乳腺癌合并重度冠状动脉狭窄的治疗  

Clinical Treatment of Breast Cancer With Severe Coronary Artery Stenosis

作　　者：魏常胜[1] 骆成玉 张树琦[1] 郭洋[1] 王长华[2] 张可心[3] 于洋[3] Wei Changsheng;Luo Chengyu;Zhang Shuqi(Department of General Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China)

机构地区：[1]首都医科大学附属北京安贞医院普外科,北京100029 [2]首都医科大学附属北京安贞医院心内科,北京100029 [3]首都医科大学附属北京安贞医院麻醉科,北京100029

出　　处：《中国微创外科杂志》2021年第3期239-242,共4页Chinese Journal of Minimally Invasive Surgery

摘　　要：目的探讨介入支架置入(percutaneous coronary intervention,PCI)术后4~6周实施乳腺癌手术的可行性和安全性。方法2014年1月~2019年1月我们对18例乳腺癌合并重度冠状动脉狭窄先行PCI,PCI术后4~6周实施乳腺癌手术(3例完成PCI术后1个月确诊乳腺癌,15例乳腺癌术前准备发现冠状动脉重度狭窄,无法耐受手术及麻醉,先行冠状动脉PCI),重视围手术期管理,术前5 d开始停用阿司匹林及氯吡格雷,使用低分子肝素钙桥接抗凝,术中及术后使用心肌保护药物。结果12例置入药物洗脱支架(drug eluting stent,DES),6例置入金属裸支架(bare metal stent,BMS)。PCI术中支架置入后即刻血管造影显示血流通畅。乳腺癌手术包括改良根治术7例,乳腺全切术+前哨淋巴结活检4例,单纯乳房切除5例,保乳乳腺区段切除+前哨淋巴结活检2例,均顺利完成乳腺癌手术。手术时间50~145 min,(89.9±27.4)min;术中出血量30~200 ml,(98.3±59.5)ml。术中、术后血压、心率及血流动力学平稳,术前与术后3 d血小板、高敏C反应蛋白、脑钠肽、心肌肌钙蛋白Ⅰ及左心室射血分数差异无显著性(P>0.05),乳腺癌手术后无心脏相关事件发生。3例乳腺癌改良根治术后恢复抗凝后出现皮瓣下出血,通过加强负压引流及加压包扎控制,效果满意。住院时间5~8 d,(6.1±1.1)d。18例术后随访12~24个月,中位随访时间15个月,均无心脏相关事件发生,无肿瘤复发及转移。结论通过加强围术期的管理,改善术中、术后心肌供血,选择恰当的手术方式,BMS与DES置入术后4周以上实施乳腺癌手术是安全的。Objective To investigate the feasibility and safety of surgical procedures for breast cancer at 4-6 weeks after percutaneous coronary intervention(PCI).Methods From January 2014 to January 2019,18 cases of breast cancer complicated with severe coronary artery stenosis were treated with PCI.Breast cancer surgery was performed 4-6 weeks after PCI(3 cases were diagnosed with breast cancer one month after PCI.And 15 cases were found severe coronary artery stenosis before breast cancer surgery,and they could not tolerate surgery and anesthesia so PCI was performed first).The perioperative management was emphasized.Aspirin and clopidogrel were stopped 5 days before operation.Low molecular weight heparin calcium was used to bridge anticoagulation.Myocardial protective drugs were used during and after operation.Results A total of 12 patients were implanted with drug eluting stent(DES),and 6 patients were implanted with bare metal stent(BMS).PCI angiography immediately after stent implantation revealed blood flow patency.Among the 18 cases of breast cancer,7 cases underwent modified radical mastectomy,4 breast resection and sentinel lymph node biopsy(SLNB),5 simple mastectomy,and 2 breast conserving surgery and SLNB,all of which were successfully completed.The operative time was 50-145 min(mean,89.9±27.4 min).The intraoperative blood loss was 30-200 ml(mean,98.3±59.5 ml).The intraoperative and postoperative blood pressure,heart rate and hemodynamics were stable.There were no significant difference before and 3 days after operation in platelet,high sensitivity C-reactive protein,brain natriuretic peptide,cardiac troponinⅠand left ventricular ejection fraction(P>0.05).No heart related events occurred after the operation.Three cases who underwent modified radical mastectomy had wound bleeding under skin flap after anticoagulation.They were treated with vacuum drainage and pressure bandage.The hospital stay was 5-8 d(mean,6.1±1.1 d).All the 18 cases were followed up for 12-24 months(median,15 months).Neither heart relate

关 键 词：乳腺癌 冠状动脉粥样硬化性心脏病 支架置入 围术期 

分 类 号：R73[医药卫生—肿瘤]