Angiographic interpretation and surgical management of right coronary artery obstructions.

We have found that even high quality arteriography and multiple projections may not clearly delineate the total extent of disease in a severely obstructed right coronary artery. Selection of the anastomotic site is more often based upon the operative findings. Totally obstructed vessels can be more aggressively explored and opened, because failure of adequate graft reconstruction does not result in significant infarction. Once a subtotally obstructed right coronary artery has been opened, the surgeon must achieve a patent anastomosis in order to avoid acute, possibility lethal diaphragmatic infarction. With careful isolation of the bifurcation and its primary branches, the majority of even heavily calcified vessels can be grafted without endarterectomy. If a totally obstructed and poor quality right coronary artery is well filled by collaterals from the left, it may not be necessary to bypass the right coronary artery when successful grafting of the left anterior descending or circumflex branches or both has been accomplished. Although the right coronary artery is frequently more diffusely diseased than the left coronary branches, with careful selection of the anastomotic site and attention to surgical detail, the vast majority of these arteries can be successfully bypassed.     

肝动脉-腹主动脉架桥重建移植肝肝动脉74例报告

探讨原位肝移植术中采用肝动脉-腹主动脉架桥重建移植肝肝动脉的疗效.方法 回顾分析2003年10月至2009年8月在中山大学附属第三医院肝移植中心行肝动脉-腹主动脉架桥重建移植肝肝动脉的74例患者的临床资料.全部患者采用供肝动脉通过供者髂动脉间置架桥与受者腹主动脉(肾动脉下方腹主动脉)行端侧吻合.总结手术治疗方法和术后并发症发生情况.所有患者均签署知情同意书,符合医学伦理学规定.结果 74例采用肝动脉-腹主动脉架桥重建肝动脉的患者中,68例治愈,6例术后早期死亡,治愈率为92%.术后急性排斥反应的发生率为18%(13/74),胆道并发症发生率为11%(8/74),肝动脉并发症发生率为14%(10/74),其中5例为架桥动脉血栓形成,5例为肝动脉(含架桥动脉)狭窄,行动脉支架置入溶栓术或动脉支架置入术,除1例上述治疗无效后行再次肝移植外,其余9例血管恢复通畅.结论 肝移植术中若无法行供、受者肝动脉端端吻合术重建肝动脉,间置髂动脉的肝动脉-腹主动脉架桥术是一种安全可靠的肝动脉重建方法.     

Coronary artery bypass graft for anomalous right coronary artery

A 27-year-old man with anomalous right coronary artery (RCA) presented with ventricular fibrillatory arrest. Computed tomography angiography revealed an anomalous RCA arising from the left sinus of Valsalva with an acute angulation at the coronary takeoff and compressed interarterial segment. This patient underwent a short saphenous vein coronary artery bypass graft to the proximal RCA and recovered uneventfully. A review of the literature and discussion of the surgical management is presented.     

Giant aneurysm of saphenous vein graft to coronary artery compressing the right atrium.

Aneurysm of reverse aortocoronary saphenous vein graft is a known complication of coronary artery bypass grafting. In this report we present a case of a 60-year-old man who presented 12 years after coronary artery bypass grafting with a giant graft aneurysm of the reverse aortocoronary saphenous vein graft to the right coronary artery, compressing the right atrium. Spiral computed tomography was used to identify the aneurysm measuring 7 x 6 x 7 cm. We also reviewed the English-language literature and found reports of 50 patients with similar aneurysms of which 30 (61%) were identified as true aneurysms and 17 (33%) were identified as pseudoaneurysms. Three patients could not be identified into either group. We reviewed the presenting symptoms, diagnostic tools, and treatment options for this rare entity. An understanding of the pathophysiology of reverse aortocoronary saphenous vein graft aneurysm is important to prevent the possibility of aneurysm rupture, embolization, myocardial infarction, or death.     

Angiographic results of the radial artery graft patency according to the degree of native coronary stenosis.

