冠状动脉旁路手术中动脉材料的选择与应用

目的 在冠状动脉旁路手术(CABG)中寻求动脉材料作旁路移植，减少因大隐静脉桥(SVG)阻塞对远期通畅率的影响。方法 34例冠心病患者以乳内动脉(IMA)和桡动脉(RA)作为血管桥行CABG，采用不接触血管技术制备动脉桥，应用药物防止动脉痉挛。结果 取乳内动脉35根，桡动脉20根，大隐静脉11根，平均移植血管1．94支，死亡1例，手术死亡率2．9％。结论 使用动脉材料行旁路移植术安全有效，预计能保持移植血管长期通畅。     

冠状动脉旁路移植术后心绞痛复发患者行冠状动脉造影术的分析

1 资料与方法 选择2005年8月～2008年1月在我院行冠状动脉旁路移植术(CABG)后,因心绞痛复发而复查冠状动脉造影的患者82例,男65例,女17例,平均年龄(61.82±9.02)岁.冠状动脉造影时间平均(36.51±23.34)个月.旁路移植血管共199支,其中左内乳动脉桥41支,大隐静脉桥156支,桡动脉桥2支.     

全动脉化冠状动脉旁路移植术的应用与疗效观察

目的:探讨全动脉化冠状动脉旁路移植术的手术技术。 方法:42例接受全动脉化冠状动脉旁路移植术的患者,其中男性37例,女性5例,年龄28～73岁,平均(57.43±7.45)岁。体外循环下搭桥16例,非体外循环下心脏不停跳搭桥26例。人均旁路3.08支(1～5支),左乳内动脉(IMA)34例,双侧IMA 8例,左侧桡动脉(RA)33例,双侧RA 9例,胃网膜右动脉(GEA)1例。 结果:术后仅1例患者因多器官功能衰竭死亡(死亡率2.4％),41例(97.6％)症状明显改善,康复出院。 结论:全动脉化搭桥手术早期临床效果满意。     

全动脉化冠状动脉旁路移植术的应用与疗效观察

目的探讨全动脉化冠状动脉旁路移植术的手术技术.方法42例接受全动脉化冠状动脉旁路移植术的患者,其中男性37例,女性5例,年龄28～73岁,平均(57.43±7.45)岁.体外循环下搭桥16例,非体外循环下心脏不停跳搭桥26例.人均旁路3.08支(1～5支),左乳内动脉(IMA)34例,双侧IMA 8例,左侧桡动脉(RA)33例,双侧RA 9例,胃网膜右动脉(GEA)1例. 结果术后仅1例患者因多器官功能衰竭死亡(死亡率2.4%),41例(97.6%)症状明显改善,康复出院.结论全动脉化搭桥手术早期临床效果满意.     

非体外循环下的冠状动脉旁路移植术--101例临床经验体会

目的 :探讨非体外循环下冠状动脉旁路移植术的手术方法及手术适应证 ,并评价其初步临床结果。　　方法 :阜外心血管病医院 1996年 5月～ 1999年 12月完成非体外循环下的冠状动脉旁路移植术 10 1例 ,包括经正中切口非体外循环下的冠状动脉旁路移植术 (OPCAB)组 76例和经胸壁小切口非体外循环下的冠状动脉旁路移植术(MIDCAB)组 2 5例 ,其中 7例在胸腔镜辅助下获取内乳动脉。　　结果 :OPCAB组 76例 ,旁路移植支数平均 2 .5 9支 ,无手术死亡 ,术后并发症包括 :心室颤动并使用主动脉球囊反搏1例 ,出血二次开胸 3例 ,胸部切口感染 2例 ,肺部并发症 2例 ,肾部并发症 1例 ;MIDCAB组 2 5例 ,旁路移植支数平均1.10支 ,无手术死亡 ,围术期心肌梗塞行再次旁路移植手术 1例 ,出血二次开胸 1例 ,胸部切口感染 1例。　　结论 :对于选择的患者 ,非体外循环下 ,不停跳冠状动脉旁路移植术是一项安全、有效的术式。     

