Contraindications to surgical correction of coronary artery disease. Modern methods of surgical treatment of heart disease. Indirect revascularization techniques

Any method of surgical treatment of coronary artery disease is highly effective.

The severity of shortness of breath decreases, angina pectoris decreases or completely disappears. Each method of surgical treatment has its own indications and contraindications.

For the treatment of coronary artery disease are used: coronary artery bypass grafting and coronary angioplasty.

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Coronary artery disease is the leading cause of premature death in middle-aged people.

In 1960, the first coronary bypass surgery in the history of medicine was performed in the United States by surgeon Robert Hans Goetz.

In Russia, the first shunting was performed in 1964 by the surgeon professor V.I. Kolesov.

The operation is aimed at:

  • reduction or elimination of clinical symptoms in a patient;
  • restoration of blood circulation in the heart muscle;
  • improving the quality of life.

The essence of the operation is that a new normal blood flow is formed in the place where the coronary arteries are affected. Shunts are used to create new arteries. This helps to prevent irreversible changes in the myocardium, and improves its contractility.

A shunt is a part of a healthy artery or vein that is taken from another part of the patient's body. The shunt can be the radial artery, the vessels of the chest. A synthetic prosthesis is rarely used.

You will find a list of drugs for the treatment of coronary heart disease.

Complications

  • sudden closure of an enlarged vessel during surgery or a few hours after it;
  • arterial bleeding from the femoral artery;
  • sudden cardiac arrest;
  • acute heart attack;
  • postoperative infectious complications;
  • damage to blood vessels by a catheter during surgery;
  • the development of acute renal failure.

The above complications are rare. This is due to the fact that thorough preparation of the patient is carried out before surgical treatment. High qualification of medical personnel and modern surgical equipment are also important.

The following are susceptible to possible complications:

  • people aged 65 and over;
  • women;
  • patients with unstable angina pectoris and myocardial infarction.

The choice of the method of surgical treatment of coronary artery disease

The methods of surgical treatment of coronary heart disease have found their place in cardiac surgery.

Coronary artery bypass grafting restores normal blood flow to the heart muscle. The heart begins to receive the oxygen it needs. The risk of myocardial infarction decreases, the patient has a chance to prolong life.

Angioplasty surgery gives the same therapeutic effects. But unlike bypass surgery, it has a more gentle method. Large skin incisions are not made, the sternum does not separate. Only the femoral artery is punctured.

But a less invasive method of angioplasty does not guarantee the complete recovery of the patient. Has many complications and risks.

According to research by American cardiologists, mortality after coronary artery bypass grafting is less than that of angioplasty.

There was an increase in life expectancy in patients with unstable angina pectoris.

Over the past 10 years, surgery for coronary heart disease (CHD) has undergone significant qualitative and quantitative changes. Against the background of significant advances in the medical treatment of coronary artery disease and its complications, surgical methods not only have not lost their value, but have become even more widely used in everyday clinical practice.

The history of IHD surgery is about 100 years old. It began with operations on the sympathetic nervous system and various types of indirect myocardial revascularization. In the second half of the 20th century, the period of development of operations for direct myocardial revascularization began. The priority in the creation of such methods belongs to V. Demikhov, who in 1952 proposed to anastomose the internal thoracic artery with the coronary arteries of the heart. And in 1964, V.Kolesov, for the first time in world practice, successfully performed mammary-coronary anastomosis on a beating heart, thereby initiating minimally invasive surgery of coronary arteries. In 1969 R. Favoloro proposed a new direction - the operation of autovenous coronary artery bypass grafting (CABG).

After the widespread introduction of coronary angiography into clinical practice, which allows accurate diagnosis of coronary artery lesions, methods of direct myocardial revascularization began to develop unusually widely. In some countries, the number of direct myocardial revascularization operations reaches more than 600 per 1 million population. The World Health Organization has established that the need for such operations, taking into account the frequency of mortality from coronary artery disease, should be at least 400 per 1 million population per year.

Today it is no longer necessary to prove the effectiveness of surgical treatment of coronary artery disease by methods of direct myocardial revascularization. Currently, operations are accompanied by a low mortality rate (0.8-3.5 percent), lead to an improvement in the quality of life, prevent the onset of myocardial infarction (MI), and increase life expectancy in many seriously ill patients.

The most important section of IHD surgery is the method of endovascular (X-ray surgical) treatment of patients with stenosing process of the coronary arteries.

In 1977, Grüntzig proposed a balloon catheter, which, by puncturing the common femoral artery, is inserted into the coronary bed and, when inflated, expands the lumen of the narrowed areas of the coronary arteries. This method, called transluminal balloon angioplasty (TLBA), quickly became widespread in the treatment of chronic ischemic heart disease, unstable angina pectoris, acute coronary circulation disorder. In addition, it is widely used in diseases of the great arteries, the aorta and its branches. In recent years, the TLBA procedure has been supplemented by the introduction of a stent into the area of ​​the dilated artery - a frame that holds the lumen of the artery in a dilated state.

The methods of endovascular treatment and surgery for coronary artery disease do not compete, but complement each other. The number of stent-based angioplasty in economically developed countries is growing steadily. Each of these methods has its own indications and contraindications. Progress in the development of new methods of surgical treatment of coronary artery disease constantly leads to the development of new directions and technologies.

Multifocal atherosclerosis

In this direction, one- and multi-stage operations are used. For example, before the operation of direct myocardial revascularization, balloon dilatation of the affected great artery can be performed, and then CABG is performed.

The number of patients with multifocal atherosclerosis is enormous. In each specific case, modern diagnostic tools make it possible to identify the arterial pool, the narrowing in which is most dangerous for the patient's life. Cardiologists and surgeons must determine the sequence of performing the surgical intervention in each of the pools.

Undoubtedly, the most important section of the problem of multifocal atherosclerosis is the combination of ischemic heart disease with narrowing of the arteries feeding the brain.

