内窥镜获取大隐静脉:技术、预后、思考与争议

Endoscopic Vein Harvesting: Technique, Outcomes, Concerns & Controversies

移植血管的选择对冠状动脉旁路移植术(CABG)短期及远期预后有着重要意义。患者术后的平稳恢复,长期生活质量的改善以及避免二次干预都和冠状动脉血管桥的通畅密不可分。考虑到桥血管远期通畅率以及术后生存率,乳内动脉是CABG患者桥血管的首选。但是,当患者存在多根冠状动脉需要搭桥时,大隐静脉仍然被广泛应用。大隐静脉获取的传统方法是采用自脚踝至腹股沟开放切口,称为开放性大隐静脉获取术(OVH)。但是这样的取桥方法会引起腿部手术切口疼痛以及感染。此外,如此长的伤口会让患者感觉极不美观。切口相关并发症以及患者对美观的需求促使内窥镜大隐静脉获取术(EVH)的产生。对于OVH和EVH两种术式,既往的文献表明EVH可以减少切口相关并发症,满足患者的美观需求,缩短住院时间,并减轻术后切口的疼痛。尽管EVH具有上述已知的优点,但是也有报道认为内窥镜技术存在损伤静脉的风险,同时在静脉桥的通畅度以及临床预后等方面存在潜在的不利因素,这些都限制了EVH的广泛应用。本综述将对EVH的技术、预后、思考以及争议等方面进行详细的剖析。

The choice of the graft conduit for coronary artery bypass grafting（CABG） has significant implications both in the short- and long-term. The patency of a coronary conduit is closely associated with an uneventful postoperative course, better long-term patient survival and superior freedom from re-intervention. The internal mammary artery is regarded as the primary conduit for CABG patients, given its association with long-term patency and survival. However, long saphenous vein（LSV） continues to be utilized universally as patients presenting for CABG often have multiple coronary territories requiring revascularization. Traditionally, the LSV has been harvested by creating incisions from the ankle up to the groin termed open vein harvesting（OVH）. However, such harvesting methods are associated with incisional pain and leg wound infections. In addition, patients find such large incisions to be cosmetically unappealing. These concerns regarding wound morbidity and patient satisfaction led to the emergence of endoscopic vein harvesting（EVH）. Published experience comparing OVH with EVH suggests decreased wound related complications, improved patient satisfaction, shorter hospital stay, and reduced postoperative pain at the harvest site following EVH. Despite these reported advantages concerns regarding risk of injury at the time of harvest with its potential detrimental effect on vein graft patency and clinical outcomes have prevented universal adoption of EVH. This review article provides a detailed insight into the technical aspects, outcomes, concerns, and controversies associated with EVH.