| Background:Coronary heart disease has become the main killer of human beings.With the acceleration of globalization,the incidence of cardiovascular and cerebrovascular diseases has increased significantly in developing countries.With the increasing number of means and methods for the treatment of coronary heart disease,interventional therapy with little trauma,rapid recovery and short hospital stay has become the first choice for many patients with coronary heart disease.However,the advantage of surgical treatment in complex multi-vessel diseases is irreplaceable.First of all,restenosis rate has always been the main problem that can not be ignored in interventional therapy.Ordinary stents are put into the stent again,and the restenosis rate for half a year is about 30%,even if drug-coated stents are placed.The restenosis rate is also about 5% [1].And not all patients with coronary artery disease are suitable for interventional stenting,such as stenosis at the bifurcation of the vessel,or a single vessel with two or more stenoses.Or complete occlusion of the entire coronary artery and so on,stenting is more difficult,and the risk is huge.In clinical practice,cardiaccoronary artery bypass grafting is still the best choice for complex multi-vessel lesions.Before that,cardiac surgeons used coronary artery bypass grafting(CABG),)under cardiopulmonary bypass in patients with poor vascular conditions and extensive lesions.The advantages of CABG were clear operation field,accurate operation and high anastomotic patency rate.With the progress of technology and the development of surgical instruments,the proportion of minimally invasive coronary artery bypass grafting without cardiopulmonary bypass has increased year by year[2].There are many methods of minimally invasive surgery,but there is still some debate about what is really minimally invasive.Each surgical method has its advantages and disadvantages,and the difficulty for surgeons is to identify appropriate surgical methods for different patients.Therefore,this study mainly provides an ideal surgical method for multi-vessel revascularization in high-risk patients,and summarizes the relevant experience.STUDY 1:Applied anatomical basis for the acquisition of internal mammary artery by left thoracic small incision.Objective:To observe the internal mammary artery in the chest wall through the anatomy and observation of the anterior lateral wall of the chest,so as to provide anatomical data for left thoracic small incision intracardiac coronary artery bypass grafting(CABG).41 specimens of routine embalming cadavers were dissected,the distribution and course of nerves and vessels in the anterior lateral wall of the chest were observed,and the length,diameter,branches of the internal mammary artery and the distance between the edge of the sternum were measured.Methods:Results:(1)The fourth or fifth costal space of the left chest was covered by pectoralis major muscle,with few levels of tissue structure and less distribution of nerves and blood vessels.(2)The length of the left internal mammary artery was 12.04±1.68 cm cm,in the first costal space,the second costal space,the third costal space,the 4th costal space,the 5th costal space and the 5th costal space,respectively,1.07±0.37cm、1.11±0.37cm、1.09±0.33cm、1.19±0.34cm、1.20±0.38cm、1.58±0.33cm、1.14±0.29cm、1.22±0.36cm、1.07±0.34 cm.The diameters of the tubes were respectively,0.24±0.06 cm 、 0.21±0.07 cm 、0.22±0.06cm、0.21±0.05cm、0.23±0.06cm、0.20±0.07cm、0.19±0.06cm、0.20±0.08cm、0.17±0.07 cm.The number of branches was 11±0.78、0.63±0.77、1.68±1.19、0.78±0.69、1.49±1.23、0.73±0.81、1.29±1.01、0.78±0.48.The length of the right internal mammary artery 12.06±1.32 cm,The distances of the right edge of sternum in the first costal space,the second costal space,the third costal space,the fourth costal space,the fifth costal space and the fifth costal space were,0.84±0.36cm、1.20±0.52cm、1.20±0.45cm、1.26±0.48cm、1.36±0.46cm、1.25±0.42 cm 、 1.42±0.41 cm 、 1.15±0.41 cm 、 1.11±0.42 cmrespectively.The diameters of the tubes were0.24±0.06 cm 、 0.28±0.10 cm 、 0.26±0.10 cm 、0.27±0.20cm、0.23±0.05cm、0.23±0.06cm、0.22±0.08cm、0.20±0.08cm、0.23±0.11 cm,respectively.The number of branches was 