Weman S M, Salminen U S, Penttilä A, Männikkö A, Karhunen P J
Department of Forensic Medicine, Helsinki University, Finland.
Int J Legal Med. 1999;112(2):107-14. doi: 10.1007/s004140050211.
The advantages and limitations of a novel post-mortem angiographic method using solidifying silicone rubber and lead oxide as a contrast medium in detecting coronary artery graft complications on a routine basis were evaluated in a series of 223 consecutive patients with fatal outcome within 30 days following coronary artery bypass grafting (CABG). Of these patients, 166 (74.4%) were male and 57 (25.6%) female (mean age 61.9 +/- 9). Coronary grafts totalled 660 (3.0 per patient) with 517 aortic and 838 coronary anastomoses. At autopsy, the rubber cast model of the grafts and coronary arterial tree was exposed by a bend scalpel and sites of possible complications were examined. Post-mortem angiographs were re-evaluated and compared with preoperative angiographs and dissection findings. By combining the findings of angiography and heart dissection, 122 (54.7%) of the 223 patients were found to have some type of complication of the graft or the anastomosis. The diagnostic sensitivity and specificity of post-mortem angiography was 100% in assessing narrowing or twisting of the graft as well as narrowing of the aortal anastomosis, whereas these findings were revealed with difficulty by autopsy dissection only. In cases with correct x-ray projection, narrowing and occlusion of the proximal aortal and distal coronary anastomosis were also reliably revealed by angiography. In contrast, graft thrombosis was clearly overdiagnosed by angiography, leading to a lower specificity (84%) but high sensitivity (100%) in detecting this complication. Post-mortem angiography also failed to detect dissection of the wall of the graft or anastomosis. Technical problems with this angiographic method were due to too low perfusion pressure, too rapid polymerizing of the silicone rubber, leakage of contrast medium into the ventricles, or faulty x-ray projections. These results suggest that our post-mortem angiographic technique, yielding a permanent rubber-cast model of the graft and anastomosis site, improves the accuracy of diagnostics of postoperative CABG complications and eases postoperative autopsy dissection, which can now be directed to confirm suspected complications.
在一系列223例冠状动脉旁路移植术（CABG）后30天内死亡的连续患者中，评估了一种新型尸检血管造影方法的优缺点，该方法使用固化硅橡胶和氧化铅作为造影剂，用于常规检测冠状动脉移植并发症。这些患者中，166例（74.4%）为男性，57例（25.6%）为女性（平均年龄61.9±9岁）。冠状动脉移植共660处（每位患者3.0处），其中主动脉吻合517处，冠状动脉吻合838处。尸检时，用弯头手术刀暴露移植血管和冠状动脉树的橡胶铸型模型，并检查可能出现并发症的部位。对尸检血管造影进行重新评估，并与术前血管造影和解剖结果进行比较。通过结合血管造影和心脏解剖的结果，发现223例患者中有122例（54.7%）存在某种类型的移植血管或吻合口并发症。尸检血管造影在评估移植血管狭窄或扭曲以及主动脉吻合口狭窄方面的诊断敏感性和特异性为100%，而这些发现仅通过尸检解剖很难发现。在X线投影正确的情况下，血管造影也能可靠地显示近端主动脉和远端冠状动脉吻合口的狭窄和闭塞。相比之下，血管造影明显过度诊断了移植血管血栓形成，导致检测该并发症的特异性较低（84%）但敏感性较高（100%）。尸检血管造影也未能检测到移植血管或吻合口壁的夹层。这种血管造影方法的技术问题是由于灌注压力过低、硅橡胶聚合过快、造影剂漏入心室或X线投影错误。这些结果表明，我们的尸检血管造影技术可生成移植血管和吻合口部位的永久性橡胶铸型模型，提高了冠状动脉旁路移植术后并发症的诊断准确性，并简化了术后尸检解剖，现在可以直接针对疑似并发症进行确认。
