内窥镜大隐静脉获取术在冠状动脉旁路移植术中的应用

目的探讨冠状动脉旁路移植术(coronary artery bypass grafting,CABG)中应用内窥镜获取大隐静脉的手术技巧及可行性和安全性。方法首都医科大学宣武医院心脏科2007年1月至2008年2月行择期CABG术患者118例,根据患者意愿分为内窥镜大隐静脉获取术(EVH)组(40例)和全程切开大隐静脉获取术(OVH)组(78例)。对2组患者高危因素和术后合并症进行比较,并对EVH组所取静脉进行组织学评价。结果2组患者下肢切口合并症高危因素的差异无统计学意义,但合并症总发生率EVH组较OVH组低,2组比较差异有统计学意义(P<0.01)。2组患者静脉获取时间相当,获取的静脉长度差异有统计学意义(P<0.05)。EVH组更多地采用了序贯吻合血管桥技术以保证完全再血管化的需要。组织学评估结果显示,内窥镜获取的大隐静脉内膜完整,质量可靠。2组患者术后平均随访5.8个月,均未再发生心肌梗死。冠状动脉CT检查结果显示,EVH组桥血管共73支,仅2支存在局限性轻度内膜增生,未见桥血管闭塞。结论EVH技术在降低术后下肢伤口合并症方面有明显优势,适用于存在高危因素的患者。内窥镜大隐静脉获取术可能成为冠状动脉旁路移植术的常规静脉获取手段。

Application of Endoscopic Great Saphenous Vein Harvesting during Coronary Artery Bypass Grafting

Objective To observe the effects of endoscopic saphenous vein harvesting technique on the prevalence of leg-wound complications after coronary artery bypass grafting, and assess the feasibility of this technique and the potential trauma of the conduits. Methods Between January 2007 and February 2008, 118 patients underwent primary coronary artery bypass grafting, and 40 patients'saphenous vein taken using endoscopic harvest system(EVH), and the others by open vein harvesting(OVH), based on patient's willingness. The operation risk factors were compared between the two groups, and the proximal vein segment that underwent endoscopic harvesting was examined with electron-microscope. Results There was no significant difference in risk factors of incision complications between the two groups, but the incidence of various incision complications was significantly lower in the EVH group(12.5%) than in the OVH group(39.7%)(P<0.01). The time of harvesting was similar between the two groups. The length of conduits was(30.3±7.45)cm and (37.7±8.01)cm with significant difference between the two groups(P<0.05). Actually, there was increase in the use of sequential grafting technique in the EVH group for revascularization. Histological studies suggested that there were no extra vein trauma associated with EVH. At the same time, we have accumulated rich experience and skills in this procedure, and realized anatomical features of vein grafts. However, because of limited experience, the patency rate of conduits and the incidence rate of myocardial infarction in the perioperative or postoperative period were not compared between the two groups, more precise observations might be required. Conclusion The decrease in incision complications of EVH was unquestionably superior to those of OVH, especially for those patients having risk factors of incision complications. With increasing experience, the EVH technique might replace conventional saphenous vein harvesting methods and become the standard option.