冠状动脉旁路移植术中乳内动脉损伤类型与处理

The pathology type and treatment of internal mammary artery damage in coronary artery bypass grafting

目的:回顾性分析冠状动脉旁路移植术(CABG)中,乳内动脉损伤的情况以及相应的应对措施。方法:自1997年7月至2017年4月,共实施了10 360例包含乳内动脉取材的CABG术,其中发生286例乳内动脉损伤;损伤后改用大隐静脉旁路移植145例(50.7%)、行损伤乳内动脉游离移植104例(36.4%)以及其他方法37例,记录和分析围术期的不良事件及死亡情况。结果:常见的乳内动脉损伤病理分型包括:内膜撕裂188例(65.7%)、夹层86例(30.0%)等。按操作失误分类,其中电刀伤183例(64.0%),牵拉伤86例(30.1%)等。围术期死亡1例、围术期心肌梗死1例、术中心室颤动2例、围术期脑梗死2例、行IABP辅助2例,术中由微创小切口转胸骨正中切口1例。结论:乳内动脉损伤在CABG术中有一定的发生率。对于不同病理分型以及不同部位的乳内动脉损伤,可以采用不同的应对方法。改用大隐静脉旁路移植、游离移植损伤的乳内动脉等13种方法,可作为CABG术中乳内动脉损伤的应对措施。

Objective： To analyze the causes and treatment method of internal mammary artery（IMA） damage in coronary artery bypass graft（CABG）. Methods： From July 1997 to April 2017, we performed 10360 CABGs with IMA harvest. In total, 286 IMAs were injured during the operation. The great saphenous vein（GSV） was used to replace the injured IMA in 145 cases（50.7%）. Moreover, 104 cases（36.4%） underwent free grafting of the IMA and other method. The adverse events during the perioperative period were analyzed. Results： The pathological reasons for IMA damage were disruption of the endothelial layer in 188（65.7%） cases and dissection in 86（30.0%） cases. Manipulation mistakes were caused by electrocautery in 183（64.0%） cases and tear damage in 86（30.1%） cases. One patient died during the perioperative period. Perioperative myocardial infarction occurred in one patient, ventricular fibrillation during surgery in two, and cerebral infarction in two. Two patients were assisted with an intra-aortic balloon pump. Moreover, minimally invasive direct CAB was converted to a full sternotomy in one patient. Conclusion： The IMA can sometimes be damaged in CABG, and different approaches are used based on its pathology reason and location. By applying the GSV and free grafting of the injured IMA, bailouts in our protocol can be used as a safe and effective way to deal with IMA damage in CABG.