Przybojewski J Z
S Afr Med J. 1982 Dec 4;62(24):908-17.
A patient underwent aortocoronary saphenous bypass grafting to the left anterior descending coronary artery (LADA) and its first diagonal branch for the relief of severe angina pectoris. There was difficulty in exposure of the LADA, which was covered by a thick layer of epicardial adipose tissue. Postoperatively the patient continued to experience severe retrosternal pain which prompted early repeat coronary angiography. This revealed an aortocoronary vein fistula (AVF) secondary to the inadvertent anastomosis of one of the saphenous vein grafts to the left anterior descending coronary vein (LADV). It was only after this procedure that clinical examination revealed a grade 2/6 high-frequency continuous murmur best heard in the 2nd and 3rd left intercostal spaces. The persistance of severe angina pectoris at rest and on effort led to performance of a revision operation. The LADV was then transected and ligated, and an extended saphenous vein reimplanted into the LADA proper. This provided complete relief from angina. This is the first such case reported in South Africa and the sixth documented. In all the aortosaphenous vein grafts had been inserted into the LADV; all exhibited the classic continuous murmur postoperatively, apart from 1 patient who had an ejection systolic murmur. None of the other 5 patients complained of postoperative angina and only 3 were subjected to revision surgery. The literature is reviewed, with emphasis on the rationale for performing the first elective aortocoronary vein anastomosis in 1968. Clinical features of iatrogenic AVF are detailed and an attempt is made to assess when re-operation is indicated. It is easy to fail to notice this complication; however, its correction can have a dramatic effect on the patient's symptoms. It is the author's belief that many more such cases exist but are not being detected, probably because of lack of appreciation of the possibility of this iatrogenic condition occurring.
一名患者接受了主动脉冠状动脉大隐静脉搭桥术，将大隐静脉移植至左前降支冠状动脉（LADA）及其第一对角支，以缓解严重心绞痛。暴露LADA时遇到困难，它被一层厚厚的心外膜脂肪组织覆盖。术后患者仍持续经历严重的胸骨后疼痛，这促使早期再次进行冠状动脉造影。造影显示，由于大隐静脉移植血管之一意外地与左前降支冠状动脉静脉（LADV）吻合，形成了主动脉冠状动脉静脉瘘（AVF）。直到此时，临床检查才发现二级/六级高频连续性杂音，在左侧第二和第三肋间间隙听诊最清晰。静息和运动时严重心绞痛持续存在，导致进行了翻修手术。随后切断并结扎LADV，将一段延长的大隐静脉重新植入LADA主干。这使心绞痛完全缓解。这是南非报道的首例此类病例，也是有记录的第六例。所有病例中，大隐静脉移植血管均被插入LADV；除1例患者有喷射性收缩期杂音外，所有患者术后均出现典型的连续性杂音。其他5例患者均无术后心绞痛主诉，只有3例接受了翻修手术。本文回顾了相关文献，重点阐述了1968年首次进行选择性主动脉冠状动脉静脉吻合术的理论依据。详细介绍了医源性AVF的临床特征，并尝试评估何时需要再次手术。这种并发症很容易被忽视；然而，对其进行纠正可对患者症状产生显著影响。作者认为，可能存在更多此类病例但未被发现，可能是因为对这种医源性情况发生的可能性认识不足。
