Fadel E, Chapelier A, Bacha E, Leroy-Ladurie F, Cerrina J, Macchiarini P, Dartevelle P
Department of Thoracic and Vascular Surgery, Hôpital Marie-Lannelongue, Paris-Sud University, Le Plessis Robinson, France.
J Vasc Surg. 1999 Apr;29(4):581-8. doi: 10.1016/s0741-5214(99)70301-0.
We previously described an original transcervical approach to resect primary or secondary malignant diseases that invade the thoracic inlet (TI). The purpose of this study was to evaluate the technical aspects and long-term results of the resection and revascularization of the subclavian artery (SA).
Between 1986 and 1998, 34 patients (mean age, 49 years) underwent en bloc resection of TI cancer that had invaded the SA. The surgical approach was an L-shaped transclavicular cervicotomy in 33 patients. In 14 of these patients, this approach was associated with a posterolateral thoracotomy (n = 10) or a posterior midline approach (n = 4). In one patient, the procedure was achieved with a single posterolateral thoracotomy approach. An end-to-end anastomosis was performed in 16 patients. In one patient, a subclavian-left common carotid artery transposition was performed. In one other patient, an end-to-end anastomosis was performed between the proximal innominate artery and the SA. The right carotid artery was transposed into the SA in an end-to-side fashion. In 16 patients, prosthetic revascularization with a polytetrafluoroethylene graft was performed. Thirty-three patients underwent postoperative radiation therapy.
There were no cases of perioperative death, neurologic sequelae, graft infections or occlusions, or limb ischemia. There were two delayed asymptomatic polytetrafluoroethylene graft occlusions at 12 and 31 months. The 5-year patency rate was 85%. During this study, 20 patients died: 18 died of tumor recurrence (5 local and systemic and 13 systemic), one of respiratory failure, and one of an unknown cause at 74 months. The overall 5-year survival rate was 36%, and the 5-year disease-free survival rate was 18%.
Tumor arterial invasion per se should not be a contraindication to TI cancer resection. This study shows that cancers that invade the SA can be resected through an L-shaped transclavicular cervicotomy, with good results with a concomitant revascularization of the SA.
我们之前描述了一种经颈入路来切除侵犯胸廓入口（TI）的原发性或继发性恶性疾病。本研究的目的是评估锁骨下动脉（SA）切除及血管重建的技术要点和长期结果。
1986年至1998年间，34例患者（平均年龄49岁）接受了侵犯SA的TI癌整块切除。33例患者采用L形经锁骨颈切术作为手术入路。其中14例患者，该入路联合后外侧开胸术（n = 10）或后正中入路（n = 4）。1例患者通过单纯后外侧开胸术完成手术。16例患者进行了端端吻合。1例患者进行了锁骨下动脉 - 左颈总动脉转位术。另1例患者在无名动脉近端与SA之间进行了端端吻合。右颈动脉以端侧方式转位至SA。16例患者采用聚四氟乙烯移植物进行人工血管重建。33例患者接受了术后放疗。
无围手术期死亡、神经后遗症、移植物感染或闭塞以及肢体缺血病例。有2例在12个月和31个月时出现无症状的聚四氟乙烯移植物延迟闭塞。5年通畅率为85%。在本研究期间，20例患者死亡：其中18例死于肿瘤复发（5例局部和全身复发，13例全身复发），1例死于呼吸衰竭，1例在74个月时死因不明。总体5年生存率为36%，5年无病生存率为18%。
肿瘤侵犯动脉本身不应成为TI癌切除的禁忌证。本研究表明，侵犯SA的癌症可通过L形经锁骨颈切术切除，同时对SA进行血管重建可取得良好效果。