非体外循环下“Y”型全动脉桥的冠状动脉旁路移植术

目的 :总结非体外循环下 (off pump)应用左侧乳内动脉与桡动脉“Y”型动脉桥 (Y arterialgraft)冠状动脉旁路移植术的临床经验。方法 :2 0 0 2年 9月至 2 0 0 4年 1月连续对 4 2例冠心病患者行非体外循环下“Y”型全动脉桥的冠状动脉旁路移植术 (YAG OPCABG)。男性 31例 ,女性 11例 ,年龄 (6 6 5±8 4 )岁。手术在全麻非体外循环心脏跳动下进行 ,所有患者均在第三肋间左心耳处行桡动脉与左侧乳内动脉 (LIMA)的“Y”型端侧吻合 ,LIMA与前降支 (LAD)吻合而桡动脉与对角支或钝缘支及后降支或左心室后侧支序贯吻合。应用瞬时血流测定仪测定血管内流量。结果 :全组无死亡 ,无围手术期心肌梗死。 1例后降支行再吻合 ,其余吻合口均通畅并有较好的流量及搏动指数。随访 2～ 17个月 ,生活质量好。结论 :YAG OPCABG具有创伤小 ,全动脉的优点 ,具有良好血流的LLMA并不能影响“Y”桥分支血流量 ,可取得良好的近期临床效果。     

胸骨下段正中较小切口非体外循环下冠状动脉旁路移植术

目的介绍并探讨经胸骨下段正中较小切口非体外循环下冠状动脉旁路移植术的外科技术和临床经验.方法经胸骨下段正中较小切口游离左侧乳内动脉,用于冠状动脉前降支旁路移植术.对冠状动脉多支病变患者同时游离大隐静脉,用于冠状动脉其它分支旁路移植术.在非体外循环,心脏跳动下,完成冠状动脉单支或多支病变血管的旁路移植术.观察术后恢复情况.结果全组22例患者采用该手术方法,其中5例为前降支单支病变,17例为多支病变.22例患者前降支旁路移植术均采用左乳内动脉.平均冠状动脉旁路移植支数2.40±1.04(1～4)支/人.冠状动脉旁路移植的靶血管包括前降支、对角支、右冠状动脉或后降支和高位边缘支.全组患者术后恢复顺利,无严重术后并发症和死亡.患者术后平均8.1±1.6天痊愈出院.结论该手术方法创伤较小,安全易行,对有手术适应证的多支病变患者是一种较好的微创冠状动脉旁路移植手术方法.     

大隐静脉顺行序贯式吻合法在非体外循环冠状动脉旁路移植术中的应用

目的 评价在非体外循环冠状动脉旁路移植术中应用大隐静脉顺行序贯式吻合法的临床效果.方法 对75例冠状动脉粥样硬化性心脏病患者行非体外循环下冠状动脉旁路移植术.左乳内动脉搭桥至前降支,其余各支靶血管以大隐静脉行序贯式搭桥,序贯吻合顺序原则上依次为对角支、回旋支（钝缘支）、左室后支、后降支.结果 全组病例均在非体外循环下完成手术.桥血管吻合数目共296个,平均（3.95±0.55）个/例.全组患者无死亡,无围术期心肌梗死.迟发性心包填塞1例,急性肾功能衰竭1例,上消化道大出血1例,均治愈.结论 非体外循环下采用＂顺行序贯式吻合技术＂行冠状动脉旁路移植手术,可减少主动脉吻合口,节约桥血管长度,并可最快恢复心脏供血,是一种快捷、安全的术式.     

