Comprehensive Aortic Center, Keck Medical Center of University of Southern California, Los Angeles, Calif.
Comprehensive Aortic Center, Keck Medical Center of University of Southern California, Los Angeles, Calif.
J Vasc Surg. 2021 Feb;73(2):466-475.e3. doi: 10.1016/j.jvs.2020.05.063. Epub 2020 Jul 1.
Revascularization of the left subclavian artery (LSA) during zone 2 thoracic endovascular aortic repair (TEVAR) maintains collateral circulation to decrease ischemic complications, including stroke, spinal cord ischemia, and upper extremity ischemia. Both open surgical and endovascular LSA revascularization techniques have been described, each with unique risks and benefits. We describe our "periscope sandwich" technique for the LSA during zone 2 TEVAR, which maintains antegrade access to the distal abdominal aorta if subsequent interventions are necessary. Technical results and short-term outcomes are compared with LSA open surgical debranching.
A single-institution retrospective review was performed for patients requiring zone 2 TEVAR with LSA revascularization by periscope sandwich technique or open surgical debranching with subclavian to carotid transposition (SCT) or carotid-subclavian bypass (CSB). The presenting aortic disease and perioperative details were recorded. Intraoperative angiography and postoperative computed tomography images were reviewed for occurrence of endoleak and branch patency.
Between January 2013 and December 2018, the LSA was revascularized by periscope sandwich in 18 patients, SCT in 22 patients, and CSB in 13 patients. Compared with open surgical debranching, periscope sandwich had a lower median estimated blood loss (100 mL vs 200 mL for pooled SCT and CSB; P = .03) and lower median case duration (133.5 minutes vs 226 minutes; P < .001). Contrast material volume (120 mL vs 120 mL; P = .98) and fluoroscopy time (13.1 minutes vs 13.3 minutes; P = .92) did not differ significantly between the groups. There was no difference in aorta-related mortality (P = .14), and LSA patency was 100%. Median follow-up for the periscope sandwich group was 11 months, with an overall estimated 91% freedom from gutter leak at 6 months.
LSA periscope sandwich technique provides safe and effective LSA revascularization during zone 2 TEVAR. LSA periscope sandwich can be used emergently with off-the-shelf endovascular components and facilitates future branched-fenestrated endovascular repair of thoracoabdominal aortic diseases.
在 2 区胸主动脉腔内修复术（TEVAR）中重建左锁骨下动脉（LSA）可维持侧支循环，减少包括中风、脊髓缺血和上肢缺血在内的缺血性并发症。已经描述了开放手术和血管内 LSA 血运重建技术，每种技术都有其独特的风险和益处。我们描述了在 2 区 TEVAR 中使用“潜望镜三明治法”进行 LSA 血运重建的技术，如果需要后续介入治疗，可以保持对远端腹主动脉的顺行入路。比较了 LSA 开放手术去分支术的技术结果和短期结果。
对 2013 年 1 月至 2018 年 12 月期间因 LSA 病变需要行 2 区 TEVAR 并接受潜望镜三明治法或开放手术去分支术（锁骨下动脉至颈动脉转位术[SCT]或颈动脉-锁骨下旁路术[CSB]）的患者进行单中心回顾性研究。记录患者的主动脉疾病和围手术期细节。对术中血管造影和术后 CT 图像进行分析，以评估内漏和分支通畅情况。
2013 年 1 月至 2018 年 12 月期间，18 例患者采用潜望镜三明治法，22 例患者采用 SCT，13 例患者采用 CSB 进行 LSA 血运重建。与开放手术去分支术相比，潜望镜三明治法的中位估计失血量（合并 SCT 和 CSB 为 100 mL 比 200 mL；P =.03）和中位手术时间（133.5 分钟比 226 分钟；P ＜.001）较低。两组间造影剂用量（120 mL 比 120 mL；P =.98）和透视时间（13.1 分钟比 13.3 分钟；P =.92）无显著差异。主动脉相关死亡率无差异（P =.14），LSA 通畅率为 100%。潜望镜三明治法组中位随访时间为 11 个月，6 个月时总体估计有 91%的患者无侧支漏。
在 2 区 TEVAR 中，LSA 潜望镜三明治法是一种安全有效的 LSA 血运重建方法。LSA 潜望镜三明治法可在紧急情况下使用现成的血管内组件，并有利于未来对胸腹主动脉疾病进行分支型腔内修复术。
