Coulson A S, Bakhshay S A
Dameron Heart Institute, Stockton, CA 95203, USA.
Heart Surg Forum. 1998;1(1):54-9.
Minimally invasive direct coronary artery bypass grafting (MIDCAB) is an attractive new alternative for revascularizing patients with high perioperative risk for standard coronary surgery. However, limited surgical exposure through a small thoracotomy makes harvesting the full length of the internal mammary artery (IMA) very difficult and time consuming. We are now employing a new alternative with a "T" shaped bridge graft constructed from the undisturbed IMA using a 4 centimeter interposition segment of donor vessel. We prefer this approach in high risk cases in order to reduce the trauma of the thoracotomy, minimize pain and narcotic use, promote early extubation, and achieve immediate post-operative mobilization and recovery in patients who would otherwise be at risk for a poor outcome with conventional grafting techniques.
From September 10, 1997 to December 19, 1997 eight high-risk patients underwent at least one "T-MIDCAB" graft from the undisturbed IMA to the coronary artery using a short segment of either radial artery or saphenous vein. All cases were performed using a limited access anterior thoracotomy through the bed of the resected costal cartilage and without intercostal retraction. Five males and three females ranging from 58 to 83 years (average 73 years) were operated using this new concept. Pre-operative ejection fractions ranged from 25% to 80% (mean 43%). Parsonnet scores ranged from 21 to 43 (average 34) with predicted mortalities ranging from 30 to 40%.
Eleven "T" grafts were placed (1.38 distals/patient). All 8 patients survived. Postoperative complications were minimal. The average length of stay was only 8 days (range 3 to 9 days). Intensive care unit stay averaged 3 days (range 1 to 4 days). One patient underwent postoperative angiography which demonstrated full patency of the conduit and all anastomoses.
"T-MIDCAB" using a bridge graft of free radial artery or saphenous vein appears to be successful in high risk patients. The authors noted shorter operative times, reduced chest wall trauma and better pain control than with standard MIDCAB and full IMA harvesting. Cautious use of this procedure as an alternative to more morbid types of surgical revascularization is advised.
微创直接冠状动脉旁路移植术（MIDCAB）是一种有吸引力的新选择，适用于围手术期风险高、无法进行标准冠状动脉手术的患者进行血管重建。然而，通过小切口胸廓切开术进行手术暴露有限，使得获取完整长度的胸廓内动脉（IMA）非常困难且耗时。我们现在采用一种新的替代方法，即使用一段4厘米的供体血管间置段，从完整的IMA构建一个“T”形桥接移植物。对于高风险病例，我们更喜欢这种方法，以减少胸廓切开术的创伤，将疼痛和麻醉药物的使用降至最低，促进早期拔管，并使那些采用传统移植技术可能预后不良的患者术后立即活动并康复。
1997年9月10日至1997年12月19日，8例高风险患者接受了至少一次“T-MIDCAB”移植，使用桡动脉或大隐静脉的短段从完整的IMA移植到冠状动脉。所有病例均通过切除肋软骨床进行有限切口前胸廓切开术，且不进行肋间牵开。5例男性和3例女性，年龄58至83岁（平均73岁），采用这一新概念进行手术。术前射血分数范围为25%至80%（平均43%）。Parsonnet评分范围为21至43（平均34），预测死亡率范围为30%至40%。
共放置了11个“T”形移植物（每位患者1.38个远端移植物）。所有8例患者均存活。术后并发症极少。平均住院时间仅为8天（范围3至9天）。重症监护病房平均住院时间为3天（范围1至4天）。1例患者术后进行了血管造影，显示移植物和所有吻合口完全通畅。
使用游离桡动脉或大隐静脉桥接移植物的“T-MIDCAB”在高风险患者中似乎是成功的。作者指出，与标准MIDCAB和完整IMA获取相比，手术时间更短，胸壁创伤更小，疼痛控制更好。建议谨慎使用该手术作为更具创伤性的手术血管重建类型的替代方法。
