Vecherskiĭ Iu Iu, Andreev S L, Zatolokin V V
Department of Cardiovascular Surgery, Research Institute of Cardiology under the Siberian Branch of the Russian Academy of Medical Sciences, Tomsk, Russia.
Angiol Sosud Khir. 2015;21(1):148-54.
The authors analysed the outcomes in a total of 73 patients subjected to coronary artery bypass grafting with the use of the "in situ" the right internal thoracic artery. Of these, 14 patients endured bypass grafting with assessment of the conformity of the length of the "in situ" right ITA as a conduit for the distal third of the right coronary artery (RCA). 16 patients underwent grafting of the RITA "in situ" with the RCA by passing through the pleural cavity. The remaining 43 patients were subjected to bilateral mammary composite bypass grafting using the radial artery (RA). A total of 22 segments of the RA were subjected to a comparative morphometric examination depending on the method of exposure. We additionally analysed 56 cases of utilizing the RA with the use of the pharmacological protocol of preventing spasm. The results were regarded statistically significant if p<0.05. We used the non-parametric criterion of Mann-Whitney. The obtained results showed that the right ITA "in situ" may be used for bypass grafting of the RCA system, excluding the risk of graft tension, if the perpendicular from the 6th intercostal space crosses the sharp edge of the heart 1.5-2 cm distal to the medial point, with the minimum number of complications after 1.5±0.3 years (7.1%). When the above-mentioned perpendicular is located proximal to the middle point of the sharp edge of the heart it is possible to use the right ITA "in situ" for the RCA system thanks to passing the conduit through the right pleural cavity under the anterior segment of the upper lobe and the medial segment of the middle lobe of the right lung with no complications after 1 year. The method of composite bypass grafting by means of the proximal segment of the right ITA "in situ" and the RA makes it possible to effectively revascularize any portions of the coronary bed (latency 94.7% after 3.0±0.8 years), to avoid manipulations on the aorta, and to save the bed of the right ITA in the middle and distal third of the sternum with no postoperative complications. It was revealed that in the conditions of decreased osmotic pressure the increase in the thickness of the vascular wall is more pronounced in the skeletonized segments of the RA (1.38±0.05 mm) as compared with the segments surrounded by connective and fatty tissue (1.09±0.04 mm). The pharmacological protocol for prevention of radial artery spasm used in 56 patients resulted in a small number of complications observed after 3.0±0.8 years (myocardial infarctions - 1.75%, angina pectoris relapse - 7%). Hence, the developed methods of using the right ITA "in situ" widen possibilities of bilateral mammary bypass grafting, excluding the existing problems of routine use of the both ITAs "in situ".
作者分析了总共73例使用“原位”右胸廓内动脉进行冠状动脉搭桥术患者的治疗结果。其中，14例患者在评估“原位”右胸廓内动脉作为右冠状动脉（RCA）远端三分之一的管道长度的一致性后进行了搭桥术。16例患者通过胸膜腔进行了“原位”右胸廓内动脉与RCA的移植。其余43例患者使用桡动脉（RA）进行了双侧乳腺复合搭桥术。根据暴露方法，共对22段RA进行了比较形态学检查。我们还分析了56例使用预防痉挛药理学方案的RA病例。如果p<0.05，则认为结果具有统计学意义。我们使用了曼-惠特尼非参数标准。获得的结果表明，如果从第6肋间空间引出的垂线在心脏锐缘内侧点远端1.5 - 2 cm处穿过心脏锐缘，“原位”右胸廓内动脉可用于RCA系统的搭桥术，排除移植张力风险，且在1.5±0.3年后并发症最少（7.1%）。当上述垂线位于心脏锐缘中点近端时，由于将管道穿过右肺上叶前段和中叶内侧段下方的右胸膜腔，“原位”右胸廓内动脉可用于RCA系统，1年后无并发症。通过“原位”右胸廓内动脉近端段和RA进行复合搭桥术的方法能够有效地使冠状动脉床的任何部分血管再通（3.0±0.8年后通畅率94.7%），避免对主动脉进行操作，并在胸骨中、远端三分之一处保留右胸廓内动脉床，术后无并发症。结果显示，在渗透压降低的情况下，与被结缔组织和脂肪组织包围的段（1.09±0.04 mm）相比，RA骨骼化段血管壁厚度增加更为明显（1.38±0.05 mm）。56例患者使用的预防桡动脉痉挛药理学方案在3.0±0.8年后观察到的并发症较少（心肌梗死 - 1.75%，心绞痛复发 - 7%）。因此，所开发的使用“原位”右胸廓内动脉的方法拓宽了双侧乳腺搭桥术的可能性，排除了常规使用双侧“原位”胸廓内动脉存在的问题。
