Takach Thomas J, Duncan J Michael, Livesay James J, Ott David A, Cervera Roberto D, Cooley Denton A
Department of Cardiovascular Surgery, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, TX 77225-0345, USA.
Ann Vasc Surg. 2011 Oct;25(7):895-901. doi: 10.1016/j.avsg.2011.06.003. Epub 2011 Aug 10.
The contemporary impact of and indications for carotid-subclavian bypass (CSB) are essential considerations in decision making for brachiocephalic reconstruction.
We analyzed operative outcomes, long-term graft patency, and the extended epidemiological impact of the primary disease process in 287 consecutive patients (mean age, 60.6 years; 43.2% male) who received CSB for symptomatic brachiocephalic disease.
Technical success was achieved in each patient. Operative mortality was 1.0% (3/287) and total (ipsilateral [1.4%, 4/287] plus contralateral [0.7%, 2/287]) stroke rate was 2.1% (6/287). Primary patency rates at 5, 10, and 15 years were 94.2 ± 1.9%, 88.6 ± 3.2%, and 86.5 ± 3.8%, respectively. Kaplan-Meier freedom from specific events at 15 years was as follows: restenosis, 86.5 ± 3.8%; death, 67.5 ± 5.2%; coronary revascularization, 59.6 ± 6.3%; myocardial infarction, 82.8 ± 3.9%; stroke, 85.6 ± 4.9%; other vascular procedure, 60.0 ± 5.5%; adverse cardiac outcome (death, myocardial infarction, or coronary revascularization), 44.5 ± 5.5%; and adverse vascular outcome (restenosis, stroke, or other vascular procedure), 48.7 ± 5.3%.
CSB produces excellent long-term patency and extended symptom relief, with acceptably low operative morbidity and mortality. Despite the durability and success of CSB, the primary disease process has an adverse impact on long-term prognosis and significantly influences decision making with regard to management. The proven durability may offer extended symptom relief to the relatively younger patient, a survival advantage associated with preservation of internal mammary artery perfusion in patients at risk for myocardial revascularization, optimal durability in patients requiring a concomitant open procedure, and preservation of limb function in patients who require aortic endovascular graft placement.
在头臂血管重建的决策过程中，颈-锁骨下动脉搭桥术（CSB）的当代影响和适应症是至关重要的考虑因素。
我们分析了287例因有症状的头臂血管疾病接受CSB的连续患者（平均年龄60.6岁；43.2%为男性）的手术结果、长期移植物通畅情况以及原发疾病过程的广泛流行病学影响。
每位患者均获得技术成功。手术死亡率为1.0%（3/287），总的（同侧[1.4%，4/287]加对侧[0.7%，2/287]）卒中率为2.1%（6/287）。5年、10年和15年的原发性通畅率分别为94.2±1.9%、88.6±3.2%和86.5±3.8%。15年时根据Kaplan-Meier法无特定事件发生的概率如下：再狭窄，86.5±3.8%；死亡，67.5±5.2%；冠状动脉血运重建，59.6±6.3%；心肌梗死，82.8±3.9%；卒中，85.6±4.9%；其他血管手术，60.0±5.5%；不良心脏结局（死亡、心肌梗死或冠状动脉血运重建），44.5±5.5%；不良血管结局（再狭窄、卒中或其他血管手术），48.7±5.3%。
CSB能产生优异的长期通畅率并能长期缓解症状，手术发病率和死亡率低至可接受水平。尽管CSB具有持久性和成功率，但原发疾病过程对长期预后有不利影响，并显著影响治疗管理决策。已证实的持久性可为相对年轻的患者提供长期症状缓解，为有心肌血运重建风险的患者带来与保留胸廓内动脉灌注相关的生存优势，为需要同期开放手术的患者提供最佳持久性，并为需要主动脉腔内移植物置入的患者保留肢体功能。
