山梨医科大学紀要　第15巻，012-016(1998)

今日の虚血性心疾患の外科治療

保坂　茂，鈴木章司，吉井新平，多田祐輔

　冠動脈バイパス術は，安全な手術手技の確立と長期安定した効果から重症虚血性心疾患治療の主役となった。しかし，昨今の高齢化から長期のグラフト開存性が望まれるばかりか，手術成績の安定からより高齢かつ他疾患を合併したhigh risk 例にまで手術適応は拡大されている。そこで，生理的特性を維持した動脈グラフトの長期開存性が証明されるにともない両側内胸動脈，右胃大網動脈，下腹壁動脈，橈骨動脈を駆使した動脈グラフトのみの多枝バイパス術が行われ，侵襲軽減のため常温体外循環や，体外循環そのものの侵襲を回避するために心拍動下手術，さらに１０�p弱の小切開拍動下手術も行われるようになった。一方，バイパス手術の適応とならない分枝末梢までに及ぶ多発狭窄例に対して，心筋内レーザー血管形成術や線維芽細胞増殖因子心筋内注射による血管新生など新たな興味深い展開もある。これら多くの方法から，個々の症例に最良の治療戦略を選択することが重要と考える。

キーワード：虚血性心疾患，冠動脈バイパス術，動脈グラフト，体外循環



Current Surgical Treatment for Ischemic Heart Disease

Shigeru HOSAKA, Shoji SUZUKI, Shinpei YOSHII and Yusuke TADA

Since surgical techniques have improved and postoperative prognosis is getting better, the coronary artery bypass grafting is recognized as the most effective treatment for severe coronary artery disease. Nowadays,a longer patency of grafts is essential because of prolonging life expectancy,and the operation is done in high-risk patients as well as in older patients such as octogenarian,following the diminution of the operative morbidity and mortality. With physiological properties, long-term patency rates of arterial grafts have been proved to be much better than those of vein grafts, so the multiple bypass operation with arterial grafts, e.g. internal mammary artery,right gastroepiploic artery, inferior epigastric artery and radial artery, is now safely performed. The normothermic cardiopulmonary bypass was successfully applied to reduce the deteriorating influences of the hypothermic cardiopulmonary bypass. In the early 1990s, coronary artery bypass grafting without cardiopulmonary bypass was developed,and in the middle 1990s, coronary revascularization on a beating heart through a minithoracotomy was reported. Recently,new procedures like transmyocardial laser revascularization and intramyocardial injection of human growth factor are performed for patients with multiple and diffuse stenosis of multiple branches who cannot undergo bypass operation. Considering the advantages and disadvantages of these treatments, the best strategy must be decided individually.



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