下肢远端动脉旁路移植治疗糖尿病下肢缺血

目的探讨治疗糖尿病下肢缺血动脉旁路移植的方法和疗效。方法从2000年7月至2004年7月，应用下肢远端动脉旁路移植手术治疗了82例2型糖尿病病人的96条下肢。主要方式为股动脉-胭动脉人工血管＋小腿动脉自体血管旁路移植术31条（32．3％），胭动脉-小腿动脉旁路移植22条（22．9％），髂动脉支架＋股动脉-胭动脉人工血管＋小腿动脉自体血管旁路移植术12条（12．5％），股动脉-小腿动脉旁路移植10条（10．4％）。结果82例中，3例全麻手术病人（4条下肢）于术后死亡，病死率为3．7％；手术成功率为96．3％，总有效率为93．7％；救肢成功率为98．9％；足部创面愈合率37．3％。76例患者（96．2％）被随访，平均随访时间为13．5个月，移植血管通畅率为92．2％；死亡率为3．9％；总有效率为87．6％；截肢率为4．5％，保肢率为95．5％。93．8％（30／32）下肢创面分别于出院2～10个月（平均6个月）后愈合。结论糖尿病下肢缺血行远端动脉旁路移植手术，可以使大多数患者得到有效治疗，从而挽救肢体或降低截肢平面。     

冠状动脉旁路移植术：第二支动脉桥血管的应用进展

冠状动脉粥样硬化性心脏病的治疗方式主要是药物治疗,经皮冠状动脉介入治疗（percutaneous coronary intervention, PCI）和冠状动脉旁路移植术（coronary artery bypass grafting, CABG） ;CABG是重症冠心病患者的主要治疗方式。近年来多支动脉或全动脉化旁路移植在冠状动脉外科兴起,但是除了左侧胸廓内动脉作为旁路移植黄金血管材料,第二支动脉桥血管的选择和使用仍存在很多挑战。本文将对临床常用的右侧胸廓内动脉,桡动脉,胃网膜右动脉和旋股外动脉降支应用进展作综述。     

全动脉化冠状动脉旁路移植74例

目的:介绍全动脉化冠状动脉旁路移植（CABG）的早期效果和经验。方法:74例全动脉化CABG的患者。74例患者分别在体外循环（CPB）和非CPB下行CABG。应用左乳内动脉（IMA）1例,左IMA加单挠动脉（RA）14例,左IMA加双RA 54例,双IMA加双RA 3例,双RA 2例。人均搭桥4.7（17）支,序贯吻合66例,“Y”和“T”型吻合分别为15和6例。结果:围手术期无死亡。本组患者随访518（平均12.2）个月,均恢复良好,无心绞痛症状再发。多普勒和16排CT示血管桥无狭窄通畅。结论:全动脉化CABG取得好的早期效果,是一种值得积极推广的方法。     

Radial artery achieves better flowmetric results than saphenous vein in the elderly

Due to the limited life expectancy and the supposed higher morbidity with complete arterial grafting, extensive arterial graft in the elderly is still questioned. It was the aim of this study to evaluate transit time flow and clinical, biochemical and echocardiographic results of elderly patients undergoing coronary artery bypass grafting (CABG) with either saphenous vein (SV) or radial artery (RA) employed as the second conduit of choice. The present study evaluates clinical and flowmetric results of a prospective series of elderly patients (≥70 years old) undergoing RA CABG (75 patients, Group A) or SV CABG (163 patients, Group B) during isolated myocardial revascularization, performed either off-pump (OPCABG) and onpump during the last 5 years at a single academic institution (between January 2003 and December 2007). Transit time flowmetric (TTF) maximum and mean flow, pulsatility index (P.I.), and graft flow reserve (GFR) were compared. Hospital outcome was analyzed. Clinical data were compared between the two groups and one-year follow-up was completed. The two groups showed comparable preoperative and intraoperative variables. When TTF analysis was considered, patients undergoing RA grafting demonstrated a significantly higher maximum (systolic) and mean flow compared to SV grafting, either in circumflex, diagonal, and right coronary territory. Pulsatility index was significantly lower in the RA group in circumflex, diagonal, and right coronary grafts. Furthermore, when GFR was calculated significantly higher values were found in RA conduits in the circumflex, diagonal, and right coronary grafts. Comparable troponin I leakage was detected between the two groups. Postoperative variables addressing hospital outcome were similar in the two groups. When echocardiographic data were analyzed, no differences were recorded in postoperative recovery of left ventricular ejection fraction and wall motion score index. One-year follow-up showed better freedom from acute cardiovascular events in the RA group (P = 0.04). Our data show that despite comparable clinical, biochemical, and echocardiographic results in elderly patients undergoing RA or SV grafting, better flowmetric results — in terms of GFR, mean flow, and Pulsatility index — can be detected in arterial conduits.     

