多普勒超声在全动脉化冠状动脉旁路移植术前桥血管筛查中的应用价值

Application value of Doppler ultrasound in preoperative bridge vascular screening for total arterialized coronary artery bypass grafting

目的探讨多普勒超声在全动脉化冠状动脉旁路移植(CABG)术前评估桡动脉及左侧乳内动脉的临床应用价值。方法回顾性研究。纳入2018年1月—2020年1月蚌埠医学院第一附属医院收治的60例冠心病患者,其中男34例、女26例,年龄44~76岁。患者术前均使用多普勒超声检查左侧乳内动脉及双侧桡动脉。(1)分别采用超声和Allen试验检测60例患者两侧手掌侧支循环类型,初步筛除两种方法检测结果均为桡动脉依赖型血管或血管异常的患者。在行全动脉搭桥的患者中,以术中检测结果为依据,比较Allen试验和超声检测判断手掌侧支循环类型的差异。(2)测量并比较桡动脉桡骨茎突处、肘关节下5 cm处(肘关节下段)及二者中点处(中段)血管内径。(3)观察在按压和放松桡动脉状态下不同侧支循环类型尺动脉的血液峰值速度(PSV)变化及增长情况。(4)记录左侧乳内动脉第二肋间水平的血管内径及PSV,观察起始部血流方向、有无狭窄及乳内动脉下端是否在第四肋间分叉。(5)分析全动脉搭桥的患者桡动脉桥血管血流量与术前桡动脉内径之间的关系。(6)观察全动脉搭桥患者术后胸闷、心绞痛症状改善情况,以及心肌梗塞等急性心血管事件发生情况。术后3个月行冠脉CTA和手部超声检查,观察桥血管通畅情况及桡侧手掌血供情况。结果(1)60例患者经过初步筛查后纳入44例患者进行全动脉搭桥手术,术中剥离78条桡动脉,术中检测均为非桡动脉依赖型,其中Allen试验检测桡动脉依赖型10条、非桡动脉依赖型68条,多普勒超声检测桡动脉依赖型3条、非桡动脉依赖型75条,超声测量判断非桡动脉依赖型血管正确率为96.2%,高于Allen试验的87.2%,差异有统计学意义(χ^(2)=4.000,P<0.05)。(2)120条桡动脉桡骨茎突处、中段及肘关节下段血管内径分别为(2.06±0.44)、(2.38±0.43)、(2.37±0.43)mm,差异有统计学意义(F=21.542,P<0.05)。(3)术前超声检测手掌侧支循环为桡动脉依赖型17条,压迫桡动脉前后尺动脉PSV变化不明显,差异无统计学意义(P>0.05)。手术证实非桡动脉依赖型血管78条,压迫桡动脉后尺动脉PSV为(69.8±13.6)cm/s,明显高于压迫前的(42.0±7.4)cm/s,差异有统计学意义(t=23.346,P<0.05)。(4)60例患者左侧乳内动脉检测均未发现存在起始段狭窄、变异、反向血流等异常情况,其中7例患者左乳内动脉在第四肋间水平分支为肌膈动脉和腹壁下动脉。60例患者第二肋间左乳内动脉血管内径(2.29±0.38)mm,PSV(67.8±15.9)cm/s;其中仅1例患者血管内径为1.5 mm,PSV为12.2 cm/s,其他患者血管内径>1.5 mm、PSV>40.0 cm/s,均在正常范围。(5)简单线性回归分析显示:77条桡动脉桥血管,术中桡动脉桥血管血流量与术前测量的桡动脉内径呈正相关:Y=18.503X-4.471,R^(2)=0.499。(6)44例患者均顺利完成全动脉搭桥手术。住院期间临床症状改善,未发生围手术期心肌梗死。出院后44例患者均随访3个月,随访期间患者无胸闷、心绞痛,无手部缺血性功能障碍等并发症;术后3个月复查冠脉CTA显示桥血管通畅,无明显异常;手部超声检查显示桡侧手掌血供正常。结论多普勒超声可以测量桥血管的内径,判断桥血管有无狭窄等异常情况,在CABG术前可精准、高效地完成对桡动脉及乳内动脉的评估;同时,多普勒超声判断非桡动脉依赖型血管的正确率高于Allen试验,具有较高的临床应用价值。

