冠状动脉慢性完全闭塞合并远端弥漫性硬化患者的血运重建治疗

目的 总结冠状动脉(冠脉)慢性完全闭塞合并闭塞远端弥漫性内膜增厚在非体外循环下行冠脉内膜剥脱加冠脉旁路移植重建心肌血运的方法,评估其有效性.方法 65例冠脉慢性闭塞患者,冠脉造影显示176支血管狭窄或闭塞,70支为完全闭塞,远端无或逆行显影差.在非体外循环冠脉旁路移植中,发现闭塞冠脉远端内膜弥漫性增厚且旁路移植后桥血流量差,遂加行内膜剥脱后重新冠脉旁路移植治疗.结果 内膜剥脱前桥血管流量2～10ml/min,搏动指数(PI)5.1～15.6;内膜剥脱后桥血管流量14～37 ml/min,PI指数均＜5.0,左心室射血分数明显改善[术前(0.47±0.12)与术后(0.52±0.15)%,t=2.17,P＜0.05].术后2例发生围手术期心肌梗死(3.1%),均无明显心脏血流动力学改变,23例在术后3～18个月复查冠脉造影,显示桥血管通畅.结论 对于冠脉慢性完全闭塞同时合并远端弥漫性内膜增厚的血运重建,非体外循环下冠脉内膜剥脱后再行旁路移植是一种安全、有效的治疗方法.

Surgical revascularization of patients with chronic total coronary occlusion combined with diffuse distal atherosclerosis

Objective To evaluate the effect of off-pump coronary endarterectomy (CE) plus off-pump coronary artery bypass grafting (off-pump CABG) on patients with chronic total occlusion (CTO) combined with diffuse distal atherosclerosis. Methods From October 2006 to August 2009,65 CTO patients with 176 angiographically confirmed vascular stenosis or occlusive lesions, 70 of which were complete occlusion, underwent off-pump CABG. During the operation, diffuse intimal thickening distal to occlusive lesion was found, and blood flow of the bridges was unfavorable.Results Therefore endarterectomy was performed, followed by CABG. The blood flow in the bridges were 2-10 ml/min versus 14-37 ml/min before versus after endarterectomy. Pulsatility index (PI) was 5.1-15.6 versus less than 5 before versus after endarterectomy. Left ventricular ejection fraction was also improved significantly [before operation: (0.47±0.12)%, after operation: (0. 52±0.15)%, t=2.17, P＜0.05]. Peri-operative myocardial infarction occurred in 2 cases, but without significant cardiac homodynamic changes. And 23 patients underwent coronary angiography to evaluate graft patency 3-18 months after operation, all of them had favorable blood flow. Conclusions It is feasible to perform off-pump CABG plus coronary endarterectomy for patients of chronic coronary total occlusion combined with diffuse distal atherosclerosis. This treatment is safe and effective.