Ischemic stroke (IS) is the second leading cause of death in many countries of the world. Together, MI and AI account for about 50 percent. of all deaths in the world. Thus, patients with damage to both coronary and brachiocephalic arteries (BCA) have a double increased risk of death - from MI and from IS.

According to our data, the frequency of hemodynamically significant BCA lesions among patients with coronary artery disease is about 16%. We conducted a study of more than 3000 patients with coronary artery disease using non-invasive screening. Along with neurological examination and BCA auscultation, the program includes Doppler ultrasound as the main non-invasive method for examining BCA lesions. It is important to note that screening revealed a higher incidence of BCA lesions in asymptomatic groups of patients.

When detecting hemodynamically significant BCA stenoses in these patients, including the asymptomatic group, angiographic examination of BCA plays the main role in the diagnosis along with coronary angiography. As a result of the study, we found that in the first place is the defeat of the internal carotid artery (ICA) - 73.4%. A rather significant group consists of patients with coronary artery disease with intrathoracic lesions of BCA (9.9%).

Damage to the left trunk of the coronary artery (LCCA) or multiple lesions of the coronary arteries in severe and unstable course of coronary artery disease in combination with BCA lesions necessitates a single-stage operation. For this, there are the following criteria: a single access (sternotomy), from which both BCA reconstruction and coronary artery bypass grafting can be performed. This is the first time we have applied this approach, since it makes it possible to avoid the formidable complications of MI and AI.

In case of ICA lesions in patients with coronary artery disease with severe angina pectoris and multiple coronary lesions and / or lesions of the ICA, we first perform reconstruction of the ICA to avoid the development of a stroke, and then revascularize the myocardium. To protect the brain, we have developed a hypothermic perfusion technique in combination with other medical methods. Hypothermal perfusion with cooling the patient to 30 C is a protection not only for the brain, but also for the myocardium. During a single-stage operation, careful monitoring of the blood circulation of the brain and myocardium is necessary. The use of this tactic has yielded good results in preventing the development of stroke.

Another approach is to divide the reconstructive operations on the coronary arteries and BCA into two stages. The choice of the first stage depends on the severity of damage to the coronary and carotid areas. With gross narrowing of the carotid artery and moderate damage to the coronary bed, the first stage is the reconstruction of the carotid arteries, and then after a while - myocardial revascularization. This approach to the choice of indications opens up great prospects in the treatment of this difficult group of patients.

Minimally invasive ischemic heart surgery

This is a new branch of coronary surgery. It is based on the performance of operations on the beating heart without the use of artificial circulation (CI) and the use of minimal access.

A limited, up to 5 cm long thoracotomy or partial sternotomy is performed in order to maintain the stability of the sternum. Both in many clinics around the world and in our center, this method has been used over the past three years. This method was introduced into the practice of the Scientific Center of the Union of Artists, Academician of the Russian Academy of Medical Sciences L. Bokeria. The operation has undoubted advantages due to the low trauma rate and the use of minimal access. On the 2-3rd day, patients leave the clinic, having stayed in the intensive care unit for less than a day. The patient is extubated in the first hours after surgery. The indications for this type of surgical treatment are still quite limited: in the leading clinics of the world, the method is used in 10-20 percent. all operations for ischemic heart disease. Typically, the internal mammary artery (IAV) is used as an arterial graft, mainly for bypassing the anterior descending artery. Stabilization of the myocardium is necessary to carry out operations and more precise performance of the anastomosis on the beating heart.

These operations are indicated in elderly, debilitated patients who cannot use infrared due to the presence of kidney disease or other parenchymal organs. Minimally invasive surgery can be performed on the right coronary artery or two branches of the left coronary artery from a left or right approach. After more than 50 operations performed in our center using minimally invasive techniques, there were no complications or deaths. The economic factor is also important, since there is no need to use an oxygenator.

Other methods of minimally invasive surgery include operations using robotics. Recently, 4 operations of myocardial revascularization were performed in our center with the help of specialists from the United States. A robot controlled by a surgeon forms an anastomosis between the coronary artery and the internal thoracic artery. But while this technique is at the stage of development.

Transmyocardial laser myocardial revascularization

The method is based on the idea of ​​improving the blood supply to the myocardium due to the blood flow directly from the left ventricular cavity. Various attempts have been made to carry out such an intervention. But only with the use of laser technology it became possible to implement this idea.

The fact is that the myocardium has a spongy structure and if multiple openings are formed in it that communicate with the cavity of the left ventricle, then the blood will enter the myocardium and improve its blood supply. In our center, L. Bokeria, after experimental development and creation of a domestic laser, together with the institutes of the Russian Academy of Sciences, carried out a series of operations on transmyocardial laser revascularization (TMLR) of the myocardium.

More than 10-15 percent patients with coronary artery disease have such severe lesions of the coronary arteries and especially their distal parts that it is not possible to perform revascularization by bypass grafting. In this large group of patients, the only method to improve myocardial blood supply is transmyocardial laser revascularization. We will not dwell on the technical details, but we will point out that transmyocardial laser revascularization is performed from a lateral thoracotomy without connecting an artificial blood circulation. In the area of ​​the myocardium with a low level of blood supply, many puncture channels are applied, through which the blood then enters the ischemic area of ​​the myocardium. These operations can be performed both independently and in combination with bypass grafting of other coronary arteries. In a large group of operated patients, good results were obtained, allowing the method to be considered close in its role to direct myocardial revascularization.

In addition to isolated TMLR, the combination of TMLR with CABG exists and is attracting more and more attention. In a significant part of patients with coronary artery disease, it is not possible to carry out complete revascularization due to the presence of diffuse lesions of one of the coronary arteries. In these cases, a combined approach can be used - bypass grafting of vessels with a passable distal bed and laser exposure in the myocardial zone, which is supplied with blood by a diffusely altered vessel. This approach is becoming more and more popular, since it allows for the most complete myocardial revascularization.

