Magovern J A, Hunter T J, Yoon P D
Department of Cardiothoracic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, USA.
Ann Thorac Surg. 2001 Feb;71(2):561-4. doi: 10.1016/s0003-4975(00)02460-7.
The minimally invasive direct coronary artery bypass procedure is not feasible if the left internal mammary artery has been used or has inadequate flow. We have applied a modified minimally invasive direct coronary artery bypass procedure, which uses a graft from the left axillary artery to the left anterior descending coronary artery in such situations.
The graft is anastomosed to the left axillary artery adjacent to the clavicle and tunneled underneath the vein, where it enters the thorax through the first interspace and courses to the left anterior descending coronary artery along the mediastinum.
Since 1997 we have used this operation in 22 patients with a mean age of 70 years (range, 52 to 83 years). All patients were high-risk candidates because of advanced age (70 +/- 7 years), depressed left ventricular function (mean left ventricular ejection fraction, 38% +/- 6%), or previous heart operation (20 of 22, 91%). Conduits for the graft were saphenous vein (n = 18) or radial artery (n = 4). Ten patients were extubated in the operating room, and the mean duration of mechanical ventilation was 5.8 +/- 6 hours. There was one operative death (1 of 22, 4.5%). The mean length of intensive care unit and hospital stay was 1.5 days (range, 1 to 6 days) and 6 days (range, 2 to 15 days), respectively. At a mean follow-up of 6 months, all discharged patients are alive and functionally improved. None have required surgical or catheter-based revascularization of the left anterior descending coronary artery.
The left axillary artery to left anterior descending coronary artery graft should be considered for high-risk patients in whom a minimally invasive direct coronary artery bypass procedure is not possible.
如果左乳内动脉已被使用或血流不足，微创直接冠状动脉旁路移植术则不可行。我们应用了一种改良的微创直接冠状动脉旁路移植术，在此种情况下使用从左腋动脉至左前降支冠状动脉的移植物。
将移植物吻合至锁骨附近的左腋动脉，并在静脉下方隧道化，移植物通过第一肋间间隙进入胸腔，然后沿纵隔走向左前降支冠状动脉。
自1997年以来，我们已对22例患者实施了该手术，患者平均年龄70岁（范围52至83岁）。所有患者均为高危患者，原因包括高龄（70±7岁）、左心室功能不全（平均左心室射血分数38%±6%）或既往心脏手术史（22例中有20例，91%）。移植物的管道为大隐静脉（n = 18）或桡动脉（n = 4）。10例患者在手术室拔管，机械通气的平均持续时间为5.8±6小时。有1例手术死亡（22例中的1例，4.5%）。重症监护病房和住院的平均时长分别为1.5天（范围1至6天）和6天（范围2至15天）。平均随访6个月时，所有出院患者均存活且功能有所改善。无一例需要对左前降支冠状动脉进行外科或基于导管的血运重建。
对于无法进行微创直接冠状动脉旁路移植术的高危患者，应考虑采用左腋动脉至左前降支冠状动脉的移植物。
