同期行冠状动脉旁路移植和腹主动脉腔内修复术

Simultaneous endovascular aortic repair and coronary artery bypass grafting

目的 总结重症冠心病（CAD）合并肾下型腹主动脉瘤（AAA）及腹主动脉贯通性溃疡（PAU）患者一期行冠状动脉旁路移植术（CABG）及腹主动脉腔内修复术（EVAR）的治疗经验.方法 2013年1月至2016年12月,13例重症CAD合并肾下型AAA及PAU患者行CABG同期EVAR治疗,其中男12例（92.3％）,女1例（7.7％）,年龄（63.7±7.3）岁.11例以冠心病相关症状就诊,2例以腹主动脉瘤/穿通性溃疡相关症状就诊,腹主动脉病变：AAA 3例,PAU 10例;2例患者合并胸主动脉PAU.CABG手术和AAA腔内治疗均按常规操作规范进行,合并胸主动脉PAU患者,同期行胸主动脉覆膜支架腔内置入术（TEVAR）.结果 先行EVAR,再行CABG7例;先行CABG,再行EVAR 6例;2例同期行TEVAR.全组行体外循环下CABG（ON-PUMP）11例,非体外CABG（OFF-PUMP）2例,平均旁路移植（2.5±0.7）支.ON-PUMP患者主动脉阻断（50.7 ±16.5） min,体外循环（58.0±11.2） min.13例共置入胸主动脉及腹主动脉覆膜支架30枚.全组术后呼吸机辅助（17.8±7.0）h,ICU（2.7±1.9）天,术后住院（8.1±2.4）天,均顺利出院.1例出院后伤口愈合不良、胸骨后感染,再次人院行胸大肌皮瓣转移术,二次术后29天突发心搏骤停死亡.12例生存,术后随访1个月～3年,患者旁路血管均通畅,支架位置及形态均良好,病变隔绝完全,无内漏.结论 对于存在适应证的患者,由一组外科团队完成手术及血管腔内操作,同期行CABG和EVAR治疗是安全、可行的.与传统的多科室会诊治后、同期或分期外科修复相比,手术创伤更小,手术时间更短,围术期并发症风险更低,效率更高,更有利于患者整体管理.

Objective To summarize experience of concomitant endovascular aneurysm aortic repair（EVAR） and coronary artery bypass grafting（CABG） for patients of severe coronary artery disease（CAD） complicated with infra-renal abdominal aortic aneurysm（AAA） or infra-renal abdominal penetrating aortic ulcer（PAU）.Methods Between January 2013 and December 2016,13 patients with severe CAD and infra-renal AAA/PAU who underwent CABG and EVAR were enrolled in this study.12 patients （92.3 %） were male and 1 patient was female （7.7 %）,the mean age of（63.7 ± 7.3） years.11 patients with CAD related symptoms,2 patients with AAA/PAU related symptoms,abdominal aortic lesions include：AAA in 3cases,PAU in 10 cases,2 patients combined with PAU of the thoracic aorta.CABG and EVAR manipulations were performed according to the routine protocol,patients who were combined with thoracic aorta PAU were treated with thoracic endovascular aortic repair （TEVAR） simultaneously.Results 7 patients received EVAR followed by CABG;6 patients received CABG followed by EVAR,TEVAR were performed in 2 patients.For all the patients,there were 11 cases of CABG were performed under the cardiopulmonary bypass（CPB） （ON-PUMP） and 2 others cases were performed without CPB（OFF-PUMP）.On the average（2.5 ± 0.7）grafts were performed.The time of aortic clamp and CPB averaged were（50.7 ± 16.5）min and （58.0 ± 11.2）min respectively for the ON-PUMP CABG patients.Totally 30 thoracic aorta and abdominal aorta stent grafts were implanted in 13 patients.The duration of postoperative mechanical ventilation time was （17.8 ± 7.0） hours,Median intensive care stay was （2.7 ± 1.9） days,while hospital stay was（8.1 ± 2.4）days.All the patients was discharged.1 patient suffered wound unhealing 2 days after discharging,followed by sternal infection,he was re-admitted and received pectoralis major myocutaneous flap transfer operation,29 days after this operation,he suffered sudden cardiac arrest and eventually dead.The other 12 surviving patients was followed up for 1 ～ 36 months,The results showed that the patency of the grafts in all patients was good,no EVAR related secondary interventions were required.Conclusion For the patients with surgical indications,the procedure of one stage CABG and EVAR completed by one surgical team was safe and feasible.Comparing with the traditional one stage or staged surgical repair,this strategy showed less surgical trauma,shorter operation time,lower perioperative risks,more efficacy and more conducive to the overall management of patients.