反射,但所有患者术后均未出现心肌梗死、脑梗死,无死亡患者。随访期间无一例患者出现心肌梗死及支架侧脑梗死。结论对于颈动脉狭窄合并冠心病患者,分期先行PCI后行CAS是安全有效的治疗方式。     

Retrograde coronary sinus perfusion for management of coexistent critical unstable carotid and coronary artery disease

The case report describes a difficult and not uncommon situation of a patient suffering from an evolving myocardial infarction with hemodynamic instability along with a critical bilateral extracranial carotid artery stenosis. A technique of retrograde coronary sinus perfusion was used to temporarily stabilize the cardiac status while the carotid lesion was being tackled.     

A logical approach to screening for coronary artery disease

Although changes in lifestyle may increase the life expectancy of persons at high risk for coronary disease, there is no cost-effective screening test that can select these persons from the general population. Exercise testing has been considered, but epidemiologic studies have not proved that it effectively identifies persons at risk for myocardial infarction or cardiac death. Theoretically, exercise testing should have limited sensitivity in predicting events because abnormal responses occur only when sufficient atherosclerotic plaque has accumulated to impede coronary flow. Abnormal test responses cannot occur before plaque has reached such dimensions. A test that indicates the presence of any atherosclerotic plaque in the coronary lumen would be more useful than one that indicates compromise of blood flow. Data show that sensitive detection of coronary calcific deposits accurately predicts the presence of atherosclerotic plaque. Sensitive radiographic techniques such as digital subtraction fluoroscopy need to be developed as screening tests. Screening studies should be blinded and include only hard endpoints, and follow-up periods should be no less than 10 years so that the detected disease can develop to its symptomatic endpoint.     

Research related to surgical treatment of coronary artery disease.

In the past 20 years, basic and clinical research have provided new information on coronary artery surgery. For example, several studies have shown that coronary artery bypass grafting is more effective than medical treatment in relieving the symptoms of chronic disabling angina pectoris. However, we still do not have definitive answers to many questions. What factors in the patient, in the operation and in the care after operation determine success in surgical treatment? Does the operation prolong useful life? Is the operation affordable? These questions are difficult. Further research is needed to solve complex problems relating to surgical vs medical treatment of coronary artery disease.     

A novel hydrodynamic approach to the treatment of coronary artery disease.

AIMS: During severe coronary stenosis, capillary resistance increases. Drag-reducing polymers (DRPs) are blood-soluble macromolecules that reduce vascular resistance, possibly by altering blood hydrodynamics and rheology. Thus, we hypothesized that DRPs would enhance myocardial perfusion distal to a severe coronary stenosis. METHODS AND RESULTS: A flow-limiting left anterior descending (LAD) coronary artery stenosis was created in 12 open chest dogs. Coronary driving pressure, flow, trans-stenotic gradient, and radiolabelled microsphere myocardial perfusion were measured. Myocardial contrast echocardiography was performed and videointensity vs. pulsing interval data in the LAD and left circumflex beds were used to derive red cell velocity and capillary volume. Relative to baseline, the stenosis decreased LAD bed capillary volume (P = 0.019) and red blood cell velocity (P = 0.010). Intravenous DRP (polyethylene oxide, 2.5 ppm) decreased LAD microvascular resistance (P = 0.003) and increased microsphere flow (P = 0.009), capillary volume (P = 0.0006), and red cell velocity (P = 0.007) despite the presence of a severe stenosis. DRP did not alter blood viscosity. CONCLUSIONS: DRPs improve perfusion to myocardium subserved by a flow-limiting coronary stenosis by decreasing microvascular resistance through an increase in capillary volume. Primary modulation of blood hydrodynamics and rheology to reduce microvascular resistance offers a novel approach to the treatment of ischaemic coronary syndromes.     

