血管腔内支架植入术的临床应用

目的 评价应用血管内支架治疗血管性疾病的临床价值。方法 对36例患有血管性疾病的患者施行了血管内支架植入术，包括胸主动脉夹层动脉瘤24例，腹主动脉真性动脉瘤3例，腹主动脉夹层动脉瘤1例，颈动脉动静脉瘘1例，左锁骨下动脉狭窄1例，左锁骨下动静脉瘘1例，髂动脉假性动脉瘤4例及股动脉狭窄1例。除1例左锁骨下动脉狭窄患者、1例股动脉狭窄患者使用了裸支架外，其余34例患者均采用带膜支架进行血管内治疗。结果 术中所有患者均未出现特殊不适，术后随访期间未见明显合并症发生。所有患者均完全消除了临床症状。结论 应用血管内支架治疗血管性疾病是一种实用且效果较好的治疗方法。     

PTCA及冠状动脉内支架植入术病人的早期康复护理

目的 观察急性心肌梗死（AMI）冠状动脉内支架植入术病人早期康复护理的效果。方法 将68例AMI急诊行经皮腔内冠状动脉成形术（PTCA）及冠状动脉内支架植入术（无严重合并症）的病人随机分为康复组和对照组各34例，对照组在介入治疗后行常规护理，康复组在常规护理的基础上行早期康复护理。结果 康复组平均离床时间、住院天数较对照组缩短的（均P＜0．05）；便秘发生率低于对照组（P＜0．01）；出院前的生活自理能力评分显著高于对照组（P＜0．05）。结论 AMI急诊PTCA及冠状动脉内支架植入（无合并症）病人实行早期康复护理是安全的，有利于促进病人早期康复，提高生活质量。     

血管内支架在肿瘤所致下腔静脉梗阻中的应用

目的探讨恶性肿瘤所至下腔静脉梗阻植入金属支架治疗的临床价值。方法18例患者中,原发性肝癌6例,肝转移癌3例,胃癌2例,腹膜后肿物2例,肾癌3例,淋巴瘤1例,胰腺癌1例。均造成下腔静脉的完全或部分梗阻,梗阻段长度30~90 mm直径0~5 mm,采用经皮股静脉穿刺植入金属支架治疗。结果18例患者均一次手术成功,患者梗阻症状积分由4~5分降至术后0~2分两者差异显著。结论金属膨式支架可迅速缓解下腔静脉恶性梗阻患者的临床症状是有效的姑息性治疗手段,值得推广。     

中国血管腔内支架植入术治疗Stanford B型主动脉夹层：Meta分析

目的 本文荟萃分析了所有纳入的关于血管腔内支架植人术治疗Stanford B型主动脉夹层的中文文章,着重了解其手术成功率、并发症和预后等。方法按预定纳入排除标准,纳入血管腔内治疗Stanford B型主动脉夹层例数≥10的所有中文文章行Meta分析。结果共纳人37篇文章1527例患者。国内手术成功率为（99．2±0．4）％,总的并发症发生率为（18．0±1．2）％,主要并发症发生率为（1．6±0．2）％,神经系统并发症发生率为（0．6±0．3）％,其中截瘫发生率为（0．1±0．04）％。急性和慢性StanfordB型主动脉夹层相比,前者血管腔内支架植入术成功率明显降低[（96．3±0．7）％VS（100．0±0．0）％,P=0．0031,而总的并发症发生率和30d死亡率则没有统计学差异。结论血管腔内治疗Stanford B型主动脉夹层技术较可行,创伤小,手术成功率高,并发症发生率明显较传统手术低。腔内治疗急性期Stanford B型主动脉夹层,手术成功率较慢性期低,但预后相仿。     

