双源CT评价冠状动脉搭桥术后桥血管通畅率的临床研究

目的比较非体外循环下冠状动脉旁路移植术（OPCABG）与常规冠状动脉旁路移植术（常规CABG）术后5年血管桥的通畅率。方法2006年1月至2008年1月间40例单独行冠状动脉旁路移植术（CABG）的患者资料回顾性地被分为OPCABG组和常规CABG组。OPCABG组通过胸骨正中切口,在非体外循环心脏不停跳下完成CABG;常规CABG组建立常规体外循环心脏停搏下完成CABG。两组术前的一般情况无明显差异。利用双源CT造影检查及CT图像后处理,研究两种术式各条血管桥的通畅情况。结果常规CABG组及OPCABG组左乳内动脉（uMA）到前降支（LAD）的通畅率都达到100％,静脉桥的通畅率分别为93．87％和94．23％,组间比较差异均无统计学意义。结论OPCABG旁路血管桥的3~5年通畅率可以和常规CABG相媲美。OPCAB治疗冠心病的初期结果显示可以减少术后并发症,减少患者术后呼吸机辅助时间、ICU留观时间和住院时间,降低住院费用。     

非体外循环和体外循环冠状动脉旁路移植术桥流量变化的对比分析

目的通过超声瞬间血流仪在术中测定体外和非体外循环冠状动脉旁路移植术患者血管桥流量和血流搏动指数变化,了解非体外循环冠状动脉旁路移植术血管桥吻合口的质量.方法91例患者采用非体外循环方法(非体外组)行冠状动脉旁路移植术,同期有107例应用体外循环方法(体外组)行冠状动脉旁路移植术,测定两组间不同旁路移植术部位的血管桥流量和血流搏动指数变化.结果冠状动脉旁路移植术两组间每个吻合口的平均血流量分别为(25.94±12.84)ml/min和(30.29±11.42)ml/min(P＜0.05);血流搏动指数分别为2.06±0.76和2.12±0.78(P＞0.05).除前降支和用大隐静脉为移植材料的对角支部位,体外组较非体外组冠状动脉桥的平均血流量明显增多(P均＜0.05)外;其余部位的平均血流量两组间无显著差异.两组间各部位总的血流搏动指数也无显著差异.结论尽管非体外循环冠状动脉桥血流量偏低,但其血流搏动指数尚满意,说明术后早期吻合口质量可靠.     

前降支旁路移植策略桥血管选择及通畅率研究

冠状动脉旁路移植术是治疗冠心病的有效手段。左前降支作为冠状动脉三大分支之一,其再血管化对于抢救患者生命、改善缺血症状非常重要,尤其是内乳动脉到左前降支的吻合至今仍是冠状动脉再血管化的“金标准”。对左前降支进行旁路移植术,可选择的桥血管材料包括游离或原位左右乳内动脉,游离或原位胃网膜右动脉,游离桡动脉、大隐静脉等。但是不同桥血管到左前降支的吻合策略和通畅率仍有待深入研究,本文总结了近30年的国内外文献资料,初步探讨不同桥血管选择策略及左前降支旁路移植的通畅率。     

双源CT冠状动脉血管造影和冠状动脉造影评价冠状动脉旁路移植术后桥血管通畅的效果

目的探讨双源CT冠状动脉血管造影和冠状动脉造影评价冠状动脉旁路移植术后桥血管通畅的效果。方法选取接受冠状动脉旁路移植术治疗的70例患者,均接受双源CT冠状动脉血管造影检查,并对其结果进行分析。25例患者在双源CT冠状动脉血管造影检查后2 w接受冠状动脉造影检查,评价双源CT冠状动脉血管造影的图像质量,并以冠状动脉造影检查结果为金标准,计算双源CT冠状动脉血管造影检查对冠状动脉旁路移植术后桥血管通畅的评价结果,分析双源CT冠状动脉血管造影检查与冠状动脉造影检查结果的一致性。结果 70例冠状动脉旁路移植术患者共搭建204支桥血管,包括65支动脉桥血管,139支静脉桥血管,动脉桥血管的通畅率明显高于静脉桥血管(P<0.05)。双源CT冠状动脉血管造影的图像质量优良率为94.29%,以冠状动脉造影检查结果为金标准,双源CT冠状动脉血管造影检查对冠状动脉旁路移植术后桥血管通畅评价的敏感性、特异性、准确性、阳性预测值、阴性预测值分别为93.61%、96.00%、94.44%、97.78%、88.89%,其与冠状动脉造影检查结果之间的一致性良好。结论在冠状动脉旁路移植术后采用双源CT冠状动脉血管造影检查,可对其桥血管通畅情况予以清晰显示和准确评价,其评估效果较好。     