Clinical features and coronary backgrounds of coexistent peripheral vascular disease in Japanese coronary artery disease patients

By use of noninvasive tests (Doppler segmental pressure study, supraorbital Doppler flow analysis, and segmental plethysmography), coexistent carotid (CTD) or lower extremity peripheral vascular disease (PVD) were diagnosed and correlated with subjective symptoms, coronary risk factors (CRFs), coronary arteriograms (CAGs), cardiac hemodynamics, and infarct size in 121 consecutive patients with documented coronary artery disease (CAD). PVD was found in 16.5%, CTD in 33.1%, and both PVD and CTD in 9.9% of the patients studied; 20% of PVD patients and 47.5% of CTD patients were asymptomatic with respect to coexistent PVD or CTD. There were no significant differences between the presence or absence of PVD or CTD as regards number of CRFs, Killip classification, cardiac hemodynamics, or number of stenotic coronary arteries. However, serum creatine kinase (CK) and CKMB release curves in the PVD group showed significantly higher peak CK and peak CKMB values than those in the PVD(-) group (4096 +/- 5408/282 +/- 263 vs 1706 +/- 1715/179 +/- 186, p less than 0.05) because of the higher prevalence (100%) of multivessel disease on CAG. Investigation of the relationship of CRFs to coexistent PVD revealed that the smoking ratio in men (86.7%) and the hypertension ratio in women (80%) were extremely high in PVD patients, and statistically significant differences between PVD(+) patients and PVD(-) groups were found with respect to the obesity ratio (p less than 0.05) in men and the hypercholesterolemia ratio (p less than 0.05) and obesity ratio (60%, p less than 0.05) in women.(ABSTRACT TRUNCATED AT 250 WORDS)     

Results of operation for coexistent obstructive hypertrophic cardiomyopathy and coronary artery disease

This study describes the operative management and outcome of 28 patients with obstructive hypertrophic cardiomyopathy and hemodynamically significant coronary artery disease. Each patient underwent coronary artery bypass grafting and concomitant left ventricular myotomy-myectomy or mitral valve replacement. The mean age at operation was 59 years (range 42 to 74). Five patients (18%) died as a result of operation, four in the immediate postoperative period and one at 2 months postoperatively. Three patients died after the immediate postoperative period of causes unrelated to the operation. The mean follow-up period for the 20 currently surviving patients was 4.8 years (range 4 months to 10.8 years). Nineteen of these patients have experienced substantial functional improvement; all are currently asymptomatic or only mildly symptomatic. Twenty-one patients underwent cardiac catheterization before and after operation; each experienced relief of left ventricular outflow tract obstruction after operation. Twelve patients had a preoperative outflow gradient greater than or equal to 50 mm Hg (average 86 +/- 7) under basal conditions, which decreased to 3 +/- 1.8 mm Hg postoperatively (p less than 0.001). Nine patients had a severe preoperative gradient only with a provocative maneuver (average 93 +/- 6 mm Hg), which decreased to 24 +/- 8 mm Hg postoperatively (p less than 0.001). Five of the 24 patients undergoing left ventricular myotomy-myectomy incurred an iatrogenic ventricular septal defect. This operative complication occurred primarily in patients with a relatively thin ventricular septum (less than 20 mm) and contributed importantly to postoperative death in two of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Treatment of combined coronary and carotid artery disease

PURPOSE OF REVIEW: The purpose of this review is to evaluate the current indications and results of treatment of combined coronary and carotid disease. Synchronous carotid stenosis in patients with coronary artery disease poses a management challenge in patients with advanced atherosclerosis. RECENT FINDINGS: Recent case series continue to demonstrate concomitant coronary and carotid disease with significant carotid stenosis greater than 70% in approximately 8% of patients evaluated for coronary artery bypass grafting. Surgical management options include staged operations addressing the carotid stenosis first, reverse staged operations addressing the coronary disease first, and combined synchronous operations addressing both territories during the same anesthetic. Recent reports demonstrate safety and acceptable risks with each operative approach. Lower trends in stroke rates were noted following staged procedures when compared with combined procedures. However, several metaanalyses showed no significant difference in rates of combined morbidity and mortality for all three strategies. Total morbidity and mortality risks for combined disease tended to be higher than for isolated coronary artery bypass grafting or carotid endarterectomy procedures performed for disease in a single vascular territory. SUMMARY: Despite a large volume of data present in the literature, the treatment indications and surgical options remain controversial. We currently advocate treatment of symptomatic territory first in favor of staged procedures and reserve combined procedures for patients with critical stenosis or symptoms in both territories.     

