Section of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy.
J Vasc Surg. 2013 Mar;57(3):684-690.e1. doi: 10.1016/j.jvs.2012.08.119. Epub 2012 Nov 20.
This single-center, prospective study aimed to investigate the technical success and outcome of intentional coverage of the left subclavian artery (LSA) in patients undergoing thoracic endovascular aortic repair (TEVAR) for traumatic rupture of the aortic isthmus at a tertiary care medical center.
From January 2005 to June 2011, patients who presented with traumatic aortic transection underwent TEVAR with coverage of the LSA when the distance between the artery and the rupture was <2 cm. At 12, 24, and 72 hours postoperatively, clinical and neurologic evaluation including transcranial Doppler insonation of the brachial artery was performed. A decrease in peak systolic velocity (PSV) >60% with respect to the contralateral one was considered relevant. Functional status of the left arm was evaluated using a provocative test. Thoracoabdominal computerized tomographic angiography was performed postoperatively at 3-, 6-, and 12-month follow-up.
Thirty-one patients (mean age 35 years) underwent emergency TEVAR for traumatic aortic transection with intentional LSA coverage during the study period. In four cases (12.9%) coverage was partial. Two patients (6.4%) died during the postoperative period due to associated lesions. No signs of vertebrobasilar insufficiency, stroke, or paraplegia were observed in any of the patients. Nine patients (36%) had severe arm claudication (ischemic pain within 60 seconds of beginning arm exercise and decrease of PSV between 50% and 60%). Risk factors for the condition were left vertebral artery diameter <3 mm (P < .0001). A significant correlation was found between the degree of PSV reduction and left arm symptoms (P < .0001). There was an improvement in ischemic arm symptoms (P < .0001) during mean follow-up of 36 months (range, 6-65 months), with only one patient (4.2%) presenting with severe claudication. Freedom from reintervention at 48 months was 93.5%. No signs of endoleaks or graft migrations were detected on computerized tomographic angiography control scans.
Coverage of the LSA during TEVAR for traumatic aortic injuries appears to be a feasible, safe method for extending the endograft landing zone without increasing the risk of paraplegia, stroke, or left arm ischemia. Left vertebral artery diameter can be used to identify patients at risk for postoperative left arm ischemia.
本单中心前瞻性研究旨在探讨在三级医疗中心对创伤性主动脉弓中断破裂患者进行胸主动脉腔内修复术（TEVAR）时，当左锁骨下动脉（LSA）与破裂口的距离<2cm 时，覆盖 LSA 的技术成功率和结果。
2005 年 1 月至 2011 年 6 月，对因创伤性主动脉横断而就诊的患者，在 TEVAR 时若 LSA 与破裂口的距离<2cm，则覆盖 LSA。术后 12、24 和 72 小时进行临床和神经学评估，包括经颅多普勒探测肱动脉。同侧 PSV 降低>60%被认为是相关的。使用激发试验评估左侧手臂的功能状态。术后 3、6 和 12 个月进行胸腹部计算机断层血管造影（CTA）随访。
在研究期间，31 例（平均年龄 35 岁）患者因创伤性主动脉横断而紧急接受 TEVAR，同时进行了 LSA 覆盖术。其中 4 例（12.9%）为部分覆盖。2 例（6.4%）患者因合并损伤在术后期间死亡。所有患者均未出现椎基底动脉供血不足、中风或截瘫的迹象。9 例（36%）患者有严重的手臂跛行（手臂运动开始后 60 秒内出现缺血性疼痛，PSV 降低 50%-60%）。该病症的危险因素是左侧椎动脉直径<3mm（P<0.0001）。PSV 降低程度与左侧手臂症状之间存在显著相关性（P<0.0001）。在平均 36 个月（6-65 个月）的随访期间，缺血性手臂症状有所改善（P<0.0001），仅有 1 例（4.2%）患者出现严重跛行。48 个月时免于再次干预的比例为 93.5%。CTA 控制扫描未见内漏或移植物移位的迹象。
在创伤性主动脉损伤行 TEVAR 时覆盖 LSA 似乎是一种可行且安全的方法，可扩大移植物的着陆区，而不会增加截瘫、中风或左侧手臂缺血的风险。左侧椎动脉直径可用于识别术后左侧手臂缺血的高危患者。