中国常用动脉化冠状动脉旁路移植术的通畅率及疗效

目前冠状动脉旁路移植术通常采用一支乳内动脉加一支或多支大隐静脉作为桥血管,大隐静脉会逐渐粥样硬化而闭塞,动脉的通畅率远高于大隐静脉。左乳内动脉已常规应用于冠状动脉旁路移植术,同应用双侧乳内动脉相比,左乳内动脉加大隐静脉被认为是远期死亡、心脏事件的独立危险因素。乳内动脉用于左侧冠状动脉时通畅率一样;原位或复合桥移植时所有的乳内动脉通畅率相同,但吻合于主动脉时通畅率降低,所以原位乳内动脉通畅率高于游离乳内动脉。胃网膜右动脉和桡动脉宜吻合于近端狭窄严重者。双侧乳内动脉+胃网膜右动脉可避免触及主动脉,最大程度地减少脑部并发症的发生。70岁以下冠状动脉旁路移植术、预期寿命5年以上者,应选择双侧乳内动脉;60岁以下没有或很少合并症的冠状动脉旁路移植术患者可考虑全动脉化搭桥手术。     

经左侧桡动脉行冠状动脉旁路移植术桥血管造影

随着近10余年来冠状动脉旁路移植术的普遍展开,冠状动脉移植术后再发心绞痛,需冠状动脉造影检查的患者越来越多。由于经右侧桡动脉人路途径无法完成左侧乳内动脉（left internal mammary artery,LIMA）的造影工作,所以常规经右侧股动脉路径,行包括LIMA桥在内的冠状动脉和桥血管造影。根据大血管走行和解剖特点,阜外医院结合临床实践,越来越多地采用左侧桡动脉路径行冠状动脉和桥血管（包括LIMA桥和大隐静脉桥）造影术。     

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。     

体外循环与非体外循环下冠脉旁路移植术后的血管桥通畅比较

目的：比较非体外循环下冠状动脉旁路移植术（OPCABG）与常规冠状动脉旁路移植术（CCABG）术后3-4年时血管桥的通畅率。方法：2003年1月-2004年12月间40例单独行冠状动脉旁路移植术（CABG）的患者资料回顾性地被分为OPCABG组和CCABG组。OPCABG组通过胸骨正中切口,在非体外循环心脏不停跳下完成CABG;CCABG组建立常规体外循环,心脏停搏下完成CABG。两组术前的一般情况无明显区别。利用多层螺旋CT（multislice spiral CT,MSCT）造影检查及CT图像后处理,研究两种术式各条血管桥的通畅情况。结果：CCABG及OPCABG组在左乳内动脉（LI MA）到前降支（LAD）的通畅率分别达到94.1%,94.4%,后降支（PDA）为88.2%,91.6%,钝缘支（包括对角支）的通畅率分别为88.9%,90.9%,静脉桥的通畅率为87.8%,88.0%,动脉桥的通畅率为85.7%,91.3%。各组间统计差别均无显著性。结论：OPCABG旁路血管桥的3-4年通畅率可以和CCABG相媲美.OPCAB治疗冠心病的初期结果显示可以减少术后并发症、减少患者术后呼吸机辅助时间和ICU留观时间、住院时间,降低住院费用,它的普及势在必然。     

64排螺旋CT评价冠状动脉旁路移植术后桥血管的效果

目的：探讨64排螺旋CT在冠状动脉桥血管的临床应用价值。方法：对42例冠状动脉旁路术后病人,共145条桥血管（其中内乳动脉46条,大隐静脉桥99条）,进行64排螺旋CT造影（CTA）。CT扫描时病人的平均心室率为（60±5）次／min。42例中20例桥血管血管吻合口冠状动脉狭窄（≥50％）或闭塞的病人及7例吻合口远端狭窄或闭塞的病人同时进行了冠状动脉造影（CAG）。结果：42例病人CTA均可评价。显示桥血管通畅125条．闭塞20条（其中内乳动脉5条,静脉桥15条）。CTA诊断冠状动脉桥血管狭窄（≥50％）或闭塞的准确性达100％。结论：CTA可以准确评价冠状动脉桥血管以及吻合口再狭窄的程度,桥血管近端吻合口的位置,可提示冠状动脉桥血管术后CAG的径路,是评价冠状动脉桥血管病变．创伤性小的首选方法。     

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.     

