Settembre Nicla, Saba Charbel, Bouziane Zakariyae, Jeannon Fanette, Mandry Damien, Malikov Serguei
Service de Chirurgie Vasculaire et Endoluminale, CHRU de Nancy, Nancy, France; Université de Lorraine, unité INSERM 1116, Nancy, France.
Service de Chirurgie Vasculaire et Endoluminale, CHRU de Nancy, Nancy, France.
Ann Vasc Surg. 2017 Oct;44:229-233. doi: 10.1016/j.avsg.2017.03.172. Epub 2017 May 9.
The aberrant right subclavian artery or arteria lusoria (AL) is the most frequent anatomical variation of the supra-aortic trunks (SAT). Treatment is only warranted in the presence of an aneurysm because of the risk of rupture, or in symptomatic cases with signs of compression of the esophagus or the trachea, with embolisms causing right upper limb ischemia of vertebrobasilar cerebrovascular accidents. The conventional surgical treatment of AL is the closure of the origin of AL and the revascularization of the right subclavian artery through a left thoracotomy. With the appearance of endovascular techniques, some of these patients can be treated with minimally invasive hybrid techniques. The aim of this study is to evaluate the feasibility of the endovascular treatment of AL based on the radioanatomical analysis of the thoracic angio-computed tomographies.
We analyzed 180 thoracic angio-computed tomographies using millimeter cuts (<1.2 mm) performed between 2010 and 2015 in the Nancy University Hospital in which an AL was fortuitously discovered. Symptomatic ALs and pediatric patients were excluded. The diameters of the SATs and the aorta and the distances between the SATs were measured. The data were processed with the t-test using the SPSS 22 software.
Our results showed the presence of a Kommerell diverticulum in 36 cases (20%) and of a bi-carotid trunk in 91 cases (50.5%). The average distance between the left subclavian artery (LSCA) and AL was 5.4 ± 4.3 mm. To obtain a proximal neck >20 mm for the implantation of a thoracic stent graft, a double transposition or bypass was always necessary (LSCA to left common carotid artery, AL to right common carotid). An additional debranching of the left common carotid artery was necessary in 33.8% of the cases and of all the SATs in 2.9% of the cases.
The radio-anatomical study showed that no patient was eligible for conventional thoracic endovascular aneurysm repair to treat an aneurysmal AL. The hybrid approach is feasible using a double transposition or a bypass before the implantation of a stent graft, if needed associated with a debranching of the common carotid arteries.
迷走右锁骨下动脉或异常锁骨下动脉（AL）是主动脉弓上分支（SAT）最常见的解剖变异。仅在存在动脉瘤有破裂风险时，或在有食管或气管受压体征的有症状病例、伴有栓塞导致右上肢缺血或椎基底脑血管意外的情况下，才需要进行治疗。AL的传统外科治疗是通过左胸切开术封闭AL的起始部并使右锁骨下动脉再血管化。随着血管内技术的出现，部分此类患者可用微创杂交技术治疗。本研究的目的是基于胸部血管计算机断层扫描的放射解剖学分析评估AL血管内治疗的可行性。
我们分析了2010年至2015年在南锡大学医院进行的180例使用毫米级切片（<1.2毫米）的胸部血管计算机断层扫描，这些扫描中偶然发现了AL。有症状的AL和儿科患者被排除。测量了SAT和主动脉的直径以及SAT之间的距离。使用SPSS 22软件通过t检验对数据进行处理。
我们的结果显示36例（20%）存在Kommerell憩室，91例（50.5%）存在双颈动脉干。左锁骨下动脉（LSCA）与AL之间的平均距离为5.4±4.3毫米。为了获得>20毫米的近端颈部以植入胸段支架移植物，总是需要进行双重转位或旁路手术（LSCA至左颈总动脉，AL至右颈总动脉）。33.8%的病例需要额外对左颈总动脉进行去分支，2.9%的病例需要对所有SAT进行去分支。
放射解剖学研究表明，没有患者适合采用传统的胸段血管内动脉瘤修复术来治疗动脉瘤性AL。如果需要，在植入支架移植物之前采用双重转位或旁路手术，必要时联合颈总动脉去分支，杂交方法是可行的。
