李波,顧承雄,李海濤,楊俊峰,韋華,李京倖,劉銳,黃信生,宋偉,李暉,李琴
論著·臨床
內(nèi)窺鏡下采集大隱靜脈作為冠狀動(dòng)脈旁路移植手術(shù)序貫橋的近期療效
李波,顧承雄,李海濤,楊俊峰,韋華,李京倖,劉銳,黃信生,宋偉,李暉,李琴
目的評(píng)價(jià)內(nèi)窺鏡下采集大隱靜脈作為序貫橋血管的近期臨床效果。方法回顧性分析應(yīng)用靜脈序貫橋行非體外循環(huán)冠狀動(dòng)脈旁路移植手術(shù)(OPCAB)并完成隨訪的241例患者的臨床資料,根據(jù)大隱靜脈取材方式將患者分為內(nèi)窺鏡靜脈采集(EVH)組85例和開放靜脈采集(OVH)組156例,比較2組術(shù)后1年時(shí)下肢水腫范圍、患者滿意程度評(píng)分、臨床預(yù)后(死亡、新發(fā)心肌梗死、再血管化)、橋血管通暢率。結(jié)果2組性別、年齡、左室射血分?jǐn)?shù)(LVEF)、左室舒張末期內(nèi)徑(LVEDD)、陳舊心肌梗死、高血壓、左主干病變等比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05),而EVH組體質(zhì)量指數(shù)、糖尿病比例高于OVH組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。與OVH組比較,EVH組序貫橋血管支數(shù)、序貫橋主干流量、主干搏動(dòng)指數(shù)、每支橋血管流量和每支橋搏動(dòng)指數(shù)等差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。EVH組手術(shù)下肢水腫比例和程度均降低、患者滿意度提高(P<0.05)。2組術(shù)后1年新發(fā)心肌梗死、再血管化及橋血管通暢率差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論CABG術(shù)中采取EVH采集小腿大隱靜脈作為序貫橋血管能有效降低下肢水腫,提高患者滿意度,但并不影響序貫靜脈橋1年通暢率。
內(nèi)窺鏡下血管采集;冠狀動(dòng)脈旁路移植術(shù);大隱靜脈;序貫吻合;近期療效
大隱靜脈是冠狀動(dòng)脈旁路移植手術(shù)(coronary artery bypass grafting,CABG)最常用的血管材料。內(nèi)窺鏡下靜脈采集(endoscopic vein harvesting,EVH)技術(shù)具有創(chuàng)傷小、疼痛輕、切口并發(fā)癥發(fā)生率低等優(yōu)點(diǎn)[1],尤其適用于糖尿病和肥胖的患者[2]。目前EVH是否會(huì)降低旁路移植術(shù)后1年通暢率和增加再血管化的比例仍存爭議[3~5],且缺乏內(nèi)窺鏡下采集大隱靜脈作為序貫橋的近期通暢性的研究。我科從2010年開始應(yīng)用此項(xiàng)技術(shù),所取大隱靜脈用于序貫吻合。本研究對(duì)本組患者術(shù)后1年的臨床預(yù)后和橋血管通暢性進(jìn)行回顧性隨訪,現(xiàn)報(bào)道如下。
1.1 臨床資料 選擇我科2011年8月—2012年11月應(yīng)用大隱靜脈作為序貫橋的非體外循環(huán)冠狀動(dòng)脈旁路移植患者(off-pump coronary artery bypass,OPCAB)241例。納入標(biāo)準(zhǔn):非體外循環(huán)冠狀動(dòng)脈旁路移植、擇期手術(shù)患者;應(yīng)用大隱靜脈作為序貫橋血管;術(shù)后規(guī)律服藥,并完成術(shù)后1年隨診。排除標(biāo)準(zhǔn):再次手術(shù)或急診手術(shù)患者;大隱靜脈曲張或下肢靜脈血栓形成的患者; EVH困難改開放靜脈采集(OVH)患者;術(shù)中未采用流量測定對(duì)橋血管和吻合口質(zhì)量控制的患者;術(shù)后未規(guī)律服藥,血壓、血糖、血脂控制不佳的患者;未按要求完成1年隨診的患者。