OBJECTIVE: Radial arteries are gaining widespread acceptance as complementary arterial conduits for surgical myocardial revascularization, but there are limited reports about its angiographic patency compared with that of the internal thoracic artery or saphenous vein according to the degree of native coronary stenosis. Therefore, we tried to evaluate the mid-term angiographic results of the radial artery graft patency focusing on the native coronary stenotic status in a prospective manner. METHODS: From March 2000 to September 2006, a total of 488 patients underwent coronary artery bypass grafting using radial artery graft at our institution. From this group, 123 patients (mean age of 59.02+/-8.9 years (range 34-73 years)) were enrolled in the present study, and underwent a postoperative angiography after surgery (mean 32 months). The angiograms were assessed visually and quantitatively. RESULTS: A total of 382 distal anastomoses were performed and 352 anastomosis remained patent (92.1%). Left internal thoracic artery showed the most excellent patency in all of the conduits (128/129, 99.2%). Overall the radial artery graft patency was 92% (160/174). In the univariate analysis, patency was significantly worse for targets of the right coronary system (left coronary system 129/135, 94.4% vs right coronary system 31/39, 79.4%. p<0.05) and the radial artery graft showed a higher patency rate in the case of a severe stenotic lesion that preoperatively revealed more than 90% stenosis (defined as critical stenotic lesion) than in the case of a less severe lesion (50%相似文献   

Systemic venous segments interposition for pulmonary artery to aorta connection

Two patients with pulmonary atresia and ventricular septal defect underwent implantation of the diminutive pulmonary arteries on the ascending aorta by interposition of short segment of azygos and innominate veins. The very thin structure of the systemic veins' wall matched perfectly the fragile pulmonary arterial wall. The anastomosis were perfectly patent and no aneurism dilatation was evident after three and four months, respectively.     

Repair of intramural hematoma of the ascending aorta without graft interposition.

A 68-year-old woman was admitted to hospital with a one-hour history of chest pain and syncopal episode. Transesophageal echocardiography showed an intramural aortic hematoma with cardiac tamponade. The patient underwent repair of the ascending aorta without graft interposition (resection and end-to-end anastomosis). The patient had an uneventful postoperative course and the 38-month follow-up was event-free. This case report shows that end-to-end anastomosis in patients with intramural hematoma and absence of intimal tearing, may provide good long-term results.     

Bovine internal thoracic artery graft. Successful use at urgent coronary bypass surgery

Bovine internal thoracic artery grafts (Bioflow) were successfully utilized in two patients for emergency coronary artery bypass grafting (CABG). One patient was an 80-year-old man with severe varicose veins and a calcified ascending aorta. Heart failure occurred after triple CABG with bilateral internal thoracic and gastroepiploic arteries. The addition of a Bioflow graft to the circumflex artery restored good cardiac function. The second case was a 54-year-old man whose patent old saphenous vein graft was accidentally injured at reoperation. Emergency use of the Bioflow to bypass the right coronary artery in combination with the right gastroepiploic artery graft to the anterior descending artery resulted in an excellent outcome. The two Bioflow grafts were patent at the 20th and 10th postoperative days, respectively. These cases strongly suggest the efficacy of Bioflow during emergency situations in CABG.     

冠状动脉旁路移植术的中远期效果随访

目的 分析冠状动脉旁路移植术(CABG)的中、远期疗效.方法 CABG术后行多层螺旋CT(MDCT)复查42例,行冠状动脉造影(SCA)复查59例;平均随访(66.79±44.27)个月.其中动脉旁路血管115支,静脉旁路血管195支.分别计算旁路血管的通畅率,比较其间的差异.结果 行MDCT复查者随访(53.93±36.80)个月,LIMA、RA、SV和CV的通畅率分别为94.7%、92.0%、85.9%和60.0%;有心绞痛再发组为83.5%,无心绞痛再发组为95.2%,差异有统计学意义.SCA复查者随访(75.95±47.09)个月,LIMA、RA、SV和CV的通畅率分别为87.1%、81.0%、53.6%和57.1%;有心绞痛再发组为62.0%,无心绞痛再发组为100.0%,差异有统计学意义.结论 MDCT可以作为一种无创检查方法来评价CABG术后旁路血管的通畅情况;动脉旁路血管的中、远期通畅率较静脉高;旁路血管病变是导致术后再发心绞痛的重要原因;旁路血管病变程度与CABG术后的随访时间密切相关.     