Long-term results of TMLR still need to be studied.

Autoarterial myocardial revascularization

Autoarterial grafts have been widely used in coronary surgery since the early 1980s, when it was shown that the distant patency of mammary-coronary anastomosis was significantly higher than the patency of autovenous shunts. Currently, mammary-coronary anastomosis is used both in world practice and in our center for almost all myocardial revascularization operations. Recently, surgeons have shown increasing interest in other arterial grafts, such as the right internal thoracic artery, right ventricular omental artery, and radial artery. A number of options for complete autoarterial revascularization have been developed, many of which are used in our clinic.

It should be emphasized that there is currently no optimal scheme for complete autoarterial revascularization. Each of the procedures has its own indications and contraindications, and a comparative assessment of the results of revascularization using various autoarteries is being carried out in the world. The general trend today is to increase the proportion of complete arterial revascularization.

Ischemic myocardial dysfunction

Among patients with coronary artery disease, there is a fairly large group of patients with sharply reduced myocardial contractility. Decreased left ventricular ejection fraction (LVEF) has traditionally been considered a major risk factor for CABG surgery. At the same time, adequate revascularization can lead to the reversal of myocardial dysfunction when it is caused by ischemia. This is the basis for the increasingly widespread use of direct myocardial revascularization operations in patients with depression of its contractile function. The most important point in the selection of patients for surgery is the differentiation of cicatricial and ischemic dysfunction. For this purpose, a number of techniques are used, including radioisotope methods, but today the method of stress echocardiography is considered the most informative. As the accumulated experience of surgical treatment of patients with sharply reduced myocardial contractility (more than 300 such operations have already been performed in our center), with correctly established indications, the risk of CABG in this group does not greatly exceed the risk of surgery in the group of ordinary patients with coronary artery disease. It is important to note that with successful surgical treatment of these patients, long-term survival significantly exceeds the survival rate with conservative treatment.

Transluminal balloon angioplasty and stenting

Endovascular methods of treatment are a separate huge section of the problem of IHD treatment. The results of endovascular methods are less stable than the results of CABG, but their advantage is that they do not require thoracotomy and artificial circulation. Endovascular methods are constantly being improved, more and more new types of stents appear, a technique of so-called atherectomy has been developed, which makes it possible to expand the lumen of the vessel prior to stent implantation by resecting a part of the atherosclerotic plaque. All these methods will undoubtedly develop.

One of the new directions is the combination of surgical and endovascular myocardial revascularization. This approach has become especially relevant in connection with the development of minimally invasive surgery. In interventions without artificial blood circulation, it is not always possible to bypass the vessels located on the posterior surface of the heart. In such cases, in addition to CABG, transluminal angioplasty and stenting of other affected coronary arteries are subsequently performed. The method certainly has good prospects.

It is necessary to draw the attention of a wide range of doctors to the new possibilities of coronary surgery, which has become a powerful social factor in the life of any society. It has great potential and leads to the prevention of myocardial infarction and its complications. In the future, its prospects are obvious, and the role of our center as a leading institution in Russia will invariably grow, subject to clear organization, funding and timely referral of patients for surgical treatment.

Professor Vladimir RABOTNIKOV,
Scientific Center for Cardiovascular
surgery them. A.N.Bakuleva RAMS.

Atherosclerotic coronary artery disease leads to the development of coronary insufficiency. A characteristic feature of coronary sclerosis is the presence of stenotic narrowing in the proximal part of the main coronary arteries and their large branches. As a result of the obstacle, blood flow to the myocardium in the area of ​​distribution of the affected artery decreases and myocardial ischemia occurs. As a result, a mismatch arises between the need for oxygen in the heart muscle and the ability to deliver it to the heart.

Clinically this discrepancy is manifested by a stenocarditis symptom complex, a characteristic feature of which is pain syndrome. Pain occurs during exercise (exertional angina) or at rest (rest angina) and is localized behind the sternum or in the region of the heart. The clinical manifestations of coronary insufficiency are very diverse and mainly depend on the severity and nature of the spread of coronary sclerosis and the degree of narrowing of the coronary arteries. Currently, along with conservative therapy for coronary heart disease, which is described in detail in the course of internal diseases, surgical methods of treating this disease are widely used.
For myocardial revascularization, indirect and direct operations have been proposed.

Among indirect interventions For a long time, Weinberg's operation was widespread: implantation of the internal thoracic artery into the myocardium in the area of ​​the affected coronary artery. Due to the structural features of the myocardium, a network of collaterals develops between the implanted and coronary arteries, through which blood flows into the pool of the stenotic coronary artery, and thus myocardial ischemia decreases. In recent goals, this operation has been abandoned due to injury ethics and comparatively low efficiency.

Currently, the most widespread is coronary artery bypass surgery: Connecting the affected coronary artery below the narrowing site to the ascending aorta using a vascular graft. At the same time, there is an immediate restoration of the coronary circulation in the zone of myocardial ischemia, the symptoms of angina pectoris largely disappear, the development of myocardial infarction is prevented, and in many cases the ability to work of patients is also restored. The indication for coronary artery bypass surgery is severe angina pectoris caused by isolated stenosing atherosclerotic lesions of one or more main coronary arteries with a narrowing of the vessel lumen by 70% or more.

Greatest effect this operation gives in patients with preserved and viable myocardium. Selective coronary angiography and ventriculography occupy a special place in the selection of patients for surgery. With the help of these methods, the anatomy of the coronary circulation, the degree of spread of coronary sclerosis, the nature of the lesion of the coronary arteries, the zone of damage to the heart muscle are studied, the ways and mechanisms of compensation for the violation of the coronary circulation are determined.

