ascending aorta coronary saphenous vein bypass grafting

1. Patients with severe angina pectoris and incapacity to work, who are ineffective after medical system treatment. 2. Coronary angiography, coronary artery stenosis more than 50% or branch stenosis more than 75% of the diameter, stenosis of the distal segment of the artery is smooth, and its diameter is 1.5mm or more. 3. After myocardial infarction, coronary angiography showed significant coronary stenosis. 4. Angina pectoris complicated with left ventricular aneurysm, or with ventricular septal defect or valvular lesion. Treatment of diseases: myocardial infarction complicated by ventricular septal angina Indication 1. Patients with severe angina pectoris and incapacity to work, who are ineffective after medical system treatment. 2. Coronary angiography, coronary artery stenosis more than 50% or branch stenosis more than 75% of the diameter, stenosis of the distal segment of the artery is smooth, and its diameter is 1.5mm or more. 3. After myocardial infarction, coronary angiography showed significant coronary stenosis. 4. Angina pectoris complicated with left ventricular aneurysm, or with ventricular septal defect or valvular lesion. Contraindications 1. Left ventricular function is low, left ventricular ejection fraction is less than 0.2, left ventricular end-diastolic pressure is greater than 3kpa (20mmhg). 2. Chronic heart failure, severe myocardial lesions, irreversible changes. 3. Systemic diseases such as severe diabetes, high blood pressure, renal function or pulmonary insufficiency. 4. Generally, those who are 65 years old should be considered carefully. Preoperative preparation 1. See extracorporeal circulation for open heart surgery before surgery. 2. Coronary angiography clearly identifies the location, extent and extent of obstruction. 3. If you have high blood pressure, you need to be treated with drugs to lower your blood pressure to the normal range. 4. For diabetics, surgery should be considered before drug control. 5. Hyperlipidemia, given a low-fat diet and anti-hyperlipidemia drugs. 6. If digitalis, quinidine, beta blockers, diuretics, anticoagulants, etc. have been used, the drug should be discontinued 3 to 5 days before surgery. 7. For patients who are preparing for saphenous vein grafting, it is necessary to know whether there is any history of surgery, ulcers, varicose veins and skin diseases in the lower limbs. Surgical procedure 1. Take the vein: supine, two lower limbs abduction and external rotation. 2cm from the inguinal ligament, in the inside of the femoral artery, make a long incision, reveal the great saphenous vein, carefully peel off with scissors, do not damage the adventitia and lymphatic vessels, cut off each branch as much as possible after cutting, 1mm from the trunk of the vein The tube is ligated with a thin wire or cut between metal clips, and then ligated at the proximal side of the thin wire. The ligation should not be too close to the trunk, nor can it be electrocoagulated to avoid damage to the endometrium. At the fossa ovalis, ligature with a 4 or 7 thread to cut the great saphenous vein. If a blood vessel is transplanted, it is necessary to cut a length of 20 cm and transplant two blood vessels, which requires 40 cm in length. After removing the vein, insert a 16-gauge needle into the distal end of the vein, slowly inject the normal saline containing heparin, check for stenosis caused by the outer membrane entanglement, and any leaks are ligated with a 3-0 to 4-0 synthetic line. . The outer membrane at both ends of the vein is peeled off to prevent the thrombus from being sewn into the lumen during anastomosis. Finally, the great saphenous vein was filled with cold heparin blood and placed in physiological saline at 4 ° C for use. 2. Establish extracorporeal circulation: establish extracorporeal circulation while cutting the saphenous vein. 3. Exposing the coronary arteries: Different methods are used to expose the coronary arteries. For example, a large gauze pad is padded slightly to the right in the left rear to reveal the left anterior descending artery, and the assistant can turn the heart up to the left to reveal the right coronary artery. The trunk and so on. 4. Coronary stoma: Touch the thickened stenosis with a finger. At the distal end of the coronary artery, find the blood vessel, select the appropriate anastomosis, use a sharp knife for a longitudinal incision, and then use scissors to expand. The length of the incision is approximately twice the diameter of the blood vessel. 5. Block coronary artery preparation anastomosis: If there is diluted blood return from the blood vessel incision, you can use a small gauze pusher to gently press the two ends of the incision. If the blood flow is more and affect the operation, you can use the innocence clamp or the silk thread. The blood vessels are sewed at both ends of the incision and pulled gently to block blood flow. 6. Coronary artery coronary anastomosis: The transplanted great saphenous vein segment is inverted, so that the proximal end is anastomosed to the distal end of the coronary artery and the distal end is anastomosed to the aorta to prevent the venous valve from obstructing blood flow. Coronal artery sutures can be used for larger diameters, while those with smaller diameters can be sutured intermittently, but most use continuous and intermittent sutures. The method is to make a pair of suture-type sutures on the side of the anastomosis with 8-0 double-head non-invasive needles, then make one-third sutures on one side and two-thirds on the other side. When the anastomosis should be intima to the endometrium, it should be sewed tightly and not leaking, and can not be too tight and lead to narrowing of the lumen. After the anastomosis, the heparin solution was injected into the large saphenous vein segment of the transplant, and the temperature was rewarmed, and the aortic occlusion forceps were opened to make the heart re-jump. 7. Great saphenous vein ascending aortic anastomosis: After the circulation is stabilized, a non-invasive side wall clamp is used to clamp the anterior wall of part of the ascending aorta. On the front wall of the clamped portion, a small oval cut is cut off, and it is more convenient to use a special hole puncher. Each transplanted vein uses its own aortic anastomosis, which usually accommodates 3 anastomosis. Subsequently, the distal end of the great saphenous vein was trimmed to the required length, and the 5-0 double-ended needle was sutured at the distal end of the ascending aortic incision and the great saphenous vein, temporarily not ligated, along the anastomosis half a week. Make continuous stitching. Then use another needle to do the continuous suture on the contralateral side. Finally, leave 1 to 2 needles, loosen the vascular blocking forceps on the saphenous vein, let the blood flow back to eliminate the air bubbles, and then slowly open the aortic side wall clamp and ligation. The last stitch is stitched. It can also be vented through the graft vein wall after ligation. 8. Close the chest incision: the anastomosis is sutured properly, and after the condition is stable, the extracorporeal circulation is slowly stopped. Close the chest after careful hemostasis.