左前降支双支移植：胸廓内动脉与补充静脉移植吻合口之间的距离对移植血管存活是否有影响？

Double grafting of the left anterior descending artery: is the distance between the internal mammary artery and supplemental vein graft anastomoses relevant in graft survival?

作者信息

Pagni S, Salloum E, Storey J, Montgomery W, Cerrito P, Van Himbergen D, Gray L A, Spence P A

机构信息

Department of Surgery, University of Louisville, KY 40202, USA.

出版信息

Eur J Cardiothorac Surg. 1998 Jan;13(1):36-41. doi: 10.1016/s1010-7940(97)00299-6.

DOI:10.1016/s1010-7940(97)00299-6

PMID:9504728

Abstract

INTRODUCTION

Under certain conditions (small internal mammary artery (IMA) or large runoff), double grafting of the left anterior descending (LAD) artery system is necessary to avoid the ominous consequences of myocardial hypoperfusion. Previous studies have shown that a saphenous vein (SVG) adjacent to an IMA graft leads to failure of the IMA. This study compares IMA flow patterns when adjacent ( < 1 cm) and separated (3-4 cm) from a SVG placed on a proximally occluded LAD.

METHODS

A SVG and right IMA (PIMA) to proximal LAD (2.5-3 mm) coronary bypass were performed in 12 mongrel dogs. The left IMA (DIMA) was anastomosed to the distal LAD (1.5 mm). All anastomoses were carried out without cardiopulmonary bypass. The native LAD was occluded proximally to the PIMA anastomosis, and all graft flows were measured in competitive and non-competitive flow conditions.

RESULTS

Isolated graft to LAD flows were similar for the three conduits. There was a drop in flow in both the PIMA and DIMA when placed in competition with the SVG (10.1+/-3.0 vs. 19.1+/-4.6 ml/min; P < 0.05). The total drop in flow was significantly greater in the PIMA (67.6 vs. 39.9%; P < 0.05). Diastolic flow was better preserved in the distal IMA graft (19.6 + 5.6 vs. 10.2+/-3.0 ml/min; P < 0.05). The patterns of flow were much different during competition and there was significant retrograde systolic flow in all PIMA grafts while there was no (n = 5) or minimal retrograde flow (n = 7) in the DIMA grafts.

CONCLUSION

An IMA graft, when adjacent to a SVG, sustains a significant decrease in both total and diastolic flows and develops an oscillating pattern of flow in early systole (retrograde then antegrade). Placing the IMA more distally on the LAD improves flow and decreases retrograde flow. In clinical situations requiring double grafting on the LAD, distance between grafts may be an important factor in maintaining IMA patency.

摘要

引言

在某些情况下（如乳内动脉较细或血流灌注范围较大），左前降支（LAD）动脉系统进行双支血管移植对于避免心肌灌注不足的不良后果是必要的。既往研究表明，与乳内动脉移植物相邻的大隐静脉（SVG）会导致乳内动脉移植物失败。本研究比较了在近端闭塞的LAD上，与SVG相邻（<1 cm）和分开（3 - 4 cm）时乳内动脉的血流模式。

方法

对12只杂种犬进行了SVG和右乳内动脉（PIMA）至近端LAD（2.5 - 3 mm）的冠状动脉搭桥术。左乳内动脉（DIMA）吻合至远端LAD（1.5 mm）。所有吻合均在非体外循环下进行。在PIMA吻合口近端闭塞自身LAD，并在竞争性和非竞争性血流条件下测量所有移植物的血流。

结果

三种血管移植物至LAD的孤立血流相似。当与SVG竞争时，PIMA和DIMA的血流均下降（10.1±3.0 vs. 19.1±4.6 ml/min；P < 0.05）。PIMA的总血流下降幅度显著更大（67.6% vs. 39.9%；P < 0.05）。远端乳内动脉移植物的舒张期血流保存更好（19.6 + 5.6 vs. 10.2±3.0 ml/min；P < 0.05）。竞争期间血流模式差异很大，所有PIMA移植物在收缩期均有明显的逆行血流，而DIMA移植物中无逆行血流（n = 5）或仅有微量逆行血流（n = 7）。