Plication of the right atrium in order to confront a right coronary artery under tension graft

An under tension graft to the right coronary artery may result in graft spasm, hypoperfusion and myocardial infarction. We suggest plication of the right atrium in order to confront the under tension graft (either arterial or venous), if tension is due to a shorter (up to 2 cm) graft than one needed. We present this technique applied to 10 of our patients. The radial artery was the under tension graft in two cases and a saphenous vein in eight. Perioperative and postoperative arrhythmias, myocardial infarction, hemorrhage and jugular or hepatic congestion were not observed. Central vein pressure remained normal. Tricuspid valve--estimated by postoperative echo--was undisturbed. Plication of the right atrium in case of an under tension graft is a quick, simple and safe technique.     

Angiographic evaluation of graft patency in minimally invasive direct coronary artery bypass grafting

BACKGROUND: The objective of this report is to describe our experience using minimally invasive direct coronary artery bypass grafting and to evaluate angiographic patency of anastomoses. METHODS: A total of 120 patients (86 men) were operated on, with ages ranging from 30 to 83 years (mean = 61.2 years). Two access routes were used: for single left anterior descending coronary artery lesions an 8 cm anterior minithoracotomy was performed at the fourth left intercostal space. Extracorporeal circulation was not used. In the last 82 patients a restraining device was used for the regional reduction of heart beats. Coronary cineangiography was carried out between postoperative days 1 and 3 in 84 (70%) patients. Anastomoses were graded: grade A, no blocks; grade B, blocks of more than 50%; grade C, occlusion. This evaluation was performed for two different periods: in the first period a restraining device was not used and in the second period a restraining device was used. RESULTS: In the first study period (38 anastomoses) coronary cineangiography showed grade A, 79%, grade B, 5.2%, and grade C, 15.8%. In the second study period (62 anastomoses), angiography showed grade A, 90.4%, grade B, 6.4%, and grade C, 3.2%. Early mortality was 1.6%. CONCLUSIONS: Minimally invasive coronary artery bypass grafting is a good alternative for some groups of patients. Anastomotic results seem to be better when a restraining device is used.     

Cryopreserved iliac artery is indispensable interposition graft material for middle hepatic vein reconstruction of right liver grafts.

Cryopreserved iliac vein grafts (IVGs) have often been used for reconstruction of middle hepatic vein (MHV) branches in right liver grafts, but their storage pool has often been exhausted in our institution due to the low incidence of deceased donor organ procurement. To overcome this shortage of IVG, we started to use cryopreserved iliac artery graft (IAG). During September and October 2004, we carried out 41 cases of adult living donor liver transplantation, including 29 right lobe grafts with MHV reconstruction. Interposition vessel grafts were autologous vein (n = 6), IVG (n = 13), and IAG (n = 10). IAG was used in 3 (21%) of 13 cases during the first month. For the next month, it was more frequently used (7 [44%] of 16) because handling of cryopreserved IAG was not difficult and its outcome was favorable. On follow-up with computed tomography for 3 months, outflow disturbance occurred in 1 (17%) of 6 autologous vein cases, in 2 (15%) of 13 IVG cases, and in 1 (10%) of 10 IAG cases. Two-month patency rate of IAG was not lower than that of IVG. In conclusion, we feel that cryopreserved IAG can be used as an interposition vessel graft for MHV reconstruction of right liver graft when cryopreserved IVG is not available.     

Change in right ventricular function during off-pump coronary artery bypass graft surgery.

OBJECTIVES: Hemodynamic derangement during displacement of beating heart in off-pump coronary artery bypass graft (OPCAB) surgery might be related with right ventricular (RV) dysfunction. We evaluated RV function and hemodynamic alterations using a thermodilution pulmonary artery catheter. METHODS: The study included 30 patients undergoing OPCAB, using single pericardial suture and tissue stabilizer. A thermodilution pulmonary artery catheter for continuous monitoring of the cardiac output (CO), right ventricular ejection fraction (RVEF) and RV volume was inserted before anesthesia. The hemodynamic variables were measured after the induction of anesthesia, 5 min after the heart was positioned for each coronary anastomosis and after the sternum was closed. RESULTS: There was no significant change in the RVEF and cardiac index during anastomosis of the left anterior descending artery and right coronary artery. However, the significantly reduced RVEF accompanied by an increase in RV afterload and decrease in the CO was observed during anastomosis of the obtuse marginal (OM) artery. RV volumes did not significantly change during anastomoses, though the right atrial pressure increased during anastomoses of all coronary arteries. CONCLUSIONS: The displacement of beating heart for positioning during anastomosis of the graft to OM artery caused significant derangement of RV function and decrease in CO. A thermodilution catheter continuously measuring the CO and RVEF was useful to monitor the change in RV function and volume during OPCAB.     