1.2 大隱靜脈采集和序貫橋吻合方法 術(shù)前檢查雙下肢深淺靜脈B型超聲,排除靜脈血栓形成和大隱靜脈曲張。大隱靜脈采集方法:(1)EVH由完成50例以上EVH手術(shù),熟練掌握該項(xiàng)技術(shù)的醫(yī)師完成(排除學(xué)習(xí)階段技術(shù)水平對(duì)橋血管通暢率的影響);使用美國Vasoview Hemopro?(Maquet)血管采集系統(tǒng);基本技術(shù)和操作要點(diǎn)同以往文獻(xiàn)報(bào)道[6]。(2)OVH由完成200例OVH手術(shù)、熟練掌握全程切開取材技術(shù)的醫(yī)師完成。從腳踝部開始,沿靜脈走行,全程切開,采用標(biāo)準(zhǔn)技術(shù)取材。使用注射器向大隱靜脈內(nèi)注水時(shí)避免過高壓力,防止靜脈內(nèi)膜損傷,影響通暢率。避免損傷周圍神經(jīng)、靜脈主干及分支。
冠狀動(dòng)脈旁路移植在非體外循環(huán)完成:通常將乳內(nèi)動(dòng)脈或大隱靜脈吻合于左前降支,先將大隱靜脈序貫橋近心端與升主動(dòng)脈端側(cè)吻合,其余按照對(duì)角支、鈍緣支、左室后支、后降支的順序進(jìn)行序貫吻合。用8-0 prolene線連續(xù)縫合遠(yuǎn)端吻合口。全部患者由同一術(shù)者完成。關(guān)胸前常規(guī)測定橋血管流量和搏動(dòng)指數(shù),必要時(shí)矯正橋血管或吻合口,確保其通暢。在序貫橋與升主動(dòng)脈近端吻合口以遠(yuǎn)測定序貫橋主干流量。測定序貫橋每支橋流量時(shí)暫時(shí)阻斷該吻合口以遠(yuǎn)的序貫橋血管,在該吻合口近端處測定該單支橋流量。
1.3 術(shù)后藥物治療與隨診 術(shù)后第2天或第3天開始應(yīng)用低分子肝素或者腸溶阿司匹林,出院后持續(xù)服用腸溶阿司匹林(100 mg/d)或者氯吡格雷(75 mg/d,適用于有消化道潰瘍患者)。囑患者嚴(yán)格控制吸煙、高脂血癥、高血壓等動(dòng)脈硬化危險(xiǎn)因素,適量運(yùn)動(dòng)。于術(shù)后3個(gè)月、6個(gè)月及1年門診隨診,內(nèi)容包括有無心絞痛再發(fā)、心肌梗死發(fā)生、心功能情況,并行生化、心電圖、超聲心動(dòng)圖等檢查,根據(jù)檢查結(jié)果由??漆t(yī)師調(diào)整用藥,根據(jù)患者情況服用他汀類藥物,控制動(dòng)脈硬化進(jìn)展。術(shù)后1年時(shí)行雙源CT 冠狀動(dòng)脈造影檢查,評(píng)價(jià)橋血管通暢情況。
1.4 術(shù)后1年隨診評(píng)價(jià) 包括以下指標(biāo):臨床預(yù)后(包括心肌梗死、再血管化);下肢水腫范圍(根據(jù)采取大隱靜脈一側(cè)下肢可凹性水腫范圍分為無水腫、踝以下和膝關(guān)節(jié)以下3種);患者對(duì)靜脈采取滿意程度評(píng)分(根據(jù)自己對(duì)手術(shù)創(chuàng)傷、質(zhì)量和總體的感受在0~100之間選擇一個(gè)數(shù)字表示對(duì)此項(xiàng)手術(shù)的滿意程度);橋血管通暢的影像學(xué)評(píng)價(jià):行雙源CT冠狀動(dòng)脈造影,由2名高年資??漆t(yī)師進(jìn)行判定。評(píng)價(jià)每個(gè)靶血管吻合口與近端另一吻合口之間的橋血管或吻合口是否通暢及有無狹窄。冠狀動(dòng)脈狹窄計(jì)算公式采用國際通用的目測直徑法,血管狹窄程度=(狹窄部分近心端正常血管直徑-狹窄處直徑)/ 狹窄段近心端血管直徑×100%。按Fitz Gibbon標(biāo)準(zhǔn)[6]分為A級(jí)(橋血管或吻合口無狹窄或狹窄<50%)、B級(jí)(橋血管或吻合口狹窄>50%)、O級(jí)(橋血管完全閉塞)。將2組所得數(shù)據(jù)進(jìn)行比較。
1.5 統(tǒng)計(jì)學(xué)分析 采用SPSS 13.0軟件進(jìn)行處理。計(jì)數(shù)資料以率表示,采用χ2檢驗(yàn);計(jì)量資料采用均數(shù)±標(biāo)準(zhǔn)差表示,采用t檢驗(yàn);非正態(tài)分布資料以中位數(shù)表示,用秩和檢驗(yàn)。P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2.1 2組術(shù)前一般情況比較 入選患者共241例。EVH組85例,OVH組156例。2組性別比、年齡、左室射血分?jǐn)?shù)(LVEF)、左室舒張末期內(nèi)徑(LVEDD)、陳舊心肌梗死、高血壓、左主干病變比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。體質(zhì)量指數(shù)(BMI)、糖尿病比例比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。見表1。
