“一站式”行胸主动脉腔内修复术联合冠状动脉旁路移植术的临床经验

Clinical Experience for“ One-stop” Performance of Thoracic Endovascular Aortic Repair and Coronary Artery Bypass Grafting

目的:探讨胸主动脉腔内修复术(TEVAR)联合冠状动脉(冠脉)旁路移植术(CABG)"一站式"治疗冠心病合并胸主动脉疾病的安全性及其临床策略。方法:回顾性分析2009-04至2016-01间,在阜外医院血管外科中心接受"一站式"TEVAR联合CABG手术治疗冠心病合并胸主动脉疾病患者20例,男性18例,平均年龄[65.2±8.5(51~82)]岁。分析"一站式"手术的实施策略及围手术期注意事项。结果:20例患者,1例植入胸主动脉支架2枚,19例植入胸主动脉支架1枚,其中3例分别同期实施腹主动脉覆膜支架植入术1例、右侧髂总动脉支架植入术1例和颈动脉内膜剥脱术1例;平均冠脉搭桥[2.4±0.94(1~4)]支,10例(50%)采用乳内动脉桥。20例患者平均住院时间[22.4±11.6(8~58)]天,6例(30%)患者接受输血治疗;低心排综合征1例(5%),采用体外膜氧合器(ECMO)辅助治疗,后又因胸液多二次开胸止血;术后30天死亡2例(10%)。17例患者(失访1例)均获得门诊或电话随访,平均随访时间[13.4±13.6(1~49)]个月,2例患者分别于术后12个月、49个月因脑血管意外去世,15例患者临床症状消失或明显减轻,生活质量改善,无手术相关死亡。结论:TEVAR联合CABG"一站式"治疗冠心病合并胸主动脉疾病中期疗效满意,若需同期行去分支手术为TEVAR创造锚定区,会增加手术时间和手术风险。

Objective： To explore the safety and strategy of thoracic endovascular aortic repair （TEVAR） combining coronary artery bypass grafting （CABG） as ＂one-stop＂ performance in treating the patients with coronary artery disease （CAD） and thoracic aorta disease. Methods： A total of 20 patients received ＂one-stop＂ treatment of TEVAR combining CABG in our hospital from 2009-04 to 2016-01 were retrospectively analyzed. There were 18 male and the mean age of patients was （65.2±8.5, 51-82） years. The performance strategy and peri-operative management were studied. Results： There were 1/20 patient received 2 stents implantation in thoracic aorta and 19 received 1 stent in thoracic aorta those including 1 case with endovascular repair of abdominal aortic aneurysm, 1 with right iliac artery stent implantation and 1 with carotid endarterectomy at meanwhile. The average number of coronary artery bypass branch was （2.4±0.94, 1-4） and 10 （50%） patients received internal mammary artery grafting. The average in-hospital time in all 20 patients was （22.4±11.6, 8-58） days. There were 6 （30%） patients received blood transfusion; 1 （5%） having low cardiac output syndrome received＆nbsp;extracorporeal membrane oxygenation （ECMO）, then received the second thoracotomy for hemostasis due to excessive pleural effusion; 2 （10%） patients died at 30 days post-operation. 1 patient lost contact and 17 received clinical or telephone follow-up visit at the average of （13.4＋13.6, 1-49） months; 2 patients died for cerebral hemorrhage at 12 and 49 months post-operation, the rest 15 had disappeared symptoms and improved quality of life, no operation related death occurred. Conclusion： TEVAR combining CABG as ＂one-stop＂ performance presented good mid-term effect in treating the patients with CAD and thoracic aorta disease; in otherwise, the operative time and risk might be increased by two step performance.