An update on internal mammary artery grafting for coronary artery disease

PURPOSE OF REVIEW: To describe recent results regarding the use of the internal mammary artery for coronary artery bypass grafting with emphasis on bilateral internal mammary artery grafting, patency, resistance to atherosclerosis, skeletonisation, composite arterial grafts, flow measurement, vasodilatation, and non-invasive imaging techniques. RECENT FINDINGS: Coronary artery bypass grafting plays an important part in coronary revascularisation and seems to be associated with a survival benefit in comparison with percutaneous coronary intervention. After 10 years, internal mammary arteries demonstrate better patency than vein grafts except when grafting moderately stenosed right coronary arteries. Bilateral internal mammary artery grafting increases survival further, but carries a higher risk of sternal complications. Skeletonisation may reduce this risk. The internal mammary arteries are used increasingly as composite arterial grafts and this technical solution should no longer be considered experimental. Perioperative flow measurement by the transit-time method is recommended while postoperative echocardiography represents an accurate method for evaluation of flow in internal mammary artery grafts. Multi-detector computed tomography allows for accurate assessment of all types of bypass conduits and native coronary arteries. At present, magnetic resonance imaging of internal mammary artery patency and flow is possible. SUMMARY: Newer studies confirm earlier data with respect to improved long-term survival when using internal mammary artery grafting, and this survival benefit is superior to percutaneous coronary intervention treatment. Bilateral internal mammary artery grafting improves survival further. Skeletonisation of the internal mammary artery provides extra length of grafts for complete arterial revascularisation. Non-invasive imaging techniques are increasingly sophisticated and may change the referral pattern for patients with coronary artery disease to either percutaneous coronary intervention or coronary artery bypass grafting.     

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。     

Hemodynamics and coronary blood flow during exercise after coronary artery bypass grafting with internal mammary arteries in children with Kawasaki disease

BACKGROUND. Saphenous vein grafts (SVG) and internal mammary artery (IMA) grafts have been used for coronary artery bypass grafting. In adult patients with bypass grafting for atherosclerotic coronary artery disease, IMA grafts have been reported to have long-term patency; however, results are conflicting on whether the graft is sufficient to meet increased myocardial oxygen demand during exercise. There have been no studies on hemodynamics and blood flow during exercise after bypass grafting with IMA in pediatric patients with Kawasaki disease. METHODS AND RESULTS. We studied 17 pediatric patients with Kawasaki disease (average age, 7.5 +/- 3.1 years), who underwent coronary artery bypass grafting with the IMA. The average number of coronary artery bypass grafts was 2.1 +/- 0.7/patient. For all patients, the left IMA was anastomosed to the left anterior descending coronary artery; for eight patients, the right IMA was also anastomosed to the right coronary artery. In addition, 11 SVGs were used. The postoperative patency rates after 1 month were 100% with the IMA graft and 91% with SVG. One year after the operation, the patency rates were 100% with IMA and 50% with SVG. Hemodynamics during exercise were measured with a bicycle ergometer, and coronary sinus blood flow was measured by the continuous thermodilution method in six patients. The relation between delta LVEDP (the difference between left ventricular end-diastolic pressure at rest and during exercise) and delta SVI (the difference between the stroke volume index at rest and during exercise) was analyzed. Four of six patients had reduced cardiac function before operation (delta LVEDP, positive; delta SVI, negative). However, after the operation, all patients demonstrated improvements in cardiac function during exercise (delta LVEDP, positive; delta SVI, positive). Coronary sinus flow per left ventricular mass increased after operation from 70 +/- 46 to 87 +/- 56 ml/min at rest (p less than 0.05) and from 139 +/- 118 to 183 +/- 150 ml/min during exercise (p less than 0.05). CONCLUSIONS. In conclusion, this study reveals improvements in both hemodynamics and coronary blood flow during exercise after coronary artery bypass grafting with IMA grafts in pediatric patients with Kawasaki disease.     

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.     