血管内超声显像在诊断主动脉夹层动脉瘤中的应用

目的　评价血管内超声 (IVUS)显像在诊断主动脉夹层动脉瘤中的作用。　方法　选择血管外科收治的主动脉夹层动脉瘤患者 82例。评价IVUS在明确夹层真假腔、破口位置、末端部位、假腔内血栓、内脏动脉与真假腔的关系、内脏动脉的缺血原因和主动脉直径等方面的作用 ,并与CT、MRI、经胸超声 (TTE)、经食管超声 (TEE)、双功能超声 (Duplex)和动脉造影 (DSA)相对照。结果　通过IVUS发现的真假腔外侧壁的超声结构差异、真假腔外侧壁交界处的特征性改变和假腔内血栓可鉴别真假腔。IVUS可发现静态狭窄和动态狭窄等内脏动脉缺血的原因。IVUS对近端破口的检出率为 1 0 0 % ,高于CT(2 8% )、MRI(2 2 % )、TTE(2 % )和TEE(61 % ) (P <0 0 1 ) ;与DSA(88% )差异无显著性意义 (P >0 0 5)。IVUS对夹层末端的检出率为 1 0 0 % ,高于Duplex(2 1 % ) (P <0 0 1 ) ;与CT(89% )和MRI(86 % )差异无显著性意义 (P >0 0 5)。IVUS对内脏动脉的检出率为 98% ,高于CT(56 % )、MRI(57% )、Duplex(1 7% )和DSA(66 % ) (P <0 0 1 )。IVUS测得的主动脉直径与CT测量值的相关系数r=0 94(P <0 0 1 )。　结论　应用IVUS能够对主动脉夹层动脉瘤的全貌有比较全面的认识。在明确内脏动脉与真假腔的关系和内脏动脉的缺血原因方面 ,IVUS优     

动脉内支架植入术在移植肾动脉狭窄治疗中的应用

移植肾动脉狭窄(TRAS)是肾移植术后常见的外科并发症之一，动脉内支架植入术(PTRAS)可以有效地对移植肾动脉狭窄进行治疗。我院采用PTRAS先后对14例移植肾动脉狭窄患者进行治疗，疗效颇佳。有关资料报道如下：     

中等程度冠状动脉狭窄的血管内超声特点与治疗决策选择

目的　应用血管内超声 (IVUS)观察冠状动脉造影中等程度冠状动脉狭窄的血管内超声特点 ,选择治疗决策。方法　应用血管内超声仪检查 3 8例血管造影狭窄程度 40 %～ 60 %患者的 43处冠状动脉病变 ;测量管腔以及血管直径和面积。结果　 43处病变中 ,脂质斑块为 3 0处 ,纤维、钙化、混合斑块分别为 4、2、5处 ,2处未发现明显病变或仅轻度内膜增生 ;其中 4处可见明显血栓影。 41处粥样硬化斑块中偏心斑块 3 6处 ( 87.8% ) ,向心斑块 5处 ( 12 .2 % )。 3 0处脂质斑块大部分可见薄的纤维帽 ,其中 5处 ( 16.7% )明显的纤维帽不完整。病变血管直径狭窄百分比 ( 4 0 .73± 13 .2 1) % ;面积狭窄百分比 ( 5 6.75± 12 .68) %。对IVUS示面积狭窄 >5 0 %的 2 5处、<5 0 %的 1处 ( 60 .5 % )且有典型临床症状的病变行进一步介入治疗 ,对IVUS示面积狭窄 <5 0 %的 17处 ( 3 9.5 % )病变未行进一步介入治疗。结论　IVUS可进一步明确血管造影中等程度冠状动脉病变的性质、严重性和稳定性 ,指导进一步的治疗     