Objective To explore the clinical application value of Doppler ultrasound in the evaluation of the radial artery and left internal mammary artery before coronary artery bypass grafting(CABG).Methods Retrospective research.This study enrolled 60 patients with coronary heart disease,including 34 males and 26 females,aged 44-76 years old,admitted to the First Affiliated Hospital of Bengbu Medical College from January 2018 to January 2020.All patients used Doppler ultrasound to examine the left internal mammary artery and bilateral radial artery before operation.(1)The types of collateral circulation on both palms of 60 patients were detected by ultrasound examination and Allen's test,and patients with radial artery-dependent blood vessels or abnormal blood vessels were initially screened out.In patients undergoing total arterial bypass,the intraoperative results of Allen's test and ultrasound examination to determine the type of palmar collateral circulation were compared.(2)The inner diameters of the blood vessels at the radial styloid process of the radial artery,5 cm below the elbow joint(lower section of the elbow joint),and the midpoint(middle section)of the two were measured and compared.(3)The peak systolic velocity(PSV)changes and growth of the ulnar artery of different collateral circulation types were observed under the pressing and relaxing states of the radial artery.(4)The inner diameter and PSV of the left internal mammary artery at the second intercostal level were recorded,the blood flow direction at the beginning was observed,and whether or not stenosis exists and whether or not the lower end of the internal mammary artery bifurcates in the fourth intercostal were determined.(5)The relationship between the blood flow of the radial artery graft and the internal diameter of the preoperative radial artery was analyzed in patients with total artery bypass graft.(6)The improvement of chest tightness,angina pectoris,and acute cardiovascular events,such as myocardial infarction,was observed in patients with total artery bypass grafting.Three months after surgery,coronary CTA and hand ultrasound were performed to observe the patency of the graft vessels and the blood supply of the radial palm.Results(1)Sixty patients were initially screened and 44 underwent total artery bypass surgery.Then,78 radial arteries were dissected during the operation.The intraoperative tests were all non-radial artery dependent.Allen's test detected 10 radial artery-dependent and 68 non-radial artery-dependent blood vessels,whereas the Doppler ultrasound detected 3 radial artery-dependent blood vessels and 75 non-radial artery-dependent blood vessels.The accuracy rate of non-radial artery-dependent blood vessels determined by ultrasound measurement was 96.2%,which was significantly higher than the 87.2% of Allen's test(χ^(2)=4.000,P<0.05).(2)The inner diameters of the blood vessels at the radial styloid process,the middle section,and the lower section of the elbow joint of the radial artery were(2.06±0.44),(2.38±0.43),and(2.37±0.43)mm,respectively,and the difference was statistically significant(n=120,F=21.542,P<0.05).(3)The preoperative ultrasound examination showed that 17 cases of palmar collateral circulation was radial artery-dependent.The PSV of the ulnar artery before and after the radial artery was not changed significantly,and the difference was not statistically significant(P>0.05).The operation confirmed 78 non-radial artery dependent vessels.The PSV of the ulnar artery after compression of the radial artery was(69.8±13.6)cm/s,which was significantly higher than the(42.0±7.4)cm/s before compression.The difference was statistically significant(t=23.346,P<0.05).(4)The left internal mammary artery of the 60 patients did not show any abnormalities,such as initial stenosis,variation,and reverse blood flow.Among them,the left internal mammary artery of seven patients branched into phrenic artery at the fourth intercostal level and the upper abdominal artery.In the 60 patients,the internal diameter of the left internal mammary artery in the second intercostal space was(2.29±0.38)mm,and the PSV was(67.8±15.9)cm/s.Among them,only one patient had a blood vessel diameter of 1.5 mm and a PSV of 12.2 cm/s.In other patients,the inner diameter of the blood vessel was more than 1.5 mm,and the PSV was more than 40.0 cm/s,all in the normal range.(5)Simple linear regression analysis showed that the blood flow of the intraoperative radial artery bridge positively correlated with the diameter of the radial artery measured before the operation(Y=18.503X-4.471,R^(2)=0.499).(6)The operation was successfully performed for all 40 patients.The clinical symptoms improved during hospitalization,and no perioperative myocardial infarction occurred.After discharge,all patients were followed up for 3 months.During the follow-up period,the patients had no chest tightness,angina pectoris,or hand ischemic dysfunction and other complications.Re-examination of the coronary artery CTA at 3 months after surgery showed that the grafts were unobstructed and no obvious abnormalities.Ultrasonography showed normal blood supply to the radial palm.Conclusions Doppler ultrasound can measure the inner diameter of the graft vessel and determine whether or not the graft vessel has stenosis or other abnormalities.It can accurately and efficiently evaluate the radial artery and internal mammary artery before CABG;at the same time,Doppler ultrasound can determine whether or not it is radial.The accuracy rate of arterial-dependent blood vessels is higher in Doppler ultrasound than in Allen's test,indicating its higher clinical application value.