Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
Ann Thorac Surg. 2011 Jul;92(1):97-102; discussion 102-3. doi: 10.1016/j.athoracsur.2011.03.089.
The need for routine left subclavian artery (LSCA) revascularization when this vessel is covered during thoracic endovascular aortic repair remains controversial. We report our results with a selective LSCA revascularization strategy during thoracic endovascular aortic repair.
Between May 2002 and March 2010, 287 thoracic endovascular aortic repair procedures were performed at our institution. LSCA coverage occurred in 145 (51%), which form the basis of this report.
Left subclavian artery revascularization was performed in 32 patients (22%) through a left common carotid-LSCA bypass. Indications for selective LSCA revascularization included spinal cord protection in 10, patent pedicled left internal mammary artery graft in 9, left arm ischemia after LSCA coverage in 5, origin of the left vertebral artery from the arch in 4, dialysis access in the left arm in 2, and vertebrobasilar insufficiency in 2. There were no instances of dominant left vertebral artery. The revascularized and non-revascularized groups had similar rates of death (6.3% vs 1.8%; p=0.21), stroke (3.1% vs 3.5%; p>0.99), permanent paraplegia or paraparesis (3.1% vs 0%; p=0.22), and type II endoleak (4.3% vs 6.5%; p>0.99). There were no instances of ischemic stroke related to left posterior circulation hypoperfusion. Four complications of carotid-subclavian bypass occurred in 3 patients (9.4%).
Selective LSCA revascularization is safe and does not appear to increase the risk of neurologic events. Further, subclavian revascularization is not without complications, which should be considered with regards to a nonselective revascularization strategy.
在胸主动脉腔内修复术（TEVAR）过程中覆盖左锁骨下动脉（LSCA）时，是否需要常规进行左锁骨下动脉重建仍然存在争议。我们报告了在胸主动脉腔内修复术中采用选择性左锁骨下动脉重建策略的结果。
2002 年 5 月至 2010 年 3 月，我们机构共进行了 287 例胸主动脉腔内修复术。LSCA 覆盖发生在 145 例（51%）患者中，这是本报告的基础。
通过左颈总动脉-左锁骨下动脉旁路手术，对 32 例患者（22%）进行了左锁骨下动脉血运重建。选择性左锁骨下动脉重建的适应证包括：10 例脊髓保护、9 例带蒂左内乳动脉移植血管通畅、5 例 LSCA 覆盖后左上肢缺血、4 例左椎动脉发自弓部、2 例左上肢动静脉瘘建立透析通路、2 例椎基底动脉供血不足。无优势左椎动脉。血运重建组和未血运重建组的死亡率（6.3%比 1.8%；p=0.21）、卒中发生率（3.1%比 3.5%；p>0.99）、永久性截瘫或不完全性截瘫发生率（3.1%比 0%；p=0.22）、II 型内漏发生率（4.3%比 6.5%；p>0.99）均相似。无左后循环灌注不足引起的缺血性卒中。3 例患者（9.4%）出现了 4 例颈动脉-锁骨下旁路并发症。
选择性左锁骨下动脉重建是安全的，似乎不会增加神经事件的风险。此外，锁骨下动脉重建并非没有并发症，在考虑非选择性重建策略时应考虑这些并发症。
