非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植术125例

目的总结非体外循环下采用双侧乳内动脉Y型桥进行完全心肌血运重建的冠状动脉旁路移植手术125例的近期疗效。方法2002年10月至2005年12月,完成125例不停跳非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植手术,术中采用带蒂半骨骼化的方法分别取材左、右侧的乳内动脉,将左、右乳内动脉端侧吻合成Y型桥;在非体外循环下,应用序贯吻合的方法进行冠状动脉搭桥手术。结果全组125例患者共搭桥413支,平均搭桥支数3．3支／例。术中流量测定桥血管均通畅。全组患者无围手术期死亡。结论非体外循环下双乳内动脉Y型桥的冠状动脉旁路移植手术是安全、有效的方法,可以实现全动脉化的完全心肌血运重建,又避免手术中对升主动脉的操作,近期效果满意。     

左侧乳内动脉Y型桥OPCAB40例近期疗效观察

目的总结非体外循环下左侧乳内动脉及桡动脉Y型桥的冠状动脉旁路移植术的疗效及安全性。方法2005年1月至2008年10月,40例冠状动脉粥样硬化性心脏病患者,采用左侧乳内动脉及桡动脉作为移植物。术中采用带蒂半骨骼化的方法分别取材左侧的乳内动脉和桡动脉,端侧吻合成Y型桥,在非体外循环下,应用序贯吻合的方法进行非体外循环下冠状动脉旁路移植术。利用Medi—stim Butterfly流量计进行桥血管流量测定,并记录血流量及搏动指数。结果全组40例共行冠状动脉旁路血管移植109支,平均2．7支／例。桥血管流量测定均通畅,左乳内动脉干流量为（33±6）ml／min,搏动指数为2．2±0．5,桡动脉流量为（41±11）ml／min,搏动指数为1．9±0．6。40例中,术后3例诉手背桡侧感觉异常、麻木,围术期心肌。梗死1例,胸腔积液2例,肺部感染1例,术中室颤1例,无脑部并发症,无胸骨、纵隔感染。随访1—38个月（平均11个月）无死亡病例。结论非体外循环下仅用左侧乳内动脉及桡动脉Y型桥的冠状动脉旁路移植术是安全、有效的,可以实现全动脉化的完全心肌血运重建目的,又避免手术中对升主动脉的操作,近期效果满意。适应于升主动脉有钙化、乳内动脉正常且粗大（〉2mm）的左主干或类似左主干病变,手术近期效果满意。     

双侧乳内动脉π型桥全动脉化冠状动脉旁路移植术

目的　研究 π型桥全动脉化心肌血运重建的临床应用。　方法　 1994年 9月到 2 0 0 2年 8月对 2 2例患者根据冠状动脉病变解剖特点选用π型桥进行全动脉化心肌血运重建 ,即 3支血管病变合并对角支 /中间支中段病变时 ,采用由左侧乳内动脉小 Y型桥与前降支和对角支 /中间支吻合 ,与双侧乳内动脉 T型桥共同构成 π型桥。　结果本组无围术期死亡 ,无心肌梗死、脑血管意外和胸骨感染发生 ;1例患者术后二次开胸止血。随访 6 0 .7± 2 3.0个月 ,无心绞痛复发需要冠脉介入治疗或手术治疗者 ,也无冠心病导致的死亡发生。　结论　对 3支血管病变合并对角支 /中间支中段冠脉病变的患者 ,双侧乳内动脉 π型桥可以顺利完成全动脉化心肌血运重建 ,中期效果良好。     

非体外循环冠状动脉搭桥术的技术改进──先吻合桥血管近端的“顺行序贯式”吻合术

目的探讨先吻合桥血管近端的“顺行序贳式”吻合技术住非体外循环心脏不停跳冠状动脉旁路移植术（off-pump coronary artery bypass grafting,OPCABG）中应用的临床意义和价值。方法56例患者行OPCABG术中采用先吻合桥血管近端的“顺行序贯式”吻合术：先行带蒂左乳内动脉与左前降支吻合;若使用游离桥血管则先与升主动脉吻合,再与左前降支吻合。然后用大隐静脉或桡动脉进行“序贯式”吻合搭桥。结果与左前降支吻合的桥血管：带蒂左乳内动脉49支,游离左乳内动脉1支,桡动脉4支,大隐静脉2支。采用大隐静脉进行“序贯式”吻合：4个吻合口（包括近端吻合口）32例,3个吻合口15例。桡动脉进行“序贯式”吻合：4个吻合口2例,3个吻合口7冽。大隐静脉-右冠状动脉单桥5支。总搭桥207支,平均3．7支／例。术后心绞痛症状全部缓解,无围术期急性心肌梗塞。54例随访2～70个月,无新发心绞痛,无死亡病例。结论应用先吻合桥血管近端的“顺行序贯式”吻合技术,可使OPCABG更简便、安全、有效,更有益于多支病变患者,尤其是急危重症的冠心病患者。     