冠心病患者冠状动脉造影与肠系膜上动脉超声多普勒血流显像的相关性研究

目的提高对冠心病患者并发肠缺血的认识,完善冠心病防治规则。方法选择经临床和数字减影血管造影（DSA）检查确诊的47例老年冠心病患者（观察组）与28例中青年冠心病患者（对照组）的肠系膜上动脉彩色多普勒血流显像结果进行对比,分析年龄与肠系膜上动脉之间以及冠状动脉病变程度与肠系膜上动脉病变之间的关系。结果观察组47例中29例（61.7％）发现肠系膜上动脉病变,对照组28例中有7例（25.0％）,两组比较差异有统计学意义（P〈0.05）。观察组冠状动脉多支血管病变27例（57.4％）,对照组有8例（28.6％）,两组比较差异有统计学意义（P〈0.05）。冠状动脉多支血管病变35例,合并肠系膜上动脉病变31例（88.6％）;单支血管病变40例,合并肠系膜上动脉病变5例（12.5％）（P〈0.05）。结论冠心病患者的年龄越大,肠系膜上动脉患病概率越大;冠状动脉病变程度越重,肠系膜上动脉病变程度越高。     

Metal stent placement for two patients with post-transplantation renal artery stenosis,using intravascular ultrasound imaging

Post-transplantation renal artery stenosis is recognized at relatively early periods after renal transplantation. We report herein our experience of utilizing transluminal expanded metal stents (Palmaz stent and Wall stent) for post-transplantation renal artery stenosis, and monitoring with intravascular ultrasound (IVUS) imaging. The recipients were a 51-year-old woman (case 1) and a 57-year-old man (case 2), and the grafts were procured from cadaveric donors. Renal function had deteriorated suddenly at 5 months after renal transplantation in case 1 and at 86 months in case 2. The cause of the graft dysfunction was renal arterial stenosis. Color doppler ultrasound imaging and angiography diagnosed post-transplantation renal artery stenosis. The renal artery stenosis was serious, being greater than 90% in both patients. Percutaneous transluminal angioplasty (PTA) was performed, but its effectiveness was not sufficient; therefore, an indwelling endoluminal metallic Palmaz stent and an indwelling Wall stent were placed at the sites of stenosis while monitoring was done with IVUS. No complications were recognized at all. The length and degree of stenosis location became clear by using IVUS, and suitable stents could be selected for the renal artery stenosis. The clinical effect was excellent; the renal function improved to the pre-hospitalization value. We conclude that the Palmaz stent and the Wall stent were useful as a noninvasive strategy for treating post-transplantation renal artery stenosis. This procedure could be performed safely and surely using IVUS.     

经桡动脉和股动脉行冠状动脉造影 和支架植入术的对比分析

目的探讨经桡动脉和股动脉行冠状动脉介入的优缺点。方法回顾分析2004年6月到2005年6月在我院接受冠状动脉造影术和支架植入术的患者235例。按股动脉途径(125例)或桡动脉途径(110例)分为两组。比较两组造影使用的导管数、动脉穿刺成功率、X线照射时间,支架植入的手术操作时间、成功率、并发症发生率。结果①冠状动脉造影:经桡动脉、股动脉行冠状动脉造影血管穿刺成功率分别为94.5%、100%(P<0.05);X线照射时间分别为(3.35±1.25)min和(2.72±0.58)min(P<0.05);造影成功率分别为93.6%、100%(P<0.05)。②PTCA或支架植入:经桡动脉、股动脉植入单个支架的手术操作时间分别为(21.43±6.21)min、(15.24±4.15)min(P<0.05);成功率分别为92.7%、97.6%(P>0.05);血管并发症发生率分别为2.7%、11.2%(P<0.01)。结论①经桡动脉行冠状动脉造影及支架植入术不需卧床、损伤小、止血方便、血管并发症少,为其优点。②经桡动脉行冠状动脉介入要求术者有较高的技术水平,血管穿刺失败和桡动脉痉挛是影响造影和支架植入成功的重要原因,且推送导管过程中需持续透视,增加了术者和患者X线照射时间。③无论从桡动脉入路还是从股动脉入路都以手术成功为最终目的,选择何种路径当根据患者的具体情况确定。     