2.2 2組序貫橋支數(shù)和術(shù)中流量測定比較 2組序貫橋血管支數(shù)、序貫橋主干流量、主干搏動(dòng)指數(shù)、每支橋血管流量和每支橋搏動(dòng)指數(shù)等比較差異均無統(tǒng)計(jì)學(xué)意義(P>0.05)。見表2。
2.3 2組術(shù)后1年隨診情況比較 EVH組下肢水腫范圍好于OVH組,患者滿意評(píng)分高于OVH組,2組比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。2組出院后新發(fā)心肌梗死和再血管化以及1年時(shí)橋血管通暢率比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。見表3。
表1 2組一般資料比較
表2 2組大隱靜脈序貫橋術(shù)中資料比較
表3 2組術(shù)后1年隨診資料對(duì)比
內(nèi)窺鏡下采集大隱靜脈可減少切口并發(fā)癥[5,6],本研究中2組BMI、糖尿病差異有統(tǒng)計(jì)學(xué)意義,表明肥胖和糖尿病患者更容易接受EVH,術(shù)后1年隨訪結(jié)果顯示下肢水腫范圍和患者滿意度好于OVH。但由于在外科醫(yī)生學(xué)習(xí)EVH階段和手術(shù)采取過程中存在損傷靜脈的風(fēng)險(xiǎn)[7],EVH是否會(huì)影響患者術(shù)后遠(yuǎn)期安全性和通暢率已受到質(zhì)疑 ,多項(xiàng)臨床薈萃分析也顯示不同的結(jié)論[8~12]。
序貫橋可用更少靜脈獲得更完全再血管化,且有更好的遠(yuǎn)期通暢率[13,14]。自應(yīng)用EVH以來,患者遠(yuǎn)期預(yù)后和橋血管通暢率的影響始終是關(guān)注的重點(diǎn)。術(shù)后1年是橋血管尤其是大隱靜脈狹窄的高發(fā)期[15,16],我們于術(shù)后1年采用雙源CT冠狀動(dòng)脈造影對(duì)橋血管進(jìn)行評(píng)價(jià)。為客觀評(píng)價(jià)靜脈采集技術(shù)對(duì)患者預(yù)后和橋血管通暢率的影響,我們排除了醫(yī)生學(xué)習(xí)EVH和OVH階段的冠狀動(dòng)脈旁路移植患者,且通過術(shù)中流量測定確保橋血管的通暢。本項(xiàng)研究隨訪結(jié)果顯示,患者使用EVH所取大隱靜脈用作序貫橋并沒有增加心肌梗死、再血管化和影響術(shù)后1年橋血管通暢率。
另外掌握EVH確實(shí)有學(xué)習(xí)曲線,技術(shù)不熟練的醫(yī)生所采取靜脈需要縫合修補(bǔ)的損傷多于OVH。如何在減少手術(shù)創(chuàng)傷和切口并發(fā)癥的同時(shí)確保血管質(zhì)量是需解決的問題。以往研究也證實(shí)EVH學(xué)習(xí)曲線階段對(duì)靜脈的損傷已經(jīng)成為橋血管衰敗的預(yù)測因素之一[17]。建立良好的培訓(xùn)機(jī)制幫助醫(yī)生跨越學(xué)習(xí)曲線、改進(jìn)EVH器械和采集技術(shù)、牢固樹立血管質(zhì)量第一的觀念使操作更安全,是解決這些問題的方法。
本研究不足之處在于僅是近期回顧性研究,EVH取大隱靜脈作為序貫橋?qū)颊咧羞h(yuǎn)期預(yù)后和通暢率的影響尚有待進(jìn)一步觀察,造影隨訪有助于更好的評(píng)價(jià)橋血管通暢率。
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Oneyearfollowupstudyofsequentialsaphenousveingraftsharvestedbyendoscopy
LIBo,GUChengxiong,LIHaitao,YANGJunfeng,WEIHua,LIJingxing,LIURui,HUANGXinsheng,SONGWei,LIHui,LIQin.
DepartmentofCardiacSurgery,CapitalMedicalUniversityAffiliatedBeijingAnzhenHospital/BeijingInstituteofHeart,LungandBloodVesselDiseases,Beijing100029,China