桡动脉在全动脉化冠脉搭桥术中的临床应用

目的探讨桡动脉在全动脉化冠脉搭桥术中的临床应用效果。方法22例患者采用乳内动脉和桡动脉行全动脉化冠脉搭桥手术，“不接触血管技术”游离桡动脉，与冠状动脉对角支、钝缘支、前降支、右冠状动脉等单独或序贯吻合，共搭桥31支。术后应用钙通道阻滞剂防止桡动脉痉挛。结果22例手术均顺利完成，痊愈出院，无围术期心肌梗塞，术后心肌缺血改善，无手部缺血并发症。随访2月～3年，无心绞痛复发，手部功能正常。结论桡动脉作为血管桥材料在全动脉化冠脉搭桥术中应用效果良好。     

高危患者主动脉内球囊反搏辅助下不停跳冠脉搭桥体会

目的探讨严重冠状动脉三支血管病变（狭窄〉75％）的高危患者在主动脉内球囊反搏（IABP）辅助下行非体外循环下冠脉搭桥术的安全性。方法回顾2002年1月至2007年12月间27例高危冠心病患者，在IABP支持下行非体外循环下冠脉搭桥术临床资料。结果本组患者冠状动脉造影均提示严重三支血管病变，15例合并左主干病变（狭窄〉75％），均属高危（EuroSeore〉6分），无术中死亡、术后死亡1例，搭桥2～7支、平均（3．2±1．1）支。结论对于冠脉严重三支血管病变高危病例，在预先置入IABP的辅助下可以安全地施行非体外循环下的冠脉搭桥术。     

大隐静脉顺行序贯式吻合技术在冠状动脉旁路移植术中的应用

目的总结冠状动脉粥样硬化性心脏病患者在非体外循环下应用大隐静脉顺行序贯式吻合技术行冠状动脉旁路移植术的治疗效果。方法 2013年1月至2015年6月,连续116例冠状动脉粥样硬化性心脏病患者在我院非体外循环下行顺行序贯式冠状动脉旁路移植术,其中男63例,女53例,平均年龄42~80(64.26±9.67)岁。采用左乳内动脉搭桥左前降支,其余各支靶血管以大隐静脉行顺行序贯式搭桥,首先吻合大隐静脉与升主动脉近端,再顺行序贯吻合对角支、回旋支、钝缘支、左室后支、后降支。结果全组患者无死亡,无围术期心肌梗死。桥血管吻合数目共436个,平均(3.75±0.53)个/例。术后低心排血量综合征3例,经给予血管活性药物联合应用主动脉内球囊反搏(IABP)治疗后痊愈。迟发性心脏压塞1例,急性肾功能衰竭1例,均治愈,患者心绞痛症状均消失,活动量明显增加而无明显不适。结论冠状动脉粥样硬化性心脏病在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术,可减少主动脉吻合口,节约桥血管长度,缩短手术时间,并可最快恢复心脏供血,是一种安全、有效的冠状动脉手术技术。     

完全性冠状动脉血管重建

作者应用大隐静脉以序贯式搭桥术对２５例冠心病患者行完全性冠状动脉血运重建。患者均为三支血管病变，左心室射血分数为２２％～６０％，左室舒张末压为１．３～４．０ｋＰａ。接受２～５支桥，人均搭桥３．６支。无围术期心肌梗塞及手术死亡，术后恢复顺利，心绞痛症状明显改善。作者对序贯式搭桥的技术特点及优点进行了讨论。     

完全性冠状动脉血运重建

作者应用大隐静脉以序贯式搭桥术对２５例冠心病患者行完全性冠状动脉血运重建。患者均为三支血管病变，左心室射血分数为２２％～６０％，左室舒张未压为１．３～４．０ｋＰａ。接受２～５支桥，人均搭桥３．６支。无围术期心肌梗塞及手术死亡，术后恢复顺利，心绞痛症状明显改善。作者对序贯式搭桥的技术特点及优点进行了讨论。     