1.1±0.72、0.92±0.70、1.9±1.14、0.65±0.67、1.85±1.08、0.61±0.67、1.07±0.69、0.85±0.69、0.56±0.78,respectively.Conclusion:The injury of left thoracic small incision is less,which is beneficial to wound healing,and the diameter of internal mammary artery is consistent with that of coronary artery,which can be used as coronary artery bypass graft.STUDY 2:Clinical application and evaluation of left thoracic small incision direct coronary artery bypass grafting.Objective:To analyze the relationship between coronary artery bypass grafting(Coronary Artery Bypass Grafting,CABG)and left anterior lateral thoracic small incision coronary artery bypass grafting(minimally invasive direct coronary artery bypass,)under cardiopulmonary bypass.MIDCAB)the therapeutic effect of two kinds of coronary artery bypass grafting on multi-vessel coronary artery disease.The purpose of this study is to provide a basis for the revascularization of multiple vessels in high-risk patients.Methods:183patients who underwent multi-vessel coronary artery bypass grafting in our hospital from October 2016 to January 2019 were analyzed retrospectively.the patients were divided into two groups according to the different treatmentschemes.Among them,77 cases were treated with left anterolateral thoracic small incision coronary artery bypass grafting(MIDCAB)(observation group),and the other 106 patients were treated with coronary artery bypass grafting under cardiopulmonary bypass(CABG)(control group).In terms of operation time,number of anastomoses,immediate blood flow,pulsatility index,incision length,ventilator assist time,average ICU time,hospital stay,drainage volume,postoperative transfusion plasma volume,postoperative RBC volume,different nodes.Inflammatory response indicators(IL-8,C-reactive protein,cardiac troponin T,creatine kinase isoenzyme),complications(hypoxia,pulmonary infection,atrial fibrillation,malignant arrhythmias,renal insufficiency.neurological complications,poor healing of sternum and so on.The differences between the two schemes are analyzed.Results:(1)According to the statistics of the general data of the two groups of patients before operation,There was no significant difference in sex,age,nutritional status,smoking history,left heart ejection fraction,basic disease,left main artery disease,number of vascular lesions and so on(p > 0.05).(2)The average operation time was 75.26 ±9.29 min in the observation group and 69.32 ±9.89 min in the control group,suggesting that there was no significant difference between the two groups(P > 0.05).(3)In terms of the patency rate of bridge vessels,the immediate blood flow measurement was 28.64 ±6.20 ml in the observation group and 27.5 ±4.98ml/min in the control group.The average pulsatility index was 2.62 ±0.54 in the observation group and 2.26 ±0.58 in the control group,suggesting that there was no significant difference between the two groups(P > 0.05).(4)In terms of incision length,the observation group(6.64 ±2.77cm)and the control group(12.95 ±2.97cm)suggested that there was significant difference in incision length between the two groups,among which the observation group had obvious advantages in incision size and cosmetology(<0.05).(5)The number of distal anastomoses in the observation group was 2.75±0.46,which was significantly less than that in the control group(3.04 ±0.44).There was significant difference between the two groups(P < 0.05).(6)In the comparison of operation-related time indexes,The average operation time in the observation group was 353.60 ±29.24 min,which was significantly higher than that in the control group(319.58 ±33.12 min).The average ventilator assist time in the observation group was 299.40 ±43.01 min,which was significantly lower than that in the control group(572.82 ±47.40min).The average ICU time of the patients in the observation group was 43.30±9.01 hours,which was significantly lower than that in the control group(73.11 ±16.32 hours).The time from operation to discharge in the observation group was 10.26 ±2.15 days,which was significantly lower than that in the control group(14.55 ±2.26 days).These differences were statistically significant(P < 0.05).