CAGB术桥血管的选择.ppt

CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually CAGB术桥血管的选择与评估 Introduction CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually 01 CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually InternalThoracicArtery 02 RadialArtery 03 GastroepiploicArtery 04 GreaterSaphenousVein CONTENTS 1 InternalThoracicArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversityNowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually InternalThoracicArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Kolessov施行了第一台成功的ITA冠状动脉搭桥计划手术 Goetz施行了第一台成功的CAGB计划手术 使用金属管道连接RITA与RCA Longmire在冠状动脉内膜切除术失误时 被迫临时行ITA coronay手术 是直接使用ITA行CAGB的第一例 ArthurMartinVineberg将ITA移植入心肌隧道 利用其侧支出血 改善心脏血运 死亡率6 History InternalThoracicArtery 抗动脉粥样硬化 CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually InternalThoracicArtery 独特的内皮 CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually InternalThoracicArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually InternalThoracicArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually 术前的乳内动脉造影B超术中游离乳内动脉 术中观察 评估方法 InternalThoracicArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Pedicled Skeletonization vs InternalThoracicArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually TheJournalofThoracicandCardiovascularSurgerycJuly2016 Pedicledandskeletonizedsingleandbilateralinternalthoracicarterygraftsandtheincidenceofsternalwoundcomplications InsightsfromtheArterialRevascularizationTrial 2056patients 1year UniversityofBristol UniversityofOxford MedicalUniversityofGdansk NorfolkandNorwichUniversityHospitalsNHSFoundationTrust InternalThoracicArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually TheJournalofThoracicandCardiovascularSurgerycJuly2016 InternalThoracicArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually TheJournalofThoracicandCardiovascularSurgerycJuly2016 InternalThoracicArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually TheJournalofThoracicandCardiovascularSurgerycJuly2016 1 双侧带蒂游离的术后胸骨并发症明显多于单侧带蒂游离 2 单侧或双侧骨骼化较单侧带蒂游离无明显差异 3 双侧带蒂游离为胸骨并发症的危险因素 对糖尿病患者及肥胖患者尤为显著 1 双侧带蒂游离的术后胸骨并发症明显多于单侧带蒂游离 2 单侧或双侧骨骼化较单侧带蒂游离无明显差异 3 双侧带蒂游离为胸骨并发症的危险因素 对糖尿病患者及肥胖患者尤为显著 2 RadialArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversityNowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually RadialArtery OriginallydescribedbyCarpentierandassociatesintheearly1970s 32 graftsoccludedat2years CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually RadialArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually RadialArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually 评估方法 术前评估 超声 血管造影临床检查 触诊搏动是否良好 Allen试验评估同侧尺动脉代偿能力取非优势前臂的桡动脉 RadialArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually ComparisonofRadialArteryandSaphenousVeinGraftStenosisMoreThan5YearsAfterCoronaryArteryBypassGrafting 326patients UniversityofToronto SunnybrookResearchInstitute UniversityHealthNetwork Copyright 2016byTheSocietyofThoracicSurgeons RadialArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually 就狭窄率而言 RA与SVGs在术后5年无明显差异 RadialArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Petrovicetal JournalofCardiothoracicSurgery 2015 10 127 Radialarteryvssaphenousveingraftusedasthesecondconduitforsurgicalmyocardialrevascularization long termclinicalfollow up 200patients 8years BelgradeUniversitySchoolofMedicine Belgrade Serbia RadialArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Petrovicetal JournalofCardiothoracicSurgery 2015 10 127 Fig 1Kaplan Meiercurvefortotalmortality Abbreviations Fig 2KaplanKaplan Meiercurveforlong termclinicaloutcomes compositeofcardiacdeath non fatalmyocardialinfarctionandrepeatrevascularization RadialArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Petrovicetal JournalofCardiothoracicSurgery 2015 10 127 就临床预后而言 RA与SVGs在术后8年无明显差异 3 GastroepiploicArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversityNowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually GastroepiploicArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually GastroepiploicArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually GastroepiploicArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually 评估方法 多排螺旋CT 平均管径在2mm以上时可用于CABG GastroepiploicArtery CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Copyright 2015bytheInternationalSocietyforMinimallyInvasiveCardiothoracicSurgery FasudilIsanEffectiveGraftVasodilatorforGastroepiploicArteryinCoronaryArteryBypassGrafting 30patients KanazawaUniversityGraduateSchoolofMedicalScience 4 GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversityNowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually GreaterSaphenousVein 易游离 即时可得 多用途 一定的抗痉挛性 无可比拟的血管长度主要缺点是随时间推移而加重的血管退变 CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually 虽有不足但仍为最常用的桥血管之一 GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually 评估方法 临床体查 观察大隐静脉的情况 有无曲张 扎止血带观察静脉弹性 感性及临床经验 B超 最直接的检测方法 可以观察平卧位 立位 充血状态下的大隐静脉的管腔直径变化 进一步评估血管的弹性老年人或者血管硬化的患者血管扩张程度远小于年轻人或者没有血管病变的患者 大隐静脉血管直径小于3mm患者 远期通畅率下降 GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Theno touchsaphenousveinforcoronaryarterybypassgraftingmaintainsapatency after16years comparabletotheleftinternalthoracicartery Arandomizedtrial OrebroUniversity SchulichHeartCentre KarolinskaInstitute Copyright 2015byTheAmericanAssociationforThoracicSurgery GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Copyright 2015byTheAmericanAssociationforThoracicSurgery GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Copyright 2015byTheAmericanAssociationforThoracicSurgery GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Post mortemconventionalsaphenouseingraft 8years Copyright 2015byTheAmericanAssociationforThoracicSurgery GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Post mortemno touchsaphenousveingraftandLITAgraft 9years Post mortemno touchsaphenousveingraft 12years Copyright 2015byTheAmericanAssociationforThoracicSurgery GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Post mortemno touchsaphenousveingraft 18years Copyright 2015byTheAmericanAssociationforThoracicSurgery GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Copyright 2015byTheAmericanAssociationforThoracicSurgery 通过平均16年的术后随访 我们发现相对常规技术 NT技术游离的SV其通畅率明显更高 甚至可与LITA媲美 GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Figure4 StructuraldamagetoconventionalOVHandEVHsaphenousvein ransversesectionsofsaphenousveinsusedincoronaryarterybypasssurgery CABG No touchsaphenousveingraft NTSVG undamagedsaphenousveinharvestedbytheno touchtechniquewithadventitiaandsurroundingperivascularfatintact TheOVH conventional OVH veinharvestedwithadventitiadamagedorremoved Dashwoodunpublished TheEVH endoscopicallyharvestedveinwithadventitiadamagedorremoved RepublishedwithpermissionfromKianiandPoston 18CopyrightWoltersKluwerHealth 2011 Largearrowindicatesintimaltearing Smallarrowsindicatepositionoftheadventitia Scalebar 2mm EVHindicatesendoscopicveinharvesting OVH openveinharvesting GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Copyright 2015byTheSocietyofThoracicSurgeons ARandomizedTrialofExternalStentingforSaphenousVeinGraftsinCoronaryArteryBypassGrafting 30patients 1years UniversityofOxford TelAvivUniversity RoyalBromptonHospital HarefieldHospital VascularGraftSolutionsLtd GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Copyright 2015byTheSocietyofThoracicSurgeons GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Copyright 2015byTheSocietyofThoracicSurgeons GreaterSaphenousVein CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversitywasfoundedinthe1950s taketheleadinNorthwestChinatocarryoutthecardiavascularsurgery Nowisthelargestcardiaccenterinourprovince wehaveteamofanesthesia extracorporalcirculation ultrasoniccardiogramandICUofourown andnearly1 000caseofoperationwascompletedannually Copyright 2015byTheSocietyofThoracicSurgeons 1 外支架用于左冠明显减少桥血管狭窄率 2 外支架用于右冠明显增加桥血管狭窄率 3 应用外支架技术时应使用缝线而不是钛夹结扎分支血管 Summary CardiavascularSurgeryDepartmentofour1stHospitalofLanzhouUniversityNo