• 南京醫(yī)科大學(xué)附屬南京第一醫(yī)院 南京市心血管病研究所 心胸外科， 南京 210006;

目的 總結(jié)再次冠狀動(dòng)脈旁路移植術(shù)(CABG)治療冠心病的臨床經(jīng)驗(yàn)和手術(shù)效果。 方法 2001年6月～2006年12月，對(duì)18例冠心病患者行再次CABG。術(shù)前心絞痛（CCS分級(jí)）III級(jí)7例，IV級(jí)11例；冠狀動(dòng)脈造影顯示：16例均有原移植靜脈狹窄/閉塞，2例左乳內(nèi)動(dòng)脈（LIMA) -左前降支（LAD）橋狹窄/閉塞，6例自體冠狀動(dòng)脈出現(xiàn)新的病變。全組均經(jīng)原胸骨正中切口徑路手術(shù)，常規(guī)體外循環(huán)（CPB）下CABG15例，非體外循環(huán)冠狀動(dòng)脈旁路移植術(shù)(OPCAB)3例；同期行室壁瘤切除、左心室成形1例，二尖瓣成形術(shù)3例，主動(dòng)脈瓣和二尖瓣雙瓣膜置換聯(lián)合右頸動(dòng)脈內(nèi)膜剝脫術(shù)1例。應(yīng)用LIMA 12例次、雙側(cè)IMA 4例次、橈動(dòng)脈3例次，其余為大隱靜脈或小隱靜脈。 結(jié)果 15例常規(guī)CABG患者主動(dòng)脈阻斷時(shí)間45～112min (57±26min) , CPB時(shí)間66～140min (78±24min) 。再次CABG每例移植血管1～5支,平均每例遠(yuǎn)端吻合口3.11個(gè)。手術(shù)結(jié)束用血流儀測(cè)定移植血管血流量均滿意（血流量 27.0±12.5 ml/min) ，搏動(dòng)指數(shù)均 lt;4.2。手術(shù)后因低心排血量需主動(dòng)脈內(nèi)球囊反搏輔助1例，術(shù)后6d發(fā)生腎功能衰竭死亡。其余17例患者術(shù)后呼吸機(jī)輔助呼吸時(shí)間5～15h，心絞痛均消失，圍手術(shù)期無(wú)心肌梗死發(fā)生，胸腔引流量為290～1 040 ml,順利恢復(fù),均出院。術(shù)后隨訪17例，隨訪時(shí)間6.0個(gè)月～4.5年，均無(wú)心絞痛發(fā)作，4例復(fù)查冠狀動(dòng)脈造影，顯示移植血管均通暢。 結(jié)論 再次CABG難度大于首次CABG，但只要手術(shù)中能正確找到靶血管，移植血管的血流可靠、完全再血管化和有良好的圍術(shù)期管理，再次CABG可達(dá)到與首次手術(shù)同樣的效果。

引用本文： 陳鑫,徐明,石開(kāi)虎等. 再次冠狀動(dòng)脈旁路移植術(shù)的臨床應(yīng)用. 中國(guó)胸心血管外科臨床雜志, 2007, 14(6): 407-. doi: 復(fù)制