(7)In the comparison of drainage,the total postoperative drainage volume in the observation group was 589.78 ±34.24 ml,which was significantly lower than that in the control group(854.41 ±792ml).The plasma volume of postoperative blood transfusion in the observation group was 345.45 ±111.86 ml,which was significantly lower than that in the control group(821.70 ±101.42ml).The amount of RBC infused in the patients after operation was 3.22 ±1.11 U,which was significantly lower than that in the control group(6.11 U ±1.08U).24hours after operation,the drainage volume in the observation group was 244.06±218.40 ml,which was significantly lower than that in the control group(465.73±39.94ml).These differences were statistically significant(P < 0.05).(8)The levels of IL-8 at T1 and T5 were about 72 μ g / L and 81 μ g / L,respectively,and there was no significant difference between the two groups(P > 0.05).The levels of IL-8 in the observation group at T2,T3 and T4 were115.21 ±9.51 μ g / L,411.82 ±42.06 μ g / L and 267.30 ±23.48 μ g / L,respectively.The levels of IL-8 in the control group were 238.98 ±218.73 μ g / L,775.81 ±35.57 μ g / L and 439.31 ±20.09 μ g / L,respectively.There was significant difference between the two groups(P<0.05).(9)The levels of C-reactive protein were compared at different time points,and at T1,T2 and T3,The levels of C-reactive protein in the two groups were about 3.1 mg/L,4.4mg/L and 5.1 mg/L,respectively.There was no significant difference between the two groups(P > 0.05).However,During the period of T4 and T5,the average level of C-reactive protein in the observation group was6.62 ±0.82 mg/L and 12.18 ±1.82 mg/L,respectively.The average level of C-reactive protein in the control group was 8.59 ±1.61 mg/L and 14.50 ±1.74 mg / L.There was significant difference between the two groups(P<0.05)(10)Compared with the level of cardiac troponin T at different time points,the level of c TNT in the two groups was about 0.08 μ g / L at T1 time,and there was no significant difference between the two groups(P > 0.05).At T2,T3,T4 and T5,the levels of c TNT in the observation group were 0.68 ±0.40 μ g / L,0.56 ±0.2 μ g / L,0.45 ±0.2 μ g / L and 0.24 ±0.09 μ g / L,respectively.The levels of c TNT in the control group were 2.91 ±0.75 μ g / L,1.71 ±0.52 μ g / L,1.02 ±0.30 μ g / L and 0.56 ±0.17 μ g / L.There was significant difference between the two groups(P<0.05)(11)The level of creatine kinase isoenzyme in the two groups was about15.4ng/ml at T1 time,and there was no significant difference between the two groups(P > 0 05).At T2,T3,T4 and T5,the levels of creatine kinase isozymes in the observation group were 20.85 ±3.87ng/ml,21.40 ±3.52ng/ml,13.09±2.90ng/ml and 9.55 ±2.96 ng / ml,respectively.The creatine kinase isoenzyme levels in the control group were 76.89 ±6.21ng/ml,45.08 ±8.28ng/ml,38.07±5.80ng/ml and 35.40 ±3.75 ng / ml,respectively.There was significant difference between the two groups(P<0.05)(12)To compare the incidence of postoperative complications,The incidence of hypoxia in the observation group was 3.9%,which was significantly lower than that in the control group(20.8%).The difference was statistically significant(P < 0.05).The incidence of pulmonary infection in the observation group was 6.5%,which was significantly lower than that in the control group(20.8%)(P < 0.05).The incidence of atrial fibrillation in the control group was 3.9%,which was significantly lower than that in the control group(15.1%).The difference was statistically significant(P < 0.05).The incidence of poor sternal healing in the observation group was 0.00%,which was significantly lower than that in the control group(3.7%).The difference was statistically significant(P < 0.05).There was no significant difference in malignant arrhythmias,renal insufficiency,neurological complications between the two groups.The difference was significant(P > 0.05),and the incidence was low.Conclusion:In clinical work,minimally invasive coronary artery bypass grafting with left anterolateral thoracic incision for the surgical treatment of multi-vessel coronary artery disease has the advantages of less trauma and fewercomplications.It is helpful to realize the rapid recovery after operation,and it is suggested to popularize and apply it in clinic. |
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