Abdominal surgery following coronary artery bypass grafting using an in situ right gastroepiploic artery graft.

OBJECTIVE: The usefulness of the gastroepiploic artery (GEA) as arterial grafts in coronary artery bypass grafting (CABG) has been studied extensively. We report our experience performing abdominal surgery after CABG using in-situ GEA. METHODS: The subjects were eight patients who underwent abdominal surgery after CABG with an in situ GEA graft. The surgical indications were malignant tumors in five patients, an infrarenal abdominal aortic aneurysm in two patients and a diaphragmatic hernia in one patient. The interval from the CABG to the abdominal surgery ranged from 3 to 19 months. RESULTS: Operations included distal gastrectomy in two cases, total gastrectomy in one case, local excision of the stomach in one case, and excision of the transverse colon in one case. Aorto-biiliac artery bypass was performed in two cases, and the diaphragmatic hernia was reconstructed using standard techniques. When the skeletonization method has been used to harvest the GEA, GEA grafts were easily identified during a laparotomy, and the abdominal procedure was performed using routine methods. One patient died of cancer, and the other patients are alive 1 year 2 months to 4 years 5 months after surgery. No patient reported recurrence of angina. CONCLUSION: The risk of abdominal reoperations should be considered when using the in situ right GEA for CABG. We recommend the skeletonization method for GEA harvest to decrease the difficulty during second abdominal operations.     

Relation between functional coronary artery stenosis and graft occlusion after coronary artery bypass grafting

ObjectivesThis study was conducted to evaluate graft patency rates during the 5 years after coronary artery bypass grafting according to the functional significance of the coronary artery stenosis, as determined by myocardial single-photon-emission computed tomography.MethodsTwo hundred ninety-five patients who underwent coronary artery bypass grafting using Y-composite grafts based on the in situ left internal thoracic artery, and in whom preoperative stress/rest myocardial single-photon-emission computed tomography and 1-year angiographies were available were enrolled. Seven hundred sixty-nine and 262 distal anastomoses were constructed to ischemic and nonischemic areas, respectively. One-year and 5-year angiographic occlusion rates were evaluated in all and 80.3% of study patients, respectively. Factors associated with graft occlusion were evaluated using generalized linear mixed-effects models.ResultsOverall 1- and 5-year graft occlusion rates were 4.3% (44 of 1031 distal anastomoses) and 5.5% (45 out of 820), respectively. The occlusion rates of grafts bypassed to vessels with functionally significant and insignificant stenosis were 2.7% (21 out of 769) and 8.8% (23 out of 262) at 1 year and were 4.0% (25 out of 618) and 9.9% (20 out of 202) at 5 years, respectively. Graft occlusion during the 5 years after coronary artery bypass grafting was associated with the functional significance of coronary artery stenosis (odds ratio, 0.50; 95% confidence interval, 0.28-0.92). The odds ratio of the graft occlusion according to functional ischemia was lower and significant in grafts to arteries with intermediate stenosis (stenosis ≥70% but <90%; odds ratio, 0.34; 95% confidence interval, 0.13-0.93) whereas it was higher and insignificant in grafts to arteries with severe stenosis (≥90% stenosis; odds ratio, 0.76; 95% confidence interval, 0.33-1.72).ConclusionsGraft occlusion during the 5 years after coronary artery bypass grafting was associated with the functional significance of coronary artery stenosis, particularly when the stenosis degree was not severe.     

Porcelain aorta in coronary artery bypass graft operations: an alternative approach

Porcelain aorta represents a serious condition for coronary artery bypass graft operations. Here we describe a simple technique to avoid any aortic manipulation during an off-pump coronary artery bypass graft procedure. The right internal thoracic artery is used as the source of blood inflow for single or sequential venous grafts. We have used this technique with good results in 5 elderly patients with eggshell aorta.