Caronno R, Piffaretti G, Tozzi M, Lomazzi C, Rivolta N, Castelli P
Vascular Surgery, Department of Surgery, University of Insubria, Ospedale di Circolo, 21100 viale Borri 57, Varese, Italy.
Surg Endosc. 2006 Jun;20(6):915-8. doi: 10.1007/s00464-005-0526-6. Epub 2006 May 11.
Surgical revascularization of the left subclavian artery (LSA) has been performed to warrant arm perfusion and to prevent paraplegia during thoracic stent graft (SG) procedures. We retrospectively investigated the outcome after intentional occlusion of the left subclavian artery during SG repair for thoracic aortic diseases.
From December 2000 to June 2005, 11 patients (mean age, 57 +/- 19 years) with a short (<1 cm) proximal aspect of a thoracic aortic lesion underwent intentional LSA coverage to expand the proximal landing zone for SG fixation. Three patients were treated in the emergency setting. We did not perform a prophylactic revascularization of the LSA prior to SG implantation. A preliminary balloon occlusion test of the LSA was not performed in this series. The SG was positioned so that its covering was immediately distal to the left common carotid artery.
SG implantation was technically successful in all patients. Intraoperative mortality was not observed; no patient suffered any impairment of left carotid artery flow. Aortography after SG implantation showed no direct flow in the LSA and refilling of the LSA via the ipsilateral vertebral artery. After the intervention, mean systolic pressure in the left arm decreased by 38 +/- 17 mmHg. The stented length of the aorta was 171 +/- 73 (median, 150). During hospitalization, no patient showed any signs of left arm malperfusion. Paraplegia was not observed. One patient developed transient ischemic attack. During a mean follow-up of 19 +/- 8 months (range, 3-36), all patients were completely asymptomatic and had no functional deficit or temperature differential between arms. No leakage was detected.
Intentional LSA occlusion seems to be well tolerated. Prophylactic surgical maneuvers may be relegated to an elective measure after an endovascular aortic intervention when intolerable signs or symptoms of ischemia occur.
在胸主动脉支架移植物（SG）手术中，已进行左锁骨下动脉（LSA）的外科血管重建，以保证上肢灌注并预防截瘫。我们回顾性研究了在胸主动脉疾病的SG修复过程中故意闭塞左锁骨下动脉后的结果。
从2000年12月至2005年6月，11例胸主动脉病变近端较短（<1 cm）的患者（平均年龄57±19岁）接受了故意的LSA覆盖，以扩大SG固定的近端着陆区。3例患者在急诊情况下接受治疗。在植入SG之前，我们未对LSA进行预防性血管重建。本系列未进行LSA的初步球囊闭塞试验。SG的放置位置使其覆盖物紧邻左颈总动脉远端。
所有患者的SG植入在技术上均成功。未观察到术中死亡；没有患者出现左颈动脉血流受损。SG植入后的主动脉造影显示LSA无直接血流，且LSA通过同侧椎动脉再充盈。干预后，左臂平均收缩压下降了38±17 mmHg。主动脉的支架长度为171±73（中位数，150）。住院期间，没有患者出现左臂灌注不良的任何迹象。未观察到截瘫。1例患者发生短暂性脑缺血发作。在平均19±8个月（范围3 - 36个月）的随访中，所有患者均完全无症状，双臂之间无功能缺陷或温度差异。未检测到渗漏。
故意闭塞LSA似乎耐受性良好。当出现无法耐受的缺血体征或症状时，预防性手术操作可在血管内主动脉介入后作为一种选择性措施。