45岁以下冠状动脉搭桥患者71例临床观察

目的:冠状动脉旁路手术已成为冠心病患者的有效治疗手段之一,青年冠心病患者逐年增多,分析我科10余年来45岁以下冠状动脉搭桥患者的临床特点。方法:连续71例45岁以下冠心病患者,在非体外循环下行冠状动脉搭桥术(Off-pump coronary artery bypass grafting,OPCAB)。对于术前确诊无左心室附壁血栓的室壁瘤患者,在OPCAB同时行左心室室壁瘤缝缩术。对于冠状动脉存在弥散性病变的患者,采用冠状动脉内膜剥脱术式。而对右冠状动脉存在弥散性病变且管径细小的患者,施行选择性冠状静脉动脉化。并对患者例数变化、旁路血管移植支数、同期采用术式、愈后、并发症发生情况及OPCAB移植血管应用情况等指标进行总结。结果:患者平均移植旁路血管(3.0±0.7)支。术后死亡2例(2.8%)。29例施行全动脉化搭桥。同期行左心室室壁瘤折叠缝缩术7例。冠状动脉内膜剥脱术1例。1996年10月至2008年12月接受OPCAB手术的患者数量与比例逐年上升,但从2006年开始,45岁以下冠心病患者接受OPCAB手术呈逐年减少趋势,与其他年龄组患者相比,双乳内动脉搭桥比例高(P<0.05)。而搭桥数目差异无统计学意义(P>0.05)。结论:青年冠状动脉搭桥患者男性比例高,冠状动脉病变弥散,双乳内动脉搭桥比例高。对于远端血管纤细的患者,可以采用选择性冠状静脉动脉化手术,近期效果满意。     

Radial artery as graft for coronary artery bypass surgery: Advantages and disadvantages for its usage focused on structural and biological characteristics

Radial artery (RA) is the most popular arterial graft after the left internal thoracic artery in both low- and high-risk patients undergoing coronary artery bypass grafting. Various arterial grafts such as the right internal thoracic artery, the right gastroepiploic artery, and the inferior epigastric artery have also gained ground over the past 30 years because of the intimal hyperplasia and atherosclerosis of the saphenous vein leading to late graft occlusion. In this review article we would like to present the utility of the RA as a graft, focused mainly on its structural and biological characteristics.     

Total arterial anaortic off-pump coronary artery bypass grafting for diffuse coronary disease – A case report

Surgical treatment of diffuse coronary artery disease remains challenging. We present here a diabetic patient, with diffuse coronary disease, revascularized using total arterial anaortic off-pump coronary artery bypass grafting. He received total nine distal grafts. He continues to be asymptomatic after more than 2 years. CT angiography follow-up shows eight out of nine grafts are patent. Anaortic off-pump coronary artery bypass grafting has the least incidence of stroke and arterial grafts have the best long-term patency rate. This is the first case report of nine arterial bypass graft performed off-pump using both internal mammary and both radial arteries. Anaortic total arterial off-pump coronary artery bypass grafting has achieved excellent intermediate term result in this patient of diffuse coronary artery disease.     

