Glass Carolyn, Maevsky Victor, Massey Todd, Illig Karl
University of Rochester Medical Center, Rochester, NY, USA.
Ann Vasc Surg. 2009 Jul-Aug;23(4):465-8. doi: 10.1016/j.avsg.2009.01.001. Epub 2009 Apr 8.
Given the increasing numbers of patients requiring long-term hemodialysis, there is an inevitably increasing population of patients with occluded central venous inflow (subclavian, innominate, and caval) despite access or access possibilities in the arm. In an effort to avoid sternotomy, we have attempted to treat these patients with a substernally tunneled subclavian to right atrial bypass. Patients treated in this fashion have an existing fistula with symptomatic venous hypertension or good fistula options but complete central vein obstruction, a patent subclavian/axillary vein to the costoclavicular junction, and no other options in the contralateral arm. Claviculectomy is performed and the subclavian vein isolated. Through a third intercostal space "minipericardiotomy," the right atrial appendage is exposed. A retrosternal tunnel is fashioned, and bypass is performed from the subclavian vein to atrial appendage. Eleven patients aged 20-70 (mean 46) years underwent surgery at our institution between February 2004 and March 2007. Three bypasses were performed with autogenous vein (two femoral and one saphenous), while eight were performed with polytetrafluoroethylene in an effort to preserve the superficial femoral vein for later leg bypass. There was one early mortality due to sepsis, and early morbidity was limited to one patient with a symptomatic pericardial effusion. Mean follow-up was 16 (range 3-43) months. Sixty-seven percent and 33% of arteriovenous fistulas remained functional at 6 and 10 months, respectively; and one patient's fistula remained functional at 21 months. Four patients (36%) developed central bypass stenosis or occlusion, one requiring a redo bypass and three angioplasty. Infection occurred in two patients (18%), with removal of autogenous vein graft in one. While a significant number of these bypasses fail, upper extremity access is maintained in a reasonable number of patients (67% at 6 months) who are not candidates for local repair or stenting and would thus have no other upper extremity access options. This technique offers an alternative to sternotomy and brachiocephalic vein reconstruction, although the superiority of one method over the other will require direct comparison.
鉴于需要长期血液透析的患者数量不断增加，尽管手臂有血管通路或有建立血管通路的可能性，但中心静脉流入道（锁骨下静脉、无名静脉和腔静脉）闭塞的患者群体仍不可避免地在扩大。为了避免开胸手术，我们尝试采用经胸骨后隧道将锁骨下静脉与右心房进行搭桥的方法来治疗这些患者。以这种方式治疗的患者存在有症状性静脉高压的现有动静脉内瘘或有良好的内瘘选择，但中心静脉完全阻塞，锁骨下静脉/腋静脉至肋锁关节通畅，且对侧手臂没有其他选择。进行锁骨切除术并分离出锁骨下静脉。通过第三肋间间隙进行“小心包切开术”，暴露右心耳。制作胸骨后隧道，然后从锁骨下静脉至心耳进行搭桥。2004年2月至2007年3月期间，我们机构有11名年龄在20 - 70岁（平均46岁）的患者接受了手术。3例搭桥手术使用了自体静脉（2例使用股静脉，1例使用大隐静脉），而8例使用了聚四氟乙烯，以保留股浅静脉供后期腿部搭桥使用。有1例因败血症早期死亡，早期并发症仅限于1例出现有症状心包积液的患者。平均随访时间为16个月（范围3 - 43个月）。动静脉内瘘在6个月和10个月时分别有67%和33%仍保持功能；1例患者的内瘘在21个月时仍保持功能。4例患者（36%）出现中心搭桥狭窄或闭塞，1例需要再次搭桥，3例需要进行血管成形术。2例患者（18%）发生感染，其中1例移除了自体静脉移植物。虽然这些搭桥手术中有相当一部分失败了，但对于那些不适合进行局部修复或支架置入且因此没有其他上肢血管通路选择的患者，仍有相当数量（6个月时为67%）的患者维持了上肢血管通路。这种技术为开胸手术和头臂静脉重建提供了一种替代方法，尽管一种方法相对于另一种方法的优越性需要直接比较。
