Elbeery J R, Brown P M, Chitwood W R
Division of Cardiothoracic Surgery, East Carolina University School of Medicine, Greenville, North Carolina 27858-4354, USA.
Ann Thorac Surg. 1998 Jul;66(1):51-5. doi: 10.1016/s0003-4975(98)00377-4.
Minimally invasive direct coronary artery bypass grafting involving beating heart left internal mammary artery to left anterior descending coronary artery anastomoses are performed with increasing frequency. Controversy exists regarding the need for intraoperative assessment of graft patency.
We designed a technique to perform arteriography of the left internal mammary artery by using left radial artery access and standard fluoroscopy to evaluate patency in the operating room. The last 50 of 87 minimally invasive direct coronary artery bypass grafting operations were evaluated by intraoperative arteriography and Doppler ultrasound. Angiograms were performed by the surgeon and involved cannulation and direct injection of contrast medium into the origin of the left internal mammary artery via the left radial artery.
Total procedure time was less than 15 minutes. No injuries to the left internal mammary artery were identified. Anastomotic occlusions were identified in 4 cases (8%), 2 of which involved sequential diagonal and left anterior descending anastomoses. These were corrected at the time of surgery with 2 cases requiring conversion to standard coronary artery bypass grafting. Qualitative assessment of grafts with Doppler ultrasound failed to definitively identify these occlusions. There were no deaths and no perioperative infarctions.
Intraoperative arteriography of the left internal mammary artery can be performed by the surgeon, and a significant number of anastomotic problems may be identified and corrected by using this technique. Therefore, a 100% early graft patency rate may be attainable.
微创直接冠状动脉旁路移植术，即不停跳下行左乳内动脉至左前降支冠状动脉吻合术的实施频率日益增加。关于术中评估移植物通畅性的必要性存在争议。
我们设计了一种技术，通过经左桡动脉途径和标准荧光透视在手术室评估左乳内动脉的通畅性，以进行左乳内动脉造影。87例微创直接冠状动脉旁路移植手术中的最后50例通过术中动脉造影和多普勒超声进行评估。动脉造影由外科医生操作，包括经左桡动脉插管并将造影剂直接注入左乳内动脉起始处。
整个操作过程耗时不到15分钟。未发现左乳内动脉损伤。4例（8%）发现吻合口闭塞，其中2例涉及依次对角支和左前降支吻合。这些在手术时得到纠正，2例需要转为标准冠状动脉旁路移植术。用多普勒超声对移植物进行定性评估未能明确识别这些闭塞情况。无死亡病例，也无围手术期梗死发生。
外科医生可在术中进行左乳内动脉造影，使用该技术可识别并纠正大量吻合问题。因此，可能实现100%的早期移植物通畅率。