冠状动脉病变程度与冠心病危险因素的相关分析

目的探讨冠心病患者冠状动脉病变的严重程度与冠心病危险因素的关系。方法选择冠心病患者116例为冠心病组,选择冠状动脉样硬化狭窄程度〈50%的患者66例为对照组。分析冠状动脉狭窄程度与冠心病危险因素的关系。结果多因素分析结果显示,LVEF、Ccr与冠状动脉粥样硬化程度呈负相关,而hs-CRP与冠状动脉粥样硬化程度呈正相关（P〈0.05或P〈0.01）。结论冠状动脉狭窄程度与LVEF、Ccr呈负相关,与hs-CRP呈正相关。     

Screening for coronary artery disease in early surgical treatment of acute aortic valve infective endocarditis

OBJECTIVESIn patients with unknown coronary status undergoing surgery for acute infective endocarditis (IE), the need to screen for coronary artery disease (CAD) and the risk of embolization during invasive coronary angiography (ICA) are debated. Coronary computed tomography angiography (CCTA) is a non-invasive alternative in these patients. We aimed to evaluate the safety and feasibility of ICA and CCTA to diagnose CAD, and the necessity to treat CAD to prevent CAD-related postoperative complications. Open in a separate windowMETHODSIn this single-centre retrospective cohort study, all patients with acute aortic IE between 2009 and 2019 undergoing surgery were selected. Outcomes were any clinically evident embolization after preoperative ICA, in-hospital mortality, perioperative myocardial infarction or unplanned revascularization and postoperative renal function.RESULTSOf the 159 included patients, CAD status was already known in 14. No preoperative diagnostics for CAD was done in 46/145, a CCTA was performed in 54/145 patients and an ICA in 52/145 patients. Significant CAD was found after CCTA in 22% and after ICA in 21% of patients. In 1 of the 52 (2%) patients undergoing preoperative ICA, a cerebral embolism occurred. The rate of perioperative myocardial infarction or unplanned revascularization in patients not screened for CAD was 2% (1 out of 46 patients).CONCLUSIONSAlthough the risk of embolism after preoperative ICA is low, it should be carefully weighed against the estimated risk of CAD-related perioperative complications. CCTA can serve as a gatekeeper for ICA in most patients with acute aortic IE.     

Coronary endarterectomy for diffuse extensive coronary artery disease

Introduction Atherosclerotic coronary artery disease is in an increasing trend in India. With the advancement of non-surgical methods of revascularisation, the patients coming for surgery are of less attractive anatomy. The role of coronary endarterectomy along with coronary artery bypass grafting for a selected group of these patients is quite promising. Materials and Methods From March 2000 to March 2005, out of 362 CABGs performed, 42 patients had undergone coronary endarterectomy. The age range being from 35 to 76 years, M: F is 38∶4 Hypertension was present in 26 (61%), diabetes mellitus in 20 (47.6%), smoking in 26 (61%) and dyslipidemia in 12 (28.5%) cases. Old myocardial infarction was present in 52.3% cases, unstable angina in 16.6%, stable angina in 23.8% and cardiogenic shock in 7.1% cases. All cases had undergone coronary artery bypass grafting with endarterectomy. Out of 18 LAD endarterectomies 17 cases LIMA was used as onlay patch. Result The average number of grafts anastomosed was 3.7. Single-vessel endarterectomy was done in 37, double vessel in 4 and four vessel in one case. LAD endarterectomy was done in 18, RCA in 12, diagonal in 10, intermediate in 1 and marginals in 8 cases. Postoperatively 3 patients had arrhythmia, two perioperative MI, one recurrent angina and one congestive cardiac failure (CCF). There was 2 (4.76%) mortality. Conclusion Hypertension and smoking are major risk factors. LAD is the most common artery requiring endarterectomy. Usage of LIMA following endarterectomy of LAD is quite satisfactory and short term results are encouraging.     