Coronary artery bypass grafting performed from a median longitudinal sternotomy in conditions of extracorporeal circulation and cardioplegia with active drainage of the left ventricular cavity. The right coronary, anterior interventricular, left circumflex arteries, as well as their largest branches can be shunted. Up to four coronary arteries are shunted at the same time. When coronary insufficiency is combined with an aneurysm of the heart, a defect of the interventricular septum, or a lesion of the valve apparatus of the heart, a simultaneous operation of bypassing the coronary artery and correction of intracardiac pathology is performed.

As a vascular graft in most cases, segments of the great saphenous vein of the thigh are used. Along with them, the internal mammary arteries can be used for bypass grafting. The first successful operations of creating a mammary-corneal anastomosis in our country were performed in 1964 by V.I.Kolesov. In addition, segments of the deep artery of the thigh or the radial artery can serve as a vascular graft.

Adequacy of the restoration of blood circulation in the affected coronary artery depends on the amount of blood flow through the shunt. The mean blood flow through the shunt is 65 ml / min. Restoration of blood circulation in the ischemic myocardium significantly improves its contractile ability: the end diastolic pressure in the left ventricle decreases, the diastolic volume of the left ventricle decreases, and the ejection fraction increases. After the operation, the symptoms of angina pectoris completely disappear or significantly decrease in patients, the tolerance to physical activity increases, the patients return to work.

Surgical treatment of acute coronary insufficiency(myocardial infarction) is aimed primarily at the speedy restoration of blood flow in a blocked coronary artery using coronary artery bypass grafting. The most effective operation is performed in the first 4-6 hours after the onset of the development of a heart attack. In cases where acute myocardial infarction is accompanied by cardiogenic shock, an auxiliary circulation can be performed using a counterpulsator. The use of circulatory support makes it possible to perform diagnostic selective coronary angiography and determine the possibility of surgical intervention, as well as to prepare for the operation and the operation itself with a lower degree of risk.

1

Ischemic heart disease (IHD) is a pathological condition characterized by a relative or absolute impairment of the blood supply to the myocardium due to damage to the coronary arteries. Surgical treatment of coronary heart disease is one of the main phenomena of medicine in the 20th century. In the group of patients with ischemic myocardial dysfunction, the revascularization operation leads to an improvement in hemodynamic parameters: a decrease in the end diastolic pressure in the left ventricle, an increase in cardiac and shock emissions, as well as the ejection fraction of the left ventricle. The results of most studies have shown that a significant improvement in the condition or complete disappearance of angina pectoris is observed in 75-95% of operated patients.

cardiac ischemia

myocardial revascularization

2. Lectures on cardiovascular surgery. Ed. L.A. Bockeria. In 2 volumes. T. 2. -M .: Publishing house NTsSSKhim. A. N. Bakuleva RAMS, 1999 .-- 194p.

3. Mouse G.D., Nepomnyashchikh L.M. Myocardial ischemia and cardiac revascularization. - Novosibirsk: Science, 1980 .-- 296p.

4. Guide to Cardiology: Textbook in 3 volumes / Ed. G.I. Storozhakova, A.A. Gorbachenkov. - 2008 .-- 672 p.

5. Cardiovascular surgery: leadership / V. I. Burakovsky, L. A. Bockeria, etc .; Ed. acad. USSR Academy of Medical Sciences V.I.Burakovsky, prof. L.A. Bockeria.- M .: Medicine, 1989.-752 p.

6. Topographic anatomy and operative surgery: textbook: in 2v. / ed. I.I. Kagan, I. D. Kirpatovsky. - M.: GEOTAR-Media, 2012. - T.2 - 576s.

7. Technique of coronary artery bypass grafting of 3-5 coronary arteries of the heart. // Breast surgery. / Ed. V. S. Rabotnikov, G. P. Vlasova, E. N. Kazakov, E. N. Kertsman. - 1985.

8. Surgical treatment of coronary circulation insufficiency. // Proceedings of the All-Union session of the Academy of Medical Sciences together with the Tomsk Medical Institute; / Ed. D.P.Demikhova. - 1953.

Indications for myocardial revascularization surgery, as well as indications for surgery in any area of ​​surgery, are based on three “whales”: the clinical picture of the disease, the anatomy of the lesion, and organ function.

The classic clinical indication for surgical treatment of a patient is severe angina pectoris resistant to drug therapy. However, the severity of clinical manifestations does not always correlate with the severity of coronary lesions. In addition, modern drug therapy is highly effective due to a sharp decrease in myocardial oxygen consumption and impact on a number of pathogenetic links in the formation of angina pectoris syndrome.

Therefore, in recent years, anatomical indications for surgery have come to the fore, namely, localization, the degree of narrowing of the coronary arteries and the number of affected vessels.

The main anatomical indications are:

  1. Significant stenosis of the left coronary artery;
  2. Significant (more than 70%) proximal stenosis of the anterior interventricular branch (LAD) and proximal stenosis of the circumflex branch;
  3. Three-vessel lesion;
  4. Bilateral lesion in the presence of significant proximal LAD stenosis in combination with a left ventricular ejection fraction of less than 50% or with ischemia confirmed by non-invasive testing;
  5. One- or two-vessel lesion with stenosis of the proximal LAD, a pronounced picture of ischemic heart disease;

Types of operations for ischemic heart disease

A. Indirect revascularization techniques

  • sympathectomy
  • cardiopexy
    • omentocardiopexy
    • pneumocardiopexy
    • pericardiopexy
  • Fieschi's operation
  • Weinberg operation

B. Direct revascularization techniques

  • coronary artery bypass grafting
  • mammary coronary artery bypass grafting
  • gastroepiploic artery anastomosis
  • autoplasty of the coronary arteries
  • coronary artery stenting
  • balloon dilatation of coronary arteries
  • endarterectomy

Indirect revascularization techniques

They arose at the dawn of coronary surgery and were associated with the lack of artificial circulation, which could protect the body and the myocardium from ischemia. At the same time, a number of techniques are still being used when it is impossible, for any reason, to carry out direct revascularization. [2, p.55]

The first operations were aimed at eliminating the pain syndrome, reducing the basal metabolic rate, or fixing organs and tissues rich in blood vessels and collaterals to the myocardium.