不停跳下冠状动脉旁路移植加左心室室壁瘤闭式成形术46例

目的总结46例不停跳下冠状动脉旁路移植（冠脉搭桥）加左心室室壁瘤闭式成形术的手术经验。方法在非体外循环及不停跳下以1．0～1．5mg／kg体重肝素抗凝。明确室壁瘤基底位置及其长度以2-0Surgipro843缝线平行左心室长轴加毡片行间断褥式缝合，使瘤腔与左心室功能心腔隔离。45例同期行冠脉搭桥术。结果27例搭桥3根，12例搭桥2根，6例搭桥1根。39例应用左乳内动脉吻合于前降支，3例于转机不停跳下完成手术，2例行前降支内膜剥脱术，2例应用IABP。全组死亡1例。余者无术后心梗发生，10—14d治愈出院。结论不停跳下冠脉搭桥加左心室室壁瘤闭式成形术可有效消除左心室矛盾运动及无效心腔，加固薄弱心室壁，防止心脏破裂；减少恶性心律失常发生；避免体外循环并发症。     

Haemangioblastoma with multiple dural arterial supply

Summary A case of primary haemangioblastoma with a marked blood supply from multiple meningeal branches of the internal and external carotid arteries is reported, and the clinical implication of detailed angiographic study of unusual feeders in this highly vascular tumour is discussed.     

MYCOTIC CERVICAL CAROTID ANEURYSM

Mycotic aneurysms of the extracranial carotid arteries are rare. with only 27 cases reported in the English literature.¹ The causative organism is most frequently Staphylococus but infections due to Streptococcus, Salmonella and Klebsiella have been reported.²Escherichia coli has been reported as the causative organism in three cases. Mycotic aneurysms usually present in the setting of generalized sepsis such as postoperative infection, septicaemia. dental sepsis, drug addiction or bacterial endocarditis. We report a patient who presented with a mycotic aneurysm of the internal carotid artery 2 months after undergoing a laparotoiny for perineal sepsis.     

Accessory left hepatic artery arising from common hepatic artery

The knowledge of anatomical variations in hepatic artery are of importance to surgeons and radiologists while performing complicated procedures like liver transplantation and transarterial chemo-embolization for hepatic tumors. The incidence of accessory left hepatic artery is less common than the right accessory hepatic artery. Here we report an anomalous accessory left hepatic artery arising from common hepatic artery in a 55 year old male cadaver.     

暂时性体外胫后动脉旁路术的解剖学研究

目的 为暂时性体外胫后动脉旁路术提供解剖学依据.方法 对5例成人尸体10侧下肢标本的胫后动脉、胫前动脉、腓动脉及其分支进行解剖学观测.结果 本组研究未发现胫后动脉缺如,全长(291±31)mum,显露部下端外径(2.8±0.5) mm.胫后动脉在小腿内侧发出穿支皮动脉存在率100％,平均发出(4±2)支,动脉外径(1.5±0.5) mm,发自中上1/3的穿支皮动脉长度最长(6.5±3.5) cm.结论 胫后动脉及小腿内侧穿支皮动脉在小腿走行恒定,变异率小,管径粗大,易于操作,供区影响小,是暂时性体外胫后动脉旁路手术的理想选择.     

Pulmonary artery diameter: means and normal limits—assessment by computed tomography angiography

Open in a separate window OBJECTIVESNormal pulmonary artery (PA) diameter remains blurred and the definitions of PA aneurysm are heterogenous. We aimed to assess PA diameters, identify a threshold for normal diameters, define PA aneurysms, possible predictors of PA size and evaluate the correlation with mid-ascending aortic diameters.METHODSBetween April 2018 and August 2019, 497 consecutive patients who underwent whole-body computed tomographic angiography were reviewed. Clinical and imaging data were collected from our institutional database. Precise three-dimensional centreline measurements were taken. Linear regression analysis was performed to detect parameters associated with PA diameter. A two-stage model was created to identify potential predictors and the resulting statistically significant interactions were tested. Data were grouped and PA, standard deviation, and upper normal limits were calculated.RESULTSAmong 497 patients with an average age of 51.4 (20.2) (74.6% males), the mean PA diameter measured 32.0 (4.6) mm [female: 31.2 (4.7) mm vs male: 32.2 (4.5) mm; P = 0.032]. The mean PA length, left PA and right PA diameters were similar between male and female patients. We found a significant correlation (r = 0.352; P < 0.001) between the PAs and mid-ascending aortic diameters. Body surface area (P = 0.032, β =  4.52 [0.40; 8.64] 95% CI) was the only significant influencing variable for PA diameter.CONCLUSIONSThe normal mean PA diameter in a reference cohort is 32.0 (4.6) mm. Body surface area is the only influencing variable of PA diameter. The normal diameters measured and corresponding upper limits of normal revealed that a PA aneurysm should not be considered below a threshold of 45 mm.     