非体外循环冠状动脉旁路移植术治疗重症冠状动脉粥样硬化性心脏病

目的探讨非体外循环冠状动脉旁路移植术治疗重症冠状动脉粥样硬化性心脏病(冠心病)的可行性. 方法回顾分析2002年1月～12月37例重症冠心病的临床资料.均采用全麻,胸骨正中切口,游离左乳内动脉及大隐静脉.心脏稳定器局部固定心肌,显露目标冠状动脉,切开后置入冠状动脉内血液分流器.一般先做左乳内动脉与左冠状动脉前降支的吻合,其余血管桥先做桥血管与主动脉的近心端吻合,然后再做桥血管与冠状动脉的吻合. 结果全组病例均在非体外循环下完成手术,搭桥1～6支,(3.2±0.5)支.术后10 d死亡1例,其余36例未发生围术期心肌梗死,无呼吸功能不全、肾功能不全、脑血管意外等严重并发症. 结论在成熟的手术技术和严格的围手术期管理的条件下,非体外循环冠状动脉旁路移植术治疗重症冠心病可行.     

冠状动脉内膜剥脱联合旁路移植治疗弥漫性冠状动脉狭窄病变的近中期效果

目的探讨冠状动脉内膜剥脱术(CE)联合冠状动脉旁路移植术(CABG)治疗弥漫性冠状动脉狭窄病变的近中期效果。方法回顾性分析2010年1月至2019年1月在南京市第一医院心胸血管外科接受CE+CABG的248例弥漫性冠状动脉狭窄病变患者的临床资料。男性201例,女性47例;年龄(65.6±8.5)岁(范围:43~79岁)。体外循环手术156例,非体外循环手术92例。共对269根病变血管完成CE,包括前降支108根,右冠状动脉140根,钝缘支21根。共完成旁路移植872支,包括左胸廓内动脉248支,桡动脉48支,大隐静脉576支,每例患者移植(3.5±0.8)支(范围:2~6支)。CE后平均血流量为(26±8)ml/min(范围:13~59 ml/min),血流指数为3.1±0.8(范围:2.0~6.7)。采用t检验或χ²检验比较体外循环和非体外循环患者的手术结果及术后通畅率。结果全组围手术期病死率为1.2%(3/248),2例死于肾功能衰竭,1例死于术后顽固性低心排血量。9例发生围手术期心肌梗死。随访(41.8±21.4)个月(范围:1~68个月)。旁路血管术后1年通畅率为78.4%(182/232),3年通畅率为69.8%(162/232)。左冠状动脉系统通畅率明显高于右冠状动脉系统(1年:87.4%比73.1%,χ²=6.533,P=0.011;3年:78.2%比64.8%,χ²=4.588,P=0.032)。体外循环组和非体外循环组旁路血管通畅率无差异(1年:80.0%比76.9%,χ²=0.277,P=0.599;3年:71.5%比67.9%,χ²=0.300,P=0.584)。结论CE+CABG治疗弥漫性冠状动脉狭窄病变可以获得较满意的完全再血管化,有较好的早、中期效果和旁路血管通畅率。体外循环和非体外循环手术具有相似的早中期结果。     