序贯桥终末端与细小靶冠状动脉侧侧和端侧吻合的疗效对比

目的:评估不停跳冠状动脉旁路移植术中,分别采用侧侧吻合与端侧吻合方式缝合大隐静脉序贯桥终末端与细小靶冠状动脉的疗效。方法:回顾性分析2012年10月至2013年4月,行不停跳冠状动脉旁路移植术且终末靶冠状动脉细小的患者共89例。其中37例患者使用侧侧吻合术,即采用侧侧吻合方法缝合大隐静脉序贯桥终末端与靶冠状动脉;52例患者使用端侧吻合术,即将大隐静脉序贯桥终末端与靶冠状动脉进行端侧吻合。术中监测桥血管流量及搏动指数,术后6个月复查超声心动图、心电图等指标,以评估手术疗效。术后1年行双源CT冠状动脉造影检查,观察终末桥血管的通畅情况。结果:两组术中终末桥血管流量分别为[(17.32±6.18)vs.(14.15±5.09)mL/min,P0.05],搏动指数分别为[(2.50±1.08)vs.(3.47±0.74),P0.05]。两组患者在围术期内均无低心排出量综合征(低心排)、恶性心律失常及心肌梗死等不良事件发生。术后6个月复查超声心动图,提示两组患者心功能均较术前改善,但两组之间差异无统计学意义(P0.05)。术后随访1年时侧侧吻合组患者均无心绞痛发作,端侧吻合组有9例患者再发心绞痛。双源CT冠状动脉造影提示:侧侧吻合组中终末桥血管均保持通畅,而端侧吻合组中8例患者的终末桥血管再狭窄(P0.05)。随访截至2014年1月底,平均随访时间为(10.7±2.5)个月,患者随访率为100%,存活率为100%。结论:采用侧侧吻合术缝合大隐静脉序贯桥终末端与细小靶冠状动脉,可改善终末桥血管的通畅性。     

Pedicled right internal mammary artery for reoperative off-pump revascularization of left anterior descending coronary artery

In situ right internal mammary artery is the graft of choice in reoperative off-pump coronary artery bypass grafting, as well as in primary on-pump coronary artery bypass grafting, unless the vessel has been used previously. However, there are not enough data about postoperative angiographic findings of the in situ right internal mammary artery in reoperative coronary artery bypass grafting with the off-pump technique. From September 1993 through January 2004, we reviewed the postoperative course and the graft patency of 12 selected patients who underwent off-pump coronary artery bypass grafting reoperation only for revascularization of the left anterior descending artery, by means of a pedicled right internal mammary artery graft. All patients were evaluated clinically and by postoperative coronary angiography. There were no early or late deaths during the mean follow-up period of 33.08 +/- 30.05 months (range, 1-77 months). The mean interval from the 1st operation to the 2nd operation was 74.1 +/- 57.01 months (range, 4.5-171 months). Postoperative coronary angiograms of all patients showed a 100% patency rate for both in situ grafts and composite grafts. We suggest that use of the in situ right internal mammary artery in off-pump coronary artery bypass grafting is a safe and reliable option for revascularizing the left anterior descending artery, especially in reoperation.     

术中即时桥血管流量测定在不停跳冠状动脉旁路移植术中的应用研究

目的:探讨术中即时血流测定(transit time flow measurement,TTFM)在不停跳冠状动脉旁路移植术中的应用价值。方法:2009年12月至2010年12月,对在北京安贞医院心外科行不停跳冠状动脉旁路移植术的427例患者,共计1 123支桥血管行术中即时血流测定,根据测定结果,定义满足以下3点标准中的2点者为桥血管失功能:1.搏动指数(PI)>5,2.左侧冠状动脉平均流量(mean graft flow,MGF)<10mL/min,右侧冠状动脉桥血管MGF<15mL/min,3.舒张期血流比例(diastolic flow,DF):左侧冠状动脉桥血管<50%,右侧冠状动脉桥血管<40%。对失功能的桥血管进行修正后再次测定血流量。结果:41例患者(41/427,9.6%)的47支桥血管(47/1 123,4.2%)诊断为失功能桥血管,修正的桥血管中13支为前降支桥血管,7支为对角支桥血管,15支为回旋支桥血管,11支为右侧冠状动脉桥血管。45支桥血管修正后流量满意,成功率为95.7%;2支桥血管修正后无明显改善。但术后6个月冠状动脉CTA检查示桥血管均通畅。结论:术中TTFM能便捷、有效地检测出由于吻合口狭窄导致的桥血管失功能,提高手术疗效,减少围术期不良心脏事件发生率。但对于冠状动脉远端血管床阻力较高的患者,其应用价值有待进一步观察。     

186例老年冠心病患者是、否体外循环下冠脉旁路移植术的比较

目的:比较老年冠心病患者体外循环与非体外循环下冠状动脉旁路移植术的疗效。方法:A组选择87例65岁以上的老年患者在体外循环下行冠状动脉旁路移植术(CCABG);B组选择79例65岁以上的老年患者在非体外循环下行冠状动脉旁路移植术(OPCABG)。结果:B组死亡率低于A组(P<0.05),术后胸腔引流量明显少于A组(P<0.05)。结论:老年冠心病患者行冠状动脉旁路移植术是安全的。