瓣膜性心脏病伴缺血性心脏病的外科治疗

目的 :总结瓣膜性心脏病伴缺血性心脏病手术治疗的早期效果和经验 ,以期提高疗效。方法 :11例患者中 ,行主动脉瓣置换术 4例 ,二尖瓣置换术 2例 ,二尖瓣和主动脉瓣双瓣置换术 1例 ,主动脉带瓣管道置换 2例 ,二尖瓣成形术 1例和三尖瓣成形术 1例 ;搭 1支桥 4例 ,搭 2支桥 1例 ,3支桥 3例 ,4支桥 3例 ,平均 (2 .5±1.3)支。结果 :11例无手术早期死亡 ,痊愈出院 ;随访 2～ 16 (平均 6 .3)个月 ,心绞痛症状消失 ,心功能明显改善。结论 :对年龄 >5 0岁瓣膜病患者或具有冠心病高危因素患者 ,应行冠状动脉造影检查 ;彻底纠正心脏病变 ,加强心肌保护 ;妥善处理术后并发症 ,手术疗效满意     

Total arterial myocardial revascularization--strategy,early and midterm results

Total arterial myocardial revascularization (TAMR) represents a new alternative procedure to the classical aorto-coronary bypass operation with venous graft material. The early and midterm results with the use of the left and right internal thoracic artery (LITA and RITA) and radial artery (RA) for coronary artery bypass grafting are analyzed to assess the suitability of these conduits for myocardial revascularization. From June 1997 to June 2001, 234 patients suffering from a coronary artery disease underwent TAMR at our institution. The bypass material consisted of 234 LITAs, 160 RITAs and 84 RAs. The most frequently used conduit combination was a T-graft (n=213) consisting of a free arterial graft (RITA or RA) centrally implanted into LIMA "in situ" using an end-to-site grafting technique. The mean left ventricular ejection fraction was 0.59+/-0.4. In 150 patients (64.1%), the operation was performed on an urgent basis and in 24 cases (10.2%) it was a reoperation. A mean of 3.3+/-0.9 coronary anastomoses per patient was performed. The mean aortic cross-clamping time was 71+/-20 minutes. In 194 cases (83%), the postoperative course was uneventful. The early mortality was 0.8% (n=2). Complications included myocardial infarction in 4 patients (1.7%), sternal infection in 2 (0.8%), renal insufficiency in 2 (0.8%), prolonged respiratory ventilation in 28 (11.9%) and reoperation for bleeding in 6 (2.5%). At a mean follow-up of 25+/-1.3 months 197 patients (96.6%) were asymptomatic. Late mortality was 3.3% (n=7). TAMR is a safe and reliable procedure with very good early and midterm results. The results reported in this study support the widened use of this coronary artery grafting strategy.     

老年患者原位乳内动脉行冠状动脉旁路移植术112例

目的　乳内动脉 (IMA)是当前国际上公认的最好的搭桥移植物 ,而在老年患者中使用较少 ,因为人们觉得IMA的使用会增加手术并发症发生率和死亡率 ,而且亚洲人比欧美人IMA细小 ,手术有一定难度 ,据此事实 ,作者总结了老年患者常规使用IMA搭桥的近中期效果、技术要点及手术指征。方法　自 1 997年 4月至 1 999年 9月 ,冠心病 1 68例接受了冠状动脉旁路移植术 (CABG)治疗 ,其中老年患者 1 1 2例 (男 1 1 0例 ,女 2例 ) ,年龄 60～ 75岁 ,平均 66 .5岁。原位IMA使用率占单纯CABG手术的 92 % ,同时行双瓣置换 2例 ,单瓣置换 8例 ,室壁瘤切除、左室成形 1 0例。结果　 1 1 1例痊愈出院 ,心绞痛消失 ,围手术期发生心肌梗死 1例 ,术后死亡 1例。近中期随访效果满意。结论　老年冠心病患者搭桥也应首选IMA ,而且可以常规使用     

Use of an autologous artery for tibial artery bypass in a trauma patient

Peripheral artery bypass grafting is a commonly performed procedure. The present report describes the use of an autologous artery for tibial artery bypass graft following a gunshot wound to the calf. Approximately 4 cm of proximal peroneal artery was harvested for use as a bypass graft. At one year postoperatively, an arterial duplex scan showed patency of the tibioperoneal trunk to the posterior artery bypass.