颈动脉粥样硬化与冠心病关系的研究

目的研究颈动脉粥样硬化与冠心病的关系。方法对301例冠状动脉造影的患者作双侧颈动脉超声检查，根据冠脉造影结果分为正常组及冠心病组，冠心病组根据冠状动脉病变支数再分为一支病变组，二支病变组，三支病变组3个亚组。测量颈总动脉后壁内中膜厚度(IMT)，斑块厚度，计算斑块积分及粥样斑块发生率。结果(1)冠心病组IMT，斑决积分及斑块发生率明显高于正常对照组(P＜0.01)。(2)随冠脉病变支数增加，斑块积分及IMT增加，亚组比较有显著性差异(P＜0.01)。(3)以IMT＞0.85mm和(或)出现粥样斑块预测冠心病，特异性75.3％，敏感性84.6％，阳性预测率88.4％。结论通过颈动脉超声检查可为冠心痛的诊断提供依据。     

颈动脉粥样硬化与冠心病关系的研究

目的:研究颈动脉粥样硬化与冠心病的关系。方法:对301例冠状动脉造影的患者作双侧颈动脉超声检查,根据冠脉造影结果分为正常组及冠心病组,冠心病组根据冠状动脉病变支数再分为一支病变组,二支病变组,三支病变组3个亚组。测量颈总动脉后壁内中膜厚度(IMT),斑块厚度,计算斑块积分及粥样斑块发生率。结果:(1)冠心病组IMT,斑块积分及斑块发生率明显高于正常对照组(P<0.01)。(2)随冠脉病变支数增加,斑块积分及IMT增加,亚组比较有显著性差异(P<0.01)。(3)以IMT>0.85mm和(或)出现粥样斑块预测冠心病,特异性75.3％,敏感性84.6％,阳性预测率88.4％。结论:通过颈动脉超声检查可为冠心病的诊断提供依据。     

A clinical approach to exercise tolerance testing in coronary artery disease

Data from exercise tolerance testing should be incorporated into clinical decision making. A strategy for stratification of individual patients into high, indeterminate, and low-risk categories using Bruce protocol exercise testing is outlined. This approach will help to ensure further evaluation of high-risk individuals without excessive testing of patients having excellent long-term prognoses.     

Transseptal approach to aortography and carotid artery stenting in pulseless disease

We report on a patient with pulseless disease (Takayasu's arteritis) in whom access to the central circulation by extremity arterial cannulation was not possible due to absent pulses in all four limbs. The transseptal approach was used for aortography, bilateral selective carotid angiography, and successful elective stent deployment in the right common carotid artery. Cathet. Cardiovasc. Diagn. 40:416–420, 1997. © 1997 Wiley-Liss, Inc.     

颈动脉粥样斑块与冠状动脉病变的相关性研究

目的探讨颈动脉粥样硬化斑块与冠状动脉病变的临床相关性。方法选择行冠状动脉造影确诊的冠状动脉病变患者133例。根据冠状动脉造影检查结果,按照病变严重程度,分为轻度狭窄组、中度狭窄组和重度狭窄组;按照冠状动脉病变支数,分为单支病变组、双支病变组和三支病变组;按照SYNTAX积分,分为0～22分组、23～32分组和≥33分组。超声检测入选患者颈总动脉、颈内动脉、颈外动脉及其分叉处有无斑块形成并进行粥样硬化斑块积分（AS积分）,分析各组颈动脉粥样硬化斑块及积分与冠状动脉病变的相关性。结果颈动脉粥样斑块形成例数及粥样硬化斑块积分与冠状动脉病变严重程度呈正相关（r分别为0.632、0.751）;与冠状动脉病变支数呈正相关（r分别为0.597、0.655）;与SYNTAX积分呈正相关（r分别为0.643、0.597）。冠状动脉轻度狭窄组与中度及重度狭窄组比较,单支病变组与双支及三支病变组比较,冠状动脉SYNTAX积分0～22分组与23～32分组及≥33分组比较,颈动脉粥样斑块形成例数及粥样硬化斑块积分差异均具有统计学意义（P〈0.05～0.01）;冠状动脉中度与重度狭窄组比较,双支及三支病变组比较,SYNTAX积分23～32分组比较与≥33分组比较,颈动脉粥样斑块形成例数及粥样硬化斑块积分差异无统计学意义（P均〉0.05）。结论颈动脉粥样斑块检查能够反映冠状动脉病变的情况,适合临床冠心病的普查及随访。     