Sympathectomy... This is a surgical operation, the task of which is to stop the transmission of nerve impulses along the sympathetic nerve fibers located in the adventitia of the vascular wall. This idea was expressed 100 years ago by the French physiologist François-Frank, who suggested that resection of the cervicothoracic sympathetic ganglia can lead to the elimination of angina pectoris. In practice, this idea was implemented in 1916 by T. Jonnesco.

Later, other techniques were proposed aimed at eliminating angina pectoris by interrupting afferent pain impulses - posterior rhizotomy (intersection of the posterior roots of the spinal cord), various types of sympathetic blockades. These operations were sharply criticized because they eliminated pain attacks, warning the patient of danger. On the other hand, according to a number of researchers, such neurosurgical interventions led to a decrease in oxygen consumption by the myocardium, which had a beneficial effect on the course of the disease.

Cardiopexy... The most widespread are operations of indirect myocardial revascularization, aimed at creating an additional source of blood supply to the heart. For the first time L. Moritz and S. Hudson in 1932 suggested using the pericardium for this purpose. Beck S. in 1935 performed scarification of the epicardium, believing that as a result of the formation of adhesions between the pericardium and the epicardium, the pericardial vessels will grow into the myocardium. The most widespread method is S. Thompson, which consists in spraying talcum powder in the pericardial cavity in order to form adhesions. These interventions have been termed cardiopericardiopexy. However, this type of surgical method for the treatment of coronary artery disease is not widespread.

In 1937 L. O'Shaughnessy first used tissue graft for myocardial revascularization. He sutured a pedicle flap to the epicardium. This operation, called omentocardiopexy, led to the development of a number of similar methods. In order to create an additional source of blood supply to the heart, surgeons used lung tissue, pectoral muscles, mediastinal fat, a skin flap, and even a portion of the small intestine.

Operation Fieschi... This is an operation of bilateral ligation of the internal thoracic arteries (IAD), proposed by the Italian surgeon D. Fieschi in 1939. According to the author, ligation of the IAD immediately below the discharge of the pericardio-diaphragmatic branch increases blood flow through this artery, which has anastomoses with the branches of the coronary arteries.

Weinberg operation... It occupies an intermediate position between indirect and direct methods of myocardial revascularization and consists in implanting the bleeding distal end of the internal thoracic artery into the myocardium, which first leads to the formation of intramyocardial hematoma, and subsequently to the development of anastomoses between the IAV and the branches of the coronary arteries. The main disadvantage of the Weinberg method was the lack of an immediate effect of revascularization.

Direct revascularization techniques

Since the mid-50s, for coronary heart disease, surgeons began to use methods of direct revascularization. Direct myocardial revascularization operations are usually understood as direct interventions on the coronary arteries. The first such intervention was coronary endarterectomy (EAE).

Coronary endarterectomy... Its pioneer was the American surgeon S. Bailey. He developed three methods of EAE: direct, antegrade and retrograde - through the orifices of the coronary arteries under conditions of artificial circulation. S. Bailey has also developed special instruments for this procedure, including microcurettes for the coronary arteries.

Endarterectomy is the removal of the inner layer of the arterial vessel wall, including the atherosclerotic altered intima and part of the media, and was developed on the peripheral arteries in 1948 by Dos Santos. Endarterectomy was often complicated by coronary artery thrombosis with the development of myocardial infarction, and the mortality rate during these interventions was very high. This procedure has retained its known meaning to the present day. With diffuse coronary artery disease, it is sometimes necessary to perform EAE in combination with CABG.

Mammary coronary artery bypass grafting... In 1964, Russian surgeon V.I.Kolesov performed the world's first successful operation of mammary-coronary anastomosis (MCA). Currently, V.I. Kolesov is recognized all over the world, and the famous American surgeon D. Eggeer called him a pioneer of coronary surgery. Kolesov V.I. applied MCA without the use of artificial blood circulation, on a beating heart. (Fig. 1)

Rice. 1. Thoracic anastomosis according to Kolesov

The main stages of the operation:

1) access to the heart, usually carried out by a median sternotomy;

2) allocation of HAV; collection of autovenous grafts, performed by another team of surgeons simultaneously with the production of sternotomy;

3) cannulation of the ascending part of the aorta and vena cava and connecting the IC;

4) clamping of the ascending part of the aorta with cardioplegic cardiac arrest;

5) the imposition of distal anastomoses with the coronary arteries;

6) removing the clamp from the ascending part of the aorta;

7) prevention of air embolism;

8) restoration of cardiac activity;

9) the imposition of proximal anastomoses;

10) disable IR;

12) suturing the sternotomy incision with drainage of the pericardial cavity.

The internal thoracic artery is isolated on a flap or skeletonized. (Fig. 2) The advantage of skeletal HAV is its longer length. At the same time, when HAV is isolated on the flap, the risk of trauma to the vessel wall decreases. For convenience, a special retractor is used for HAV isolation. In order to relieve vascular spasm, a papaverine solution is injected into the HAV lumen and the HAV is wrapped in a napkin soaked in the same papaverine solution. The operation is carried out under conditions of moderately hypothermic IC (28-30 ° C).

The advantages of the method:

Greater correspondence between the diameters of the internal thoracic and coronary arteries;

Anastomosis is applied between homogeneous tissues;

Due to the small diameter of the internal thoracic artery, the volumetric blood flow through it is less than through the autovenous shunt, but the linear velocity is higher, which theoretically should reduce the incidence of thrombosis;

Only one anastomosis needs to be applied, which shortens the operation time;

The internal mammary artery is rarely affected by atherosclerosis.

Limitations of the method:

There are only two internal mammary arteries, which limits the ability to revascularize multiple arteries;

Isolation of the internal mammary artery is a more complex procedure.

