Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA.
Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA.
J Vasc Surg. 2022 Dec;76(6):1486-1492. doi: 10.1016/j.jvs.2022.05.027. Epub 2022 Jul 8.
Preservation of antegrade flow to the left vertebral artery (LVA) is often achieved by transposition or bypass to the left subclavian artery during zone 2 thoracic endovascular aortic repair. An anomalous LVA (aLVA) originating directly from the aortic arch is a common arch variant with a reported incidence of 4% to 