DeBakey Heart & Vascular Center, Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Tex.
College of Medicine, Texas A&M University, Bryan, Tex.
J Vasc Surg Venous Lymphat Disord. 2019 May;7(3):420-427. doi: 10.1016/j.jvsv.2018.10.024. Epub 2019 Feb 18.
Outflow tract stenosis is the leading cause of hemodialysis access loss. Many lesions are highly resistant to endovascular treatment, necessitating open surgical intervention. We present our experience using medial claviculectomy for treatment of recalcitrant lesions at the thoracic outlet.
We retrospectively reviewed patients who underwent medial claviculectomy for dialysis-associated venous thoracic outlet syndrome at our institution between February 2013 and February 2018. Data collection included demographics, past medical history, access history, subsequent procedures, preoperative and postoperative brachial volume flows, and access use.
We performed 25 medial claviculectomies in 25 patients with central venous stenosis. Four patients underwent concomitant central venous bypass and were excluded from this study. Twelve accesses were created at our institution; of these, the average access age was 41.6 months (±26.7 months). All patients previously underwent multiple angioplasty attempts to treat outflow stenosis and continued to have residual symptoms and poor fistula function. Medial claviculectomy with venolysis and angioplasty were performed to treat residual outflow stenosis at the level of the subclavian vein. Twenty-one patients had residual stenosis requiring angioplasty. Six patients had subclavian rupture requiring stent graft placement. All patients reported symptom improvement and immediate use of the fistula after medial claviculectomy. Nineteen (76%) patients reported complete resolution of symptoms after the procedure. Ultimately, eight (32%) ipsilateral arteriovenous accesses were lost, and six (24%) patients died in follow-up with patent, functional fistulas. Median length of follow-up was 17 months (interquartile range, 5-28 months). The 18-month primary patency and secondary patency with regard to subclavian vein interventions were 28% (95% confidence interval, 13.8%-56.1%) and 84% (95% confidence interval, 69.7%-100%), respectively. One patient required ligation for high-output cardiac failure. One patient had contralateral brachiocephalic jailing, which was corrected with kissing brachiocephalic stents.
Medial claviculectomy is an effective treatment of recalcitrant central venous stenosis of the thoracic outlet. Balloon angioplasty or stent or stent graft placement is often necessary after extrinsic compression is alleviated and demonstrates acceptable secondary patency rates.
流出道狭窄是血液透析通路丧失的主要原因。许多病变对血管内治疗具有高度抗性，需要进行开放手术干预。我们介绍了使用锁骨内切除术治疗锁骨下出口处顽固性病变的经验。
我们回顾性分析了 2013 年 2 月至 2018 年 2 月期间在我院因透析相关静脉性锁骨下出口综合征而行锁骨内切除术的患者。数据收集包括人口统计学资料、既往病史、通路史、后续手术、术前和术后肱动脉体积流量以及通路使用情况。
我们对 25 例锁骨下静脉狭窄患者进行了 25 例锁骨内切除术。4 例患者同时行中心静脉旁路术，因此排除在本研究之外。12 例通路在我院建立；其中，平均通路年龄为 41.6±26.7 个月。所有患者均曾接受多次血管成形术尝试治疗流出道狭窄，但仍有残留症状和瘘管功能不良。行锁骨内切除术、静脉松解术和血管成形术治疗锁骨下静脉水平的残余流出道狭窄。21 例患者存在需要血管成形术的残余狭窄。6 例患者发生锁骨下破裂，需放置支架移植物。所有患者在锁骨内切除术治疗后均报告症状改善和立即使用瘘管。19 例（76%）患者在术后完全缓解症状。最终，8 例（32%）同侧动静脉通路丧失，6 例（24%）患者在随访中因有功能的瘘管而死亡。中位随访时间为 17 个月（四分位距，5-28 个月）。锁骨下静脉介入治疗的 18 个月原发性通畅率和继发性通畅率分别为 28%（95%置信区间，13.8%-56.1%）和 84%（95%置信区间，69.7%-100%）。1 例患者因高输出性心力衰竭而行结扎术。1 例患者出现对侧头臂干血管受压，采用吻臂头臂支架纠正。
锁骨内切除术是治疗锁骨下出口处顽固性中心静脉狭窄的有效方法。在缓解外部压迫后，常需要进行球囊血管成形术或支架或支架移植物置入，且具有可接受的继发性通畅率。