Rice. 2.mammary coronary bypass grafting

Coronary artery bypass grafting... The idea to create a bypass shunt between the aorta or systemic artery and the coronary vessel bypassing the area affected and narrowed by atherosclerosis was clinically realized by Rene Favaloro in 1967. Earlier, in 1962, David Sabiston (Duke University), using a large saphenous vein as a vascular prosthesis , placed a shunt between the aorta and the coronary artery. However, the message about this operation appeared in 1973, that is, after 9 years.

Coronary artery bypass grafting (Fig. 3) belongs to the category of effective operations in the surgical treatment of coronary heart disease. The operation of coronary artery bypass grafting with a segment of the great saphenous vein of the thigh is performed under artificial circulation. Surgical approach: usually a median longitudinal sternotomy, which allows approaching the descending branches of the right and left coronary arteries. The operation begins with the isolation of the coronary artery, ligation above the occlusion site. Distal arteriovenous anastomosis is applied. The next stage of the operation involves the imposition of a proximal aortovenous anastomosis by lateral squeezing of the ascending aorta, in which an oval opening with a diameter of 1 * 0.3 cm is excised, and an end-to-side anastomosis is applied. In addition to the great saphenous vein of the thigh, use the internal thoracic, radial, lower epigastric autoartery. In case of multiple lesions of the coronary arteries, several shunts are performed (from 2 to 6). [6, p.179]

Rice. 3. Coronary artery bypass grafting

There are several technical options for coronary artery bypass grafting (Fig. 4, 5):

1. "Serpentine" or sequential shunt

This is the name of a shunt with successive anastomoses, that is, using one graft, several coronary arteries or a coronary artery are shunted at two levels. In this case, successive side-to-side anastomoses are applied between the graft and the revascularized vessel, and one distal end-to-side anastomosis is applied. Cases of shunting with one autovenous graft up to 5 coronary arteries have been described. The best option is to bypass two, maximum three branches with one graft.

2. U-shaped shunt

It is created by suturing the proximal anastomosis of one of the shunts to the side of the other. It is used for significant thinning of the wall of the ascending part of the aorta or with a small area of ​​the aorta and a large number of revascularized vessels.

Rice. 4 Y-shaped shunt

Fig. 5 "Serpentine" or sequential shunt

Coronary stenting... This is an operation that allows you to restore blood flow in the coronary arteries by implanting stents at the site of the narrowing of the coronary artery. A stent is an intravascular prosthesis for supporting the wall of the affected vessel and maintaining the diameter of its lumen. The design of the stent is a thin mesh frame made of an inert metal alloy of the highest quality, which is expanded by a balloon inside the vessel to the required diameter.

Types of stents:

· Metal stent (Bare Metal Stent) - intravascular prosthesis made of stainless steel or cobalt-chromium alloy. The use of metal stents is associated with a risk of thrombosis in the first 30 days and requires dual antiplatelet therapy for 1 month, as well as a 20-30% risk of restenosis (re-narrowing of the vessel) within 6-9 months after implantation.

Antiproliferative drug-eluting stent - A coated cobalt-chromium alloy intravascular prosthesis that releases a drug that prevents re-narrowing of the vessel. The drug layer subsequently dissolves.

Coronary artery stenting technique. (Fig. 6)

At the stage of coronary angiography, the nature, location and degree of narrowing of the coronary arteries are determined, after which they proceed to the operation.

Under fluoroscopic control, the stent is brought to the stenosis, after which the surgeon inflates the balloon on which the stent is worn with a syringe with a manometer (deflator) to a certain pressure. The balloon inflates, the stent expands and presses against the inner wall, thereby forming a rigid frame. To be sure that the stent is fully extended, the balloon is inflated several times. The balloon is then deflated and removed from the artery along with a guidewire and catheter. The stent remains and preserves the vessel lumen. One or more stents may be used depending on the length of the artery lesion.

Rice. 6. Stages of artery stenting

Despite the low complication rate, coronary stenting carries a certain risk.

The main complications encountered during stenting are cerebrovascular (0.22%), vascular (from 2%), and death (1.27%). The main factor limiting the effectiveness of coronary stenting is the restenosis process. Restenosis - repeated narrowing of the lumen of the vessel, leading to a decrease in blood flow. In-stent restenosis - re-narrowing of the lumen of the coronary vessel inside the stent.

Risk factors for restenosis are:

- genetic predisposition to increased proliferation of the neointima;

- diabetes;

- parameters of the affected segment: diameter of the vessel, length of injury, type of stenosis;

- features of the course of the procedure: the extent of the vessel injury, residual dissection, the number of implanted stents, the diameter of the stent and the ratio of its area to the surface of the vessel.

Coronary artery balloon angioplasty... In the last 10-15 years in the treatment of coronary artery disease, myocardial revascularization by transluminal balloon dilation (angioplasty) of stenotic coronary arteries has been used. The method was introduced into cardiological practice in 1977 by A. Gruntzig. The indication for angioplasty of the coronary arteries in patients with coronary artery disease is hemodynamically significant damage to the coronary artery in its proximal parts, provided there is no pronounced calcification and damage to the distal bed of this artery.

To perform angioplasty of the coronary arteries, a system of two catheters is used: a guide catheter and a dilation catheter. After performing coronary angiography by the usual method, the angiographic catheter is replaced with a guide catheter, through which a dilation catheter is passed into the stenotic coronary artery. The maximum diameter of the can is 3–3.7 mm when filled; in the collapsed state, its diameter is 1.2–1.3 mm. The catheter is passed into the stenotic artery. Distal to the area of ​​stenosis, the antegrade pressure in the artery decreases and thus the perfusion pressure is fixed distal to the stenosis (due to collateral blood flow). When the balloon reaches the stenotic segment, the latter is under a pressure of 5 atm. fill with 30% contrast agent solution. The balloon is in this state for 5-60 s, after which it is emptied and the perfusion pressure below the stenosis is measured again. If necessary, the can can be refilled several times. The decrease in the pressure gradient serves as the main guideline for termination of the procedure. Repeated angiographic control allows you to determine the degree of residual stenosis.