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2. 　Lawrie GM, Morris GC Jr, Earle N. Long-term results of coronary bypass surgery. Analysis of 1698 patients followed 15 to 20 years. Ann Surg,1991,213(5):377-385.
3. 　Calafiore AM, Di Giammarco G, Teodori G, et al. Late results of first myocardial revascularization in multiple vessel disease: single versus bilateral internal mammary artery with or without saphenous vein grafts. Eur J Cardiothorac Surg, 2004,26(3):542-548.
4. 　Hilker M, Buerke M, Lehr HA, et al. Bypass graft disease: analysis of proliferative activity in human aorto-coronary bypass grafts. Heart Surg Forum, 2002, 5(Suppl 4):S331-341.
5. 　Silva JA, White CJ, Collins TJ, et al. Morphologic comparison of atherosclerotic lesions in native coronary arteries and saphenous vein graphs with intracoronary angioscopy in patients with unstable angina. Am Heart J, 1998,136(1):156-163.
6. 　van Eck FM, Noyez L, Verheugt FW, et al. Changing profile of patients undergoing redo-coronary artery surgery. Eur J Cardiothorac Surg, 2002, 21(2):205-211.
7. 　de Feyter PJ. The fatal attraction of saphenous venous bypass grafts. Eur Heart J, 2000,21(9):697-698.
8. 　Bilfinger TV, Vosswinkel JA, Rialas CM, et al. Functional assessment of disease-free saphenous vein grafts at redo coronary artery bypass grafting. Ann Thorac Surg, 2000, 69(4):1183-1187.
9. 　Baklanov DV, Peters KG, Seidel AL, et al. Neovascularization in intimal hyperplasia is associated with vein graft failure after coronary artery bypass surgery. Vasc Med, 2003,8(3):163-167.
10. 　Loop FD, Lytle BW, Cosgrove DM, et al. Reoperation for coronary atherosclerosis. Changing practice in 2509 consecutive patients. Ann Surg,1990,212(3):378-385.
11. 　Lytle BW, Loop FD, Taylor PC, et al. Vein graft disease: the clinical impact of stenoses in saphenous vein bypass grafts to coronary arteries. J Thorac Cardiovasc Surg, 1992,103(5):831-840.
12. 　Ashraf O. Redo coronary bypass grafting: role of arterial grafts and time interval. J Thorac Cardiovasc Surg, 2006,132(1):209-210.
13. 　Machiraju VR. How to avoid problems in redo coronary artery bypass. J Card Surg, 2002,17(1):20-25.
14. 　Rankin JS, Tuttle? RH, Wechsler AS, et al.Techniques and benefits of multiple internal mammary artery bypass at 20 years of follow-up. Ann Thorac Surg, 2007, 83(3):1008-1015.
15. 　Lytle BW, Loop FD, Taylor PC, et al. The effect of coronary reoperation on the survival of patients with stenoses in saphenous vein bypass grafts to coronary arteries. J Thorac Cardiovasc Surg, 1993,105(4):605-612.
  1. 1. 　Di Mauro M, Iac｀o AL, Contini M, et al. Reoperative coronary artery bypass grafting: analysis of early and late outcomes. Ann Thorac Surg, 2005,79(1):81-87.
  2. 2. 　Lawrie GM, Morris GC Jr, Earle N. Long-term results of coronary bypass surgery. Analysis of 1698 patients followed 15 to 20 years. Ann Surg,1991,213(5):377-385.
  3. 3. 　Calafiore AM, Di Giammarco G, Teodori G, et al. Late results of first myocardial revascularization in multiple vessel disease: single versus bilateral internal mammary artery with or without saphenous vein grafts. Eur J Cardiothorac Surg, 2004,26(3):542-548.
  4. 4. 　Hilker M, Buerke M, Lehr HA, et al. Bypass graft disease: analysis of proliferative activity in human aorto-coronary bypass grafts. Heart Surg Forum, 2002, 5(Suppl 4):S331-341.
  5. 5. 　Silva JA, White CJ, Collins TJ, et al. Morphologic comparison of atherosclerotic lesions in native coronary arteries and saphenous vein graphs with intracoronary angioscopy in patients with unstable angina. Am Heart J, 1998,136(1):156-163.
  6. 6. 　van Eck FM, Noyez L, Verheugt FW, et al. Changing profile of patients undergoing redo-coronary artery surgery. Eur J Cardiothorac Surg, 2002, 21(2):205-211.
  7. 7. 　de Feyter PJ. The fatal attraction of saphenous venous bypass grafts. Eur Heart J, 2000,21(9):697-698.
  8. 8. 　Bilfinger TV, Vosswinkel JA, Rialas CM, et al. Functional assessment of disease-free saphenous vein grafts at redo coronary artery bypass grafting. Ann Thorac Surg, 2000, 69(4):1183-1187.
  9. 9. 　Baklanov DV, Peters KG, Seidel AL, et al. Neovascularization in intimal hyperplasia is associated with vein graft failure after coronary artery bypass surgery. Vasc Med, 2003,8(3):163-167.
  10. 10. 　Loop FD, Lytle BW, Cosgrove DM, et al. Reoperation for coronary atherosclerosis. Changing practice in 2509 consecutive patients. Ann Surg,1990,212(3):378-385.
  11. 11. 　Lytle BW, Loop FD, Taylor PC, et al. Vein graft disease: the clinical impact of stenoses in saphenous vein bypass grafts to coronary arteries. J Thorac Cardiovasc Surg, 1992,103(5):831-840.
  12. 12. 　Ashraf O. Redo coronary bypass grafting: role of arterial grafts and time interval. J Thorac Cardiovasc Surg, 2006,132(1):209-210.
  13. 13. 　Machiraju VR. How to avoid problems in redo coronary artery bypass. J Card Surg, 2002,17(1):20-25.
  14. 14. 　Rankin JS, Tuttle? RH, Wechsler AS, et al.Techniques and benefits of multiple internal mammary artery bypass at 20 years of follow-up. Ann Thorac Surg, 2007, 83(3):1008-1015.
  15. 15. 　Lytle BW, Loop FD, Taylor PC, et al. The effect of coronary reoperation on the survival of patients with stenoses in saphenous vein bypass grafts to coronary arteries. J Thorac Cardiovasc Surg, 1993,105(4):605-612.