GUChengxiong,E-mail:Anzhengu@sohu.com
ObjectiveTo evaluate the short term clinical effects of sequential saphenous vein graft harvested by endoscopy.MethodsRetrospectively analyzed 241 patients who
off pump coronary artery bypass grafting and finished the one year follow up with sequential saphenous vein graft from Aug 2011 to Nov 2012. Based on vein harvesting methods, the patients were divided into endoscopic vein harvesting group (EVH) and open vein harvesting group (OVH). The compared items included edema area in the lower limbs, patients' satisfaction score, clinical outcomes (myocardial infarction and revascularization) and graft patency.ResultsThere were no significant differences of 2 groups of gender, age, LVEF, LVEDD, old myocardial infarction, hypertension, left main disease (P>0.05), while in EVH group, body mass index, diabetes is higher than the OVH group, the difference was statistically significant (P<0.05). Compared with OVH group, there were no significant sequential grafts count, sequential bridge, main trunk flow pulsatility index, blood flow of each bridge and a bridge pulsate index with EVH group (P>0.05).In EVH group, the satisfaction of operation were improve and lower extremity edema ratio decreased (P<0.05). After 1 years, new myocardial infarction, revascularization and the patency rates did not show statistically significant among the 2 groups (P>0.05).ConclusionSequential saphenous vein graft harvested via EVH during off pump CABG can effectively reduce lower limb edema and improve patient's satisfaction without affecting graft patency one year after the surgery.
Endoscopic vein harvesting; Coronary artery bypass grafting ; Saphenous vein; Sequential graft;Short-term effects
國家自然科學(xué)基金資助項(xiàng)目(No.81370746)
100029 首都醫(yī)科大學(xué)附屬北京安貞醫(yī)院心臟外科/北京市心肺血管疾病研究所心臟外科
顧承雄,E-mail:Anzhengu@sohu.com
10.3969/j.issn.1671-6450.2014.06.001
2014-04-09)