颈动脉粥样硬化与冠心病的关系

目的:探讨颈动脉粥样硬化与冠心病的关系. 方法:根据冠状动脉造影结果将101例病人分为冠心病组及对照组,再根据受累血管数将冠心病组又分为一支病变组、二支病变组及三支病变组.应用高频超声测定所有病例双侧颈总动脉的内-中膜厚度(IMT)、颈总动脉内径,进行分析. 结果:冠心病组的左颈动脉的平均IMT为(0.91±0.13)mm,平均内中膜横切面面积(IMCSA)为(22.13±3.21)mm2,而对照组的左颈动脉的平均IMT为(0.84±0.06)mm,平均IMCSA为(18.06±1.15)mm2,两组的差异有统计学意义(P＜0.01);冠心病组斑块发生率为63.7%,对照组的斑块发生率为34.6%,差异有统计学意义(P＜0.01).以左颈总动脉IMT0.845 mm为界限预测冠心病的敏感性为68.8%,特异性为67.3%;以左颈总动脉IMCSA19 mm2为界限预测冠心病的敏感性为87.5%,特异性为84.6%. 结论:颈动脉粥样硬化可作为冠心病的预测因子,为临床诊断提供依据.     

颈动脉粥样硬化与冠心病的关系

目的:探讨颈动脉粥样硬化与冠心病的关系。方法:根据冠状动脉造影结果将101例病人分为冠心病组及对照组,再根据受累血管数将冠心病组又分为一支病变组、二支病变组及三支病变组。应用高频超声测定所有病例双侧颈总动脉的内-中膜厚度(IMT)、颈总动脉内径,进行分析。结果:冠心病组的左颈动脉的平均IMT为(0.91±0.13)mm,平均内中膜横切面面积(IMCSA)为(22.13±3.21)mm2,而对照组的左颈动脉的平均IMT为(0.84±0.06)mm,平均IMCSA为(18.06±1.15)mm2,两组的差异有统计学意义(P<0.01);冠心病组斑块发生率为63.7%,对照组的斑块发生率为34.6%,差异有统计学意义(P<0.01)。以左颈总动脉IMT0.845mm为界限预测冠心病的敏感性为68.8%,特异性为67.3%;以左颈总动脉IMCSA19mm2为界限预测冠心病的敏感性为87.5%,特异性为84.6%。结论:颈动脉粥样硬化可作为冠心病的预测因子,为临床诊断提供依据。     

颈动脉内中膜厚度与冠心病的关系分析

目的：通过颈动脉内-中膜厚度（IMT）的测定,分析颈动脉粥样硬化与冠心病的关系。方法：对158例接受脉造影的患者行颈动脉IMT及斑块超声检查,比较有无冠脉病变及不同程度冠脉病变与颈动脉IMT的关系。结果：无冠心病者50例,冠心病单支病变组53例,多支病变组55例。冠心病患者的颈动脉IMT[单支病变（0．91±0．1）mm）,多支病变（1．08±0．15）min]分别明显高于非冠心病者[（0．83±0．08）mm,P均〈0．057,冠心病患者的斑块检出率[单支病变52．6％,多支病变65．7％]分别明显高于非冠心病者的32％（P均〈0．05）。多支冠状动脉病变组的颈动脉IMT及斑块检出率明显高于单支冠状动脉病变组（P均〈0．05）。结论：颈动脉粥样硬化对冠心病有一定的预测价值,颈动脉IMT可作为间接反映冠状动脉病变程度的指标。