Atherosclerosis of the ascending aorta and coronary artery bypass. Pathology, clinical correlates, and operative management.
Atherosclerosis of the ascending aorta and coronary artery bypass. Pathology, clinical correlates, and operative management.
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升主动脉和冠状动脉搭桥的动脉粥样硬化。
DOI：
10.1016/s0022-5223(20)31425-2
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发表时间：
1991
期刊：
影响因子：
--
通讯作者：
C. Everson
中科院分区：
文献类型：
--
作者：
N. Mills;C. Everson
对1981年1月至1988年12月行冠状动脉搭桥术的1735例患者的分析表明，152例(8.8%)患者有轻度(4.5%)、中度(2.2%)和重度(2.0%)的升主动脉粥样硬化。发现了三种不同的病理模式。中风在严重类型的主动脉疾病患者中的流行促使一种新的手术技术的发展，该技术已在16名患者中使用。它涉及一种“无接触”的升主动脉技术，在此基础上，对乳内动脉移植物进行近端大隐静脉端侧吻合。年龄49~80岁，平均68.9岁。16例患者行远端动静脉吻合62例，近端大隐静脉-内乳端侧吻合26例。内乳动脉自由血流量130~420ml/min。两人在医院死亡与这项技术无关。没有中风或心绞痛复发。发现主干左冠状动脉病变(50%)、显著的颈动脉病变(79%)和腹主动脉闭塞或动脉瘤(93%)的发病率异常高。所有冠状动脉搭桥术患者都必须怀疑升主动脉粥样硬化，这些患者有明显的颈动脉、腹主动脉和主要左冠状动脉病变，升主动脉造影显示主动脉壁不规则，升主动脉与其外膜之间粘连，升主动脉苍白外观，以及主动脉插管刺伤处少量出血。一种避免对升主动脉进行任何操作并使用乳内动脉作为冠状动脉搭桥术的唯一供血来源的“无接触”技术，是预防主动脉夹损伤、“垃圾心脏”或严重升主动脉疾病中风的有效方法。所有接受冠状动脉搭桥术的患者都必须在手术前进行升主动脉造影检查。
Analysis of 1735 patients who underwent coronary artery bypass grafting from January 1981 through December 1988 revealed 152 (8.8%) patients with mild (4.5%), moderate (2.2%), or severe (2.0%) atherosclerosis of the ascending aorta. Three distinct pathologic patterns were found. The prevalence of stroke in patients with the severe type of aortic disease prompted development of a new operative technique that has been used in 16 patients. It involves a “no-touch” technique of the ascending aorta whereupon the proximal saphenous vein anastomoses are performed end to side to internal mammary artery grafts. Ages ranged from 49 to 80 years (mean 68.9). The 16 patients had 62 distal artery and vein anastomoses and 26 proximal saphenous vein-internal mammary end-to-side anastomoses. Internal mammary artery free flows ranged from 130 to 420 ml/min. Two hospital deaths were unrelated to the technique. There have been no strokes or recurrences of angina. An inordinately high incidence of main left coronary disease (50%), significant carotid disease (79%), and abdominal aortic occlusive or aneurysm disease (93%) was discovered. Ascending aortic atherosclerosis must be suspected in all coronary bypass patients with associated significant carotid, abdominal aortic, and main left coronary artery disease, aortic wall irregularity on ascending aortic angiography, adhesions between the ascending aorta and its adventitia, pale appearance of the ascending aorta, and minimal bleeding of an aortic cannulation stab wound. A “no-touch” technique that avoids any manipulation of the ascending aorta and that uses the internal mammary arteries as the sole source of blood supply for coronary bypass is an effective method to prevent aortic clamp injury, “trash heart,” or stroke from severe ascending aortic disease. Preoperative angiographic visualization of the ascending aorta of all patients undergoing coronary artery bypass is mandatory.