A case of vascular transplantation anaesthetic management in patients with non-stop coronary artery bypass in patients with two-sided cervical artery and one-sided vertebral artery aclination

Patient, male, 64 years old, 170 cm, 75kgHe was admitted to hospital with a seizure of chest pain for 7 years, aggravated by 2dThe patient suffered chest pain after exertion 7 years ago,diagnosedcoronary atherosclerosis heart disease, 3 lesions1 pre-implante e-stent stentTwo years ago, chest pain was again, showing 50% stenosis in the left trunk; The examination also found severe stenosis on one side of the neck artery and a closed on the other; Chest pain intermittent attack, containing nitroglycerin 3 to 5min can be alleviated2d chest pain aggravated, night sleep is also intermittent attacks, can not be alleviatedEmergency department with "coronary atherosclerosis heart disease, instability angina, double neck artery severe stenosis" transferred to our hospitalpatientshypertension20 years, up to 160/100mmHg, unregulated treatment; Check: body temperature 36.5 degrees C, HR 70 times/min, RR 16 times/min, BP 115/75mmHg, generally goodAuxiliary Examination: Hemoglobin 14.8g/L, Hct 0.422, Plt 215 x 109/L; BNP: 409.5pg/ml, hs-cTn I 0.744ng/ml; residual test no abnormality; Electrocardiogram: sinus heart rhythm, left ventricular hypertrophy, old underwall infarction; UGG.LVEF:47%, sectional ventricular wall movement abnormal, left heart enlargement associated with reduced functiontheof the vascularin the neck: the artery in the right neck is closed, and the near end of the artery in the left neck is changed by the high resistance of the low-flow velocity Cervical artery angiography bilateral artery and right vertebral artery axilation Lower extremities vascular ultrasound: multiple plaques in the arteries of the lower extremities, and multiple stenosis in the near section of the shallow artery of the left femoral Coronary shadow: the left trunk near section is irregular, the front lowering near section bracket is irregular, the outer part of the far section is 95% narrow, the swing ingress opening is 95% narrow, the near segment of the right coronary vein is narrow, the maximum weight is 99%, the near middle is 100% closed diagnosis : coronary heart disease; unstable angina; coronary artery stent implantation; heart function level II; hypertension 3 (extremely high risk); hyperlipidemia; cerebral infarction; and two-sided cervical artery closure to carry out non-stop coronary artery bypass vascular transplantation Preoperative convening cardiology, respiratory medicine, neurology, neurosurgery, ICU consultation The first day of surgery placed intra-aortic cyostos (Intra-aortic balloons, IABP) In the operating room to absorb oxygen, monitoring, venous puncture Whole hemp-induced opioids are mainly The trachea intubation is mechanically ventilated Open central vein suction compound maintenance BIS 40 to 60 in surgery Intermittent added muscle looseness, calm Maintain blood pressure heart rate at the target Head ice cap, maintaining cerebrooxygen saturation (Regional Cerebral oxygen saturation, rSO2) 70% to 98% There was no change in the pupils during surgery The total intake was 3,100 ml, the urine volume was 2,700 ml, and the bleeding was 1,000 ml He returned to the ward after surgery the first day after surgery to remove the trachea intubation, after the extraction of the tube 8h removed the aortic balloon back beat He was transferred back to the general ward on the 6th day after the operation and discharged from the hospital on the 12th day after the operation discuss coronary heart disease and carotid artery stenosis are cogens Coronary atherosclerosis combined cervical artery stenosis rate of 3% to 22%, cervical artery stenosis is one of the important causes of stroke stroke and death in the perioperative period 30% of stroke after CABG was associated with significant hemodynamic fluctuations in cervical artery stenosis The incidence of high stenosis or closed stroke in the two-sided carotid artery can reach more than 20% Heart surgery cases with severe lesions occurring at the same time in the inner artery of the double neck and one side of the vertebral artery are rare Patients with coronary heart disease with severe cervical artery stenosis are more likely to undergo stage or contemporaneous intradural desorption or interventional surgery patients expect to solve coronary problems, monitoring and maintaining brain function is difficult Preoperative evaluation and multi-disciplinary collaboration are critical, anesthesia must take into account the balance of cardiomyocardial oxygen supply and demand, reduce cardiomyocardial stress, combined with heart tolerance, comprehensive daily blood pressure dynamic monitoring results to maintain a slightly higher average arterial pressure The maintenance of PaCO2 in the normal range, to ensure that brain perfusion as early as possible to assess postoperative nerve function the high risk of perioperative in this case, surgical anesthesia is facing great challenges On the basis of full communication between doctors and patients, from planning to the implementation of anaesthetic individual treatment Focus on the patient's preoperative blood pressure, heart rate 48h continuous monitoring, analysis of meaningful data As a reference for blood pressure and heart rate regulation during surgery The blood pressure target of 110 to 140/70 to 90 mmHg was determined Preoperative transcranial doppler ultrasound, TCD checked cerebrovascular lateral branch circulation Good reflux of patients is associated with the formation of lateral branch of the two-sided cervical artery closure, preoperative multidisciplinary consultation and advance placement of aortic cystic backfighting and other improved safety measures The normal value of rSO2 is 55% to 75% Continuous rSO2 monitoring can reduce postoperative stroke Maintaining rSO2 80% or more can effectively reduce the occurrence of postoperative neurological complications the patient's surgery rSO2 was maintained at 78% to 98% During the operation to avoid head over-bias and hard to touch the neck artery, reduce plaque shedding Combined cerebrovascular axictoration of non-stop-jumping heart bypass vascular transplantation of anaesthetic management to maintain the balance of cardiovascular oxygen supply and demand, and strive to BP, HR fluctuations not more than 90%-110% of the base value Shorten the operation time and strengthen the surgical anesthesia Pay attention to the details Reducing brain oxygen metabolism rate to improve brain oxygen supply is the cornerstone of brain protection, head ice cap cooling is widely used Often used for CPR, multi-disciplinary consultation spent during surgery to cool the patient's head ice cap during surgery as an attempt to protect the brain in this rare case , although the patient has serious cerebrovascular problems, but through multi-disciplinary collaboration, careful preparation Close monitoring and treatment to strengthen brain protection Eventually coronary artery surgery returned well