合并甲状腺功能低下病人的冠状动脉旁路移植术

目的 探讨冠心病(CAD)合并甲状腺功能低下(甲低)病人的冠状动脉旁路移植术(CABG)围术期外科处理的临床效果.方法 2002年9月至2009年6月,1347例CABG中21例(A组)合并甲低需要甲状腺激素替代治疗,男6例,女15例;平均(60.4±14.2)岁.体外循环下手术4例(包括心脏停跳手术1例),非体外循环下CABG 17例.术前均口服左旋甲状腺素,FT3、FT4、TSH、TT3、TT4明显改善后手术.同期对照20例甲状腺功能正常CABG者(B组),其中4例体外循环下CABG.观察两组术前、术中、术后甲状腺功能指标以及近端吻合时血流动力学指标.结果 围术期应用放射免疫法甲状腺激素水平检测,非体外循环下手术者,A组17例FT3术前及术中水平为[(1.39±0.36)pg/ml对(1.29±0.32)pg/ml]、B组16例为[(2.28±0.36)pg/ml对(2.19±0.34)pg/ml];体外循环下手术者,A组4例FT3术前及术中水平为[(1.53±0.51)pg/ml对(0.85±0.40)pg/ml]、B组4例为[(2.08±0.24)pg/ml对(1.96±0.26)pg/ml].A、B两组术中心排指数[(2.7±1.4)L·min-1·m-2对(2.8±1.5)L·min-1·m-2,P=0.53].A组1例重度甲低病人体外循环下心脏停跳手术后因心脏复跳困难死亡,20例生存者均为心脏不停跳方式手术者,其中17例为非体外循环手术,术后随访2～30个月均有心功能改善,射血分数(EF)由术前0.48±0.17增加至术后0.55±0.21.B组均生存.两组间术中血流动力学、手术预后、住院时间[(12.2±4.7)天对(10.1±3.9)天]、呼吸机辅助[(17.6±9.1)h对(15.1±13.7)h],差异无统计学意义.结论 冠心病合并甲低病人,术前准备充分,采用心脏不停跳手术方式较安全,非体外循环下手术对病人FT3激素水平影响较小;围术期甲状腺素治疗是关键;重度甲低病人体外循环下手术风险大.     

机器人非体外循环冠状动脉旁路移植与支架置入"杂交"手术治疗多支冠状动脉病变

目的 总结达芬奇S机器人系统行非体外循环冠状动脉旁路移植与支架置入"杂交"手术治疗多支冠状动脉病变的技术特点和优势.方法 2007年至2011年,使用da Vinic S全机器人系统完成非体外循环冠状动脉旁路移植术163例,其中12例患者因两支或三支冠状动脉病变,在机器人手术后行分站式支架置入术.男9例,女3例;年龄(56.0±9.7)岁;均有心绞痛症状,冠状动脉造影显示严重的前降支或对角支病变,合并回旋支或右冠状动脉的病变;4例有心肌梗死病史.先对所有患者前降支病变行机器人非体外循环下冠状动脉旁路移植术,术后待患者恢复平稳再行其他病变冠状动脉支架置入术.冠状动脉造影评价在再血管化效果.结果 所有患者均成功接受机器人非体外循环冠状动脉旁路移植术,术后恢复顺利,随后成功接受支架置入术.全组无并发症.结论 机器人非体外循环冠状动脉旁路移植和支架置入"杂交"手术可最大限度的减小手术创伤并实现冠状动脉完全再血管化.

Abstract：

Objective Summary the first group of robotic bypass surgery on the beating heart and stent placement in distinct hybrid session in China. Methods 163 cases patients accepted selective operation of robotic coronary bypass grafting on the beating heart form April 2007 to January 2011. 12 cases had multi coronary vessels stenosis accepted stent placement after robotic surgery in a hybrid manner. The average age of patients was ( 56. 0 ± 9.74 ) years old. 3 case was female and 9 cases were male. All the patients had a medical history of angina. The coronary arterioangiography showed sever left anterior descend ing or diagonal branch stenosis in all patients. And 4 cases had myocardial infarction history. All the patients had good lung function and had no medical history of pleurisy. Without sternotomy, through 3 ports about 1 cm in left thorax, the left internal mammary artery was obtained and simultaneously single vessel coronary artery bypass grafting through small thoracotomy or totally endoscopic coronary bypass (TECAB) was performed on beating heart. The bridge patency and revascularization was accessed by arterioangiography. Results All cases successfully accepted robotic bypass surgery on the beating heart and stent placement in distinct hybrid session without complication. Conclusion Hybrid coronary artery revascularization enable adequate revascularization of patients with multivessel coronary artery disease without sternotomy and with the advantage of the most durable option.