Pagni S, Qaqish N K, Senior D G, Spence P A
Department of Cardiology, Jewish Hospital, University of Louisville, Kentucky 40202, USA.
Ann Thorac Surg. 1997 Jun;63(6 Suppl):S64-7. doi: 10.1016/s0003-4975(97)00416-5.
Anterior wall myocardial revascularization through a left anterior minithoracotomy is an increasingly accepted procedure. Technical failure at the anastomotic site, promoting persistent or recurrent angina, is known to occur and may be underrecognized. This report summarizes the incidence of technical failure in an initial clinical experience and describes potential causes of early postoperative complications.
Between December 1995 and May 1996, 15 patients underwent left internal mammary artery-to-left anterior descending artery revascularization without extracorporeal circulation. The surgical indication was single-vessel coronary disease in all patients. We exposed the left anterior descending artery target site through a 10-cm left anterior fourth space thoracotomy. The fourth costal cartilage was resected and the left internal mammary artery was harvested under direct visualization. Two 4-0 polypropylene sutures snared in tourniquets proximal and distal to the anastomotic site were used to obtain a bloodless field and stabilization of the left anterior descending artery.
All patients had procedures initially deemed successful based on disappearance of angina or postoperative transthoracic Doppler examination of the internal mammary artery 3 to 5 days postoperatively. However, 3 patients presented with recurrent angina at 2, 6, and 8 weeks. Angiography or direct visualization at operation demonstrated the technical complication (stenosis at the anastomotic site in 2 and snare injury in the native vessel in 1). Two patients required reoperation.
Initial results with minimally invasive coronary bypass grafting have generated great enthusiasm worldwide, but there is no consensus on how the procedure should be performed. These results suggest that a nonstabilized anastomosis results in an unacceptable failure rate. Furthermore, sutures encircling the left anterior descending artery should not be used for vessel stabilization as injury of the artery may occur.
通过左前小切口进行前壁心肌血运重建是一种越来越被认可的手术。已知吻合部位的技术失败会导致持续性或复发性心绞痛，且可能未被充分认识。本报告总结了初步临床经验中技术失败的发生率，并描述了术后早期并发症的潜在原因。
1995年12月至1996年5月期间，15例患者在非体外循环下接受了左乳内动脉至左前降支动脉的血运重建。所有患者的手术指征均为单支冠状动脉疾病。我们通过10厘米的左前第四肋间开胸术暴露左前降支动脉靶点。切除第四肋软骨，在直视下获取左乳内动脉。在吻合部位近端和远端的止血带中圈套两根4-0聚丙烯缝线，以获得无血视野并稳定左前降支动脉。
所有患者最初根据心绞痛消失或术后3至5天对乳内动脉进行的经胸多普勒检查被认为手术成功。然而，3例患者在术后2周、6周和8周出现复发性心绞痛。血管造影或术中直视显示技术并发症（2例吻合部位狭窄，1例原位血管圈套损伤）。2例患者需要再次手术。
微创冠状动脉搭桥术的初步结果在全球范围内引起了极大的热情，但对于该手术的实施方式尚无共识。这些结果表明，不稳定的吻合会导致不可接受的失败率。此外，不应使用环绕左前降支动脉的缝线来稳定血管，因为可能会发生动脉损伤。
