Zamorano C, Diethrich E B
Heart Lung. 1975 May-Jun;4(3):402-8.
When a candidate for aortocoronary bypass has an associated lesion of the aorta orone of its major branches, a single operation may be indicated for correction of both problems. Three typical cases illustrate the concept of the combined approach to surgical management of coronary arterial lesions and associated carotid arterial disease, abdominal aortic aneurysm, and superficial-femoral arterial disease. An aortocoronary bypass candidate with carotid stenosis may be in imminent danger of both myocardial infarction and stroke. The selection of the proper sequence of operations under these circumstances is extremely important because any form of hypotension might produce a stroke. Cardiopulmonary bypass usually results in at least a transient reduction of the systemic pressure which would further compromise the blood flow across the tight stenosis of the carotid artery. Therefore, we recommended repair of the carotid lesion before aortocoronary bypass is attempted in order to avoid the possibility of postoperative stroke. The combined presence of coronary arterial disease and abdominal aortic aneurysm is indication for operation, but resection of the aneurysm involves cross-clamping of the aorta, and subsequent changes in arterial pressure might impair the coronary circulation and lead to myocardial infarction. On the other hand, the systemic heparinization required for the establishment of cardiopulmonary bypass and arterial pressure changes could affect the integrity of aneurysm. Unless the abdominal aneurysm is expanding, however, we elect to perform coronay revascularization first, with resection and graft replacement of the aneurysm immediately after heparin reversal. Occlusive disease of the superficial femoral artery can be corrected immediately following aortocoronary bypass. Since the femoral and upper leg incisions have been performed, in certain cases it is convenient to complete the femoral popliteal bypass while the chest is being closed, thus saving a separate operation to correct the femoral occlusive disease.
当进行主动脉冠状动脉搭桥术的患者伴有主动脉或其主要分支之一的病变时，可能需要进行单次手术来同时纠正这两个问题。三个典型病例说明了联合手术治疗冠状动脉病变及相关颈动脉疾病、腹主动脉瘤和股浅动脉疾病的概念。患有颈动脉狭窄的主动脉冠状动脉搭桥术候选患者可能同时面临心肌梗死和中风的紧迫危险。在这种情况下选择合适的手术顺序极为重要，因为任何形式的低血压都可能导致中风。体外循环通常至少会使体循环压力短暂降低，这会进一步损害通过颈动脉严重狭窄处的血流。因此，我们建议在尝试进行主动脉冠状动脉搭桥术之前先修复颈动脉病变，以避免术后中风的可能性。冠状动脉疾病和腹主动脉瘤同时存在是手术指征，但切除动脉瘤需要钳夹主动脉，随后的动脉压力变化可能损害冠状动脉循环并导致心肌梗死。另一方面，建立体外循环所需的全身肝素化和动脉压力变化可能影响动脉瘤的完整性。然而，除非腹主动脉瘤在扩大，否则我们选择先进行冠状动脉血运重建，在肝素逆转后立即切除动脉瘤并进行移植置换。股浅动脉闭塞性疾病可在主动脉冠状动脉搭桥术后立即纠正。由于已经进行了股部和大腿切口，在某些情况下，在关闭胸部时完成股腘动脉搭桥很方便，从而节省了一次单独纠正股动脉闭塞性疾病的手术。