The main criterion for success is considered to be a decrease in the degree of stenosis after angioplasty by more than 20%. According to the summary data of the National Heart, Lung and Blood Institute (USA), the total positive result of balloon dilatation of the coronary arteries is achieved in about 65% of patients. The likelihood of success with this procedure increases in young patients with a short history of angina pectoris and in proximal arterial lesions.

The main complications of coronary angioplasty are

Acute myocardial infarction (5.3%)

Occlusion of the coronary artery (4.6%)

Spasm of the coronary artery (4.5%)

Ventricular fibrillation (1.8%)

The clinical effect of coronary artery angioplasty is the disappearance or significant reduction of angina attacks in about 80% of patients with a successful procedure, an increase in exercise tolerance in more than 90%, and an improvement in myocardial contractility and perfusion.

Bibliographic reference

Ivanova Yu.Yu. SURGICAL TREATMENT OF ISCHEMIC HEART DISEASE // International Student Scientific Bulletin. - 2015. - No. 6 .;
URL: http://eduherald.ru/ru/article/view?id=14267 (date of access: 12/13/2019). We bring to your attention the journals published by the "Academy of Natural Sciences"

Surgical treatment of ischemic heart disease consists in myocardial revascularization - restoration of impaired blood supply to the myocardium, as well as in the treatment of complications of coronary artery disease: heart aneurysms, thrombosis, valve insufficiency, etc. Myocardial revascularization, like pharmacotherapy of ischemic heart disease, has three main goals : improving the prognosis of the disease, reducing the symptoms of the disease and improving the patient's quality of life.

Methods of myocardial revascularization:

direct (direct revascularization) - restoration of blood flow along natural, already existing pathways (that is, coronary arteries);

indirect (indirect revascularization) - creation of additional blood flow paths bypassing the affected arteries.

The most common method of direct revascularization is percutaneous intervention in the coronary arteries, and indirect - coronary artery bypass grafting. Each revascularization method has its own advantages and disadvantages, as well as indications and contraindications. The main factors determining the choice of one method or another are the severity of symptoms, the nature of the lesion and the individual cardiovascular risk. From a surgical point of view, an important factor is the technical feasibility of performing the intervention, which implies not only the required equipment, but also the nature of the damage to the coronary arteries. In addition, when choosing a revascularization method, concomitant diseases, as well as the patient's desire, are taken into account. The decision on the need and method of surgical treatment of coronary artery disease is usually made jointly by cardiologists and cardiac surgeons.

The main indications for myocardial revascularization:

equivalent of stenosis of the left coronary artery trunk - hemodynamically significant stenosis of the anterior interventricular artery and the circumflex artery;

hemodynamically significant stenosis of the great vessels.

Main contraindications for myocardial revascularization:

stenosis of one or two coronary arteries without pronounced proximal narrowing of the anterior interventricular artery, in the presence of mild symptoms of angina pectoris or in the absence of adequate drug therapy;

borderline stenosis of the coronary arteries (except for the left trunk of the coronary artery) and the absence of signs of myocardial ischemia in non-invasive examination;

hemodynamically insignificant stenosis; high risk of perioperative complications and death;

oncological diseases (contraindications are assessed individually, taking into account the chosen method of revascularization).

Note

The above contraindications are taken into account, as a rule, for percutaneous interventions on the coronary arteries and for coronary artery bypass grafting. But for other methods of revascularization, for example, laser, some of the contraindications, on the contrary, become indications.

Percutaneous coronary artery interventions

The introduction into practice of percutaneous interventions on the coronary arteries has opened a new branch of medicine - invasive cardiology. Since 1977, when A. Gruentzig first performed catheter dilatation of coronary arteries, the number of such operations is growing, reaching, according to the latest data, over 1 million per year. This method of treatment of coronary artery disease does not require long-term hospitalization, is carried out under local anesthesia, which significantly reduces the cost of treatment and rehabilitation time.

The development of new technologies in this area made it possible to carry out manipulations on the coronary arteries under the control of intravascular ultrasound, which significantly improves the quality of the intervention and reduces the possibility of perioperative complications.

Percutaneous interventions on the coronary arteries include the following basic manipulations to restore blood flow through the affected arteries:

balloon angioplasty of the coronary arteries;

endoprosthetics (stenting) of coronary arteries;

direct intravascular effect on atherosclerotic plaque.

Coronary artery balloon angioplasty

The method consists in inflating the balloon catheter in the area of ​​coronary artery stenosis.

Endoprosthetics (stenting) of coronary arteries

After angioplasty of the affected area of ​​the artery, an endoprosthesis is installed in this area - a stent, which is a metal perforated tube (cylinder), inserted into the lumen of the vessel in a folded form and deployed at the target site. The stent owes its name to the English dentist C. Stent, who was the first to create and put it into practice.

The stent is a mechanical obstacle to stenosis, presses the intima of the artery that has been dissected during angioplasty, expanding the lumen of the artery more than during angioplasty.

The use of stents significantly improves the results of treatment, reduces the risk of unfavorable outcomes of surgery: restenosis of the coronary arteries is observed 30% less frequently than with angioplasty, therefore, the need for repeated revascularization of the target artery decreases.

Direct effect on atherosclerotic plaque

To directly affect atherosclerotic plaque, various intravascular methods are used: laser burning, destruction with special drills, cutting off the plaque with an atherotomy catheter, etc.

Indications for Percutaneous Coronary Artery Interventions:

hemodynamically significant stenoses in one or more coronary arteries available for catheter technology;

short-term occlusion of coronary arteries (up to 3–6 months);

violation of patency of coronary bypass grafts;

acute coronary syndrome (after or instead of unsuccessful thrombolysis).