锁骨下动脉、腋动脉、肱动脉血管广泛血栓形成1例

1病例资料患者,男,44岁。右上肢肿胀刺痛1个月加重伴手指麻木发凉5d,于2007年12月13日18：00急诊入院。患者自述于1个月前出现右侧手指指尖麻木,近5d右上肢麻木、胀痛明显加重,自测不到脉搏,右上肢皮肤苍白,皮温低,呈持续性,伴胸闷、气短、大汗。心电图：窦性心率（正常心电图）;右上肢血管超声：右侧锁骨下动脉下段、腋动脉、肱动脉血管闭塞（完全性血栓形成）;血压16／10kPa;血糖正常。以“左上肢动脉栓塞”收住入院。患者既往有小儿麻痹症病史,右下肢发育短小、无力,长期扶双拐行走;常伴有右上肢苍白,皮肤发凉,肱动脉、桡动脉、尺动脉脉搏测不到。     

Successful surgical management for aneurysms of single coronary artery with a fistulous connection to the right ventricle

While a coronary artery fistula with aneurysmal formation is rare, a fistula/aneurysm combination occurring in single coronary artery is even rarer. Here, we report the successful surgical correction of a right ventricular fistula with a large aneurysm of 30 mm and a daughter aneurysm within a case of single coronary artery.     

Safe evolution towards routine off-pump coronary artery bypass: negotiating the learning curve

Objective: Off-pump coronary artery bypass (OPCAB) hopes to avoid morbidity associated with cardiopulmonary bypass, improving clinical outcomes. Yet its technical difficulty and unfamiliarity raise concern that adoption of OPCAB might be associated with poorer outcomes during each surgeon's ‘learning curve’. We examined trends in patient selection over time as a single surgeon's practice evolved to routine OPCAB. Methods: Between 10-1-96 and 12-31-01, 1479 consecutive patients had isolated coronary artery bypass grafting (CABG). Clinical data were gathered prospectively and reviewed retrospectively. Trends in adoption of OPCAB and clinical outcomes were examined. Results: There were 756 OPCAB and 723 CABG/cardiopulmonary bypass patients. The practice evolved from 90% conventional CABG to 93% OPCAB. An abrupt transition coincided with evolution of techniques to expose the obtuse marginal arteries, and improvements in suction-based coronary stabilizers. Mortality was 1.0% for the off-pump group and 2.1% for the on-pump group. Careful patient selection helped maintain acceptable outcomes during the ‘learning curve’. Patients with depressed left ventricular ejection fraction, left main disease, and complex three vessel disease were excluded from OPCAB until significant experience (>200 cases) was attained. Presently, all isolated coronary bypass cases are candidates for OPCAB except patients with ischemic ventricular arrhythmias, those in cardiac arrest, and those for whom previous left pneumonectomy or deep pectus excavatum prevent rightward mobilization of heart. Conclusions: Despite a significant learning curve, evolution to routine OPCAB can be achieved while maintaining good patient outcomes. The development of specialized techniques, coronary stabilizers, and apical suction devices allows the application of OPCAB to virtually all coronary bypass patients, as surgeon experience matures.     

Minimally Invasive Multiple Coronary Artery Bypass Grafting with Composite Graft Using in situ Right Gastroepiploic and Radial Arteries

Minimally invasive surgery/coronary artery bypass grafting (MICS CABG) via left thoracotomy and multiple CABG is a reported alternative to the standard sternotomy approach. However, harvesting the right internal thoracic artery (RITA) under direct vision requires high surgical skill. We describe MICS CABG with the left internal thoracic artery (LITA) and a composite graft using the in situ right gastroepiploic artery (GEA) and radial artery (RA) to achieve complete coronary revascularization. No complications occurred, and postoperative computed tomography showed patency of all grafts. Our experience suggests that this composite graft can be used safely and effectively in MICS CABG for complete arterial revascularization without difficulty.