CHRU de Lille, Marseille, France.
J Thorac Cardiovasc Surg. 2012 Dec;144(6):1416-20. doi: 10.1016/j.jtcvs.2012.01.031. Epub 2012 Feb 11.
Both retrograde femoral and subclavian artery catheterization techniques have been described as the most common methods for the implantation of the Medtronic CoreValve percutaneous aortic valve (Medtronic Inc, Minneapolis, Minn). The subclavian artery has been shown to be a safe and effective alternative access route in patients with unfavorable femoral access. Of the patients who are identified as candidates for subclavian artery access, a subset possess a patent left internal thoracic artery to left anterior descending artery. This patent left internal thoracic artery presents an additional anatomic and clinical variable that must be taken into consideration to ensure procedural safety and efficacy. We describe the Medtronic CoreValve percutaneous aortic valve implantation using the subclavian arterial approach in patients with a patent left internal thoracic artery and report our study's findings.
The CoreValve percutaneous aortic valve is a self-expandable nitinol-based frame with a porcine pericardial valve. The subclavian access was created by a small infraclavicular surgical incision to expose the artery. Rapid ventricular pacing was used to reduce cardiac output to perform the balloon aortic valvuloplasty via a 12F sheath inserted into the subclavian artery. An 18F sheath was then inserted into the artery down into the ascending aorta and used for introduction of the delivery catheter and implantation of the percutaneous aortic valve.
With the use of this method, 19 patients (76 ± 13 years) whose surgical risk was deemed excessive because of severe comorbidity and in whom transfemoral catheterization was considered unfeasible or at risk of severe complications have received implants. Subclavian artery or left internal thoracic artery injury did not occur in any patient. Two deaths occurred. One patient died of right coronary artery occlusion during the procedure, and one patient died 48 hours after the procedure as the result of a tamponade after the temporary pacemaker wire ablation.
This initial experience suggests that subclavian transarterial aortic valve implantation in patients with a patent left internal thoracic artery to left anterior descending artery is feasible and safe with satisfactory short-term outcomes.
逆行股动脉和锁骨下动脉置管技术已被描述为植入美敦力 CoreValve 经皮主动脉瓣（美敦力公司，明尼苏达州明尼阿波利斯）的最常见方法。锁骨下动脉已被证明是在股动脉通路不佳的患者中安全有效的替代通路。在被确定为锁骨下动脉入路候选者的患者中，有一部分人存在左内乳动脉至前降支的通畅。这种通畅的左内乳动脉带来了另一个解剖学和临床变量，必须加以考虑，以确保手术的安全性和疗效。我们描述了使用锁骨下动脉入路进行美敦力 CoreValve 经皮主动脉瓣植入术的方法，该方法适用于存在通畅的左内乳动脉的患者，并报告了我们的研究结果。
CoreValve 经皮主动脉瓣是一种自扩张的镍钛合金框架，带有猪心包瓣。锁骨下动脉通路是通过小的锁骨下切口暴露动脉来建立的。快速心室起搏用于减少心输出量，通过插入锁骨下动脉的 12F 鞘管进行球囊主动脉瓣成形术。然后将 18F 鞘管插入动脉进入升主动脉，并用于引入输送导管和植入经皮主动脉瓣。
使用这种方法，19 名患者（76 ± 13 岁）接受了植入治疗，这些患者因严重合并症而被认为手术风险过高，且经股动脉导管插入术被认为不可行或存在严重并发症的风险。没有患者发生锁骨下动脉或左内乳动脉损伤。有 2 例死亡。一名患者在手术过程中发生右冠状动脉闭塞死亡，另一名患者在手术后 48 小时因临时起搏器导丝消融后出现心脏压塞而死亡。
这一初步经验表明，在存在通畅的左内乳动脉至前降支的患者中，经锁骨下动脉经皮主动脉瓣植入术是可行和安全的，具有令人满意的短期结果。