Contraindications for percutaneous interventions:

lesion of the left coronary artery trunk, in which coronary artery bypass grafting is preferable (however, in a number of clinical situations, angioplasty and stenting of the trunk are possible);

limited technical capabilities, for example, the absence of stents with the potential need for their use;

anatomical features of the lesion - extended occlusions, pronounced calcification, diffuse lesions of the coronary arteries;

left ventricular aneurysm requiring surgical treatment, especially in combination with intracardiac thrombosis; the presence of contraindications to coronary angiography.

Benefits of Percutaneous Coronary Artery Interventions

A shorter rehabilitation period in comparison with coronary bypass grafting, due to the absence of abdominal surgery and the need to use artificial blood circulation, as a result, the complications associated with them.

With successful interventions, their immediate clinical efficacy is high: the incidence of attacks decreases, up to their complete disappearance, the functional class of angina pectoris decreases, the contractile function of the myocardium improves, which together leads to a decrease in the volume of drug treatment, an increase in exercise tolerance and an improvement in the quality of life of patients. ...

Disadvantages of Percutaneous Coronary Artery Interventions

The issue of preventing the recurrence of coronary artery disease after percutaneous interventions remains unresolved at the moment. According to various sources, the recurrence rate ranges from 32 to 40% within 6 months after surgery. Restenosis occurs due to the proliferation of smooth muscle cells in the area of ​​angioplasty and / or vascular thrombosis. The frequency of relapses (restenosis and reocclusion of target coronary arteries) is significantly reduced by endoprosthetics (stenting) of coronary arteries, especially drug-eluting stents (paclitaxel, sirolimus, everolimus, etc.), which prevents proliferation and the formation of blood clots.

There remains a need for a fairly long-term antiplatelet therapy.

Long-term results of percutaneous interventions on the coronary arteries: percutaneous interventions have an advantage over the pharmacotherapy of coronary artery disease for several years after the intervention. As the time increases, the differences disappear.

Coronary artery bypass grafting

The method consists in creating new blood flow paths (shunts) bypassing the stenotic portion of the coronary artery. The distal end of the shunt is sutured to the coronary artery below the stenotic site (distal anastomosis), the proximal end is sutured directly to the aorta (proximal anastomosis).

For shunting, venous grafts (autoveins) and arterial (internal mammary arteries, radial arteries, gastroepiploic arteries, lower epigastric) are used. At the same time, for some arterial grafts (for example, the internal mammary artery), most often it is not required to create a proximal anastomosis - the blood flow is carried out directly from the artery bed. Arterial grafts have advantages over venous grafts: they are practically not at risk of dysfunction for many years after surgery.

The volume of coronary artery bypass grafting is determined by the number of affected arteries supplying blood to the viable myocardium. Each ischemic area must be revascularized. The main arteries and their large branches of the first order with a diameter of at least 1.5 mm are subject to bypass grafting. Restoration of blood supply in the area of ​​postinfarction cardiosclerosis in most cases is considered inappropriate.

At the moment, coronary artery bypass grafting can be performed both in conditions of artificial circulation, and without it - on a beating heart. In recent years, the so-called mini-invasive bypass surgery using small approaches and special surgical techniques has become more widespread, which can significantly reduce the patient's rehabilitation time and reduce the number of complications.

Indications for coronary artery bypass grafting:

with angina FC I – II

stenosis of the left trunk of the coronary artery;

equivalent stenosis of the left coronary artery: hemodynamically significant stenosis of the anterior interventricular artery and the circumflex artery;

three-vessel lesion;

proximal stenosis of the anterior interventricular artery over 70%, isolated or in combination with stenosis of any major branch (right coronary artery or circumflex branch of the left coronary artery);

with angina FC III-IV

stenosis of the left trunk of the coronary artery;

equivalent stenosis of the left coronary artery - hemodynamically significant stenosis of the anterior interventricular artery and the circumflex artery;

three-vessel lesion;

two-vessel lesion with an ejection fraction of less than 50% or obvious myocardial ischemia;

single-vessel lesion with a large area of ​​ischemic myocardium;

angina pectoris refractory to drug treatment;

additional indications

drug therapy does not control angina pectoris;

non-invasive methods demonstrate a wide prevalence of the ischemic zone;

high probability of success with an acceptable risk of perioperative complications;

the patient's consent (if medically indicated) to this method of revascularization after receiving comprehensive information about the risk of complications.

Contraindications to coronary artery bypass grafting:

diffuse coronary artery disease;

social and psychological factors;

patient refusal to intervene.

Notes (edit)

1. The old age of the patient is not a contraindication, but the risk of perioperative complications in this category of patients is higher due to concomitant diseases.

2. Significant impairment of left ventricular function (PI less than 35%, LV CDP over 25 mm Hg) is not a contraindication, but worsens the prognosis of the operation.

3. Postponed myocardial infarction is not a contraindication.

The main causes of recurrent coronary artery disease after coronary artery bypass grafting: the progression of atherosclerosis with damage to new (unshunted) coronary arteries, as well as the coronary bed located distal to the functioning bypass; dysfunction of shunts (usually venous).

Results of coronary artery bypass grafting

Coronary artery bypass grafting improves the prognosis of the disease only in the following clinical situations:

the presence of stenosis of the trunk of the left coronary artery;

proximal stenosis of the three main coronary arteries;

stenosis of two main arteries, one of which is the anterior interventricular artery;

dysfunction of the left ventricle.

In other clinical situations, coronary artery bypass grafting has no advantages over pharmacotherapy in influencing the prognosis of the disease, but it has significant advantages in improving the quality of life.

Indications for surgical treatment in the presence of a left ventricular aneurysm: all of the above factors for angina pectoris in combination with severe ventricular arrhythmias; left ventricular thrombosis; heart failure of the second degree or higher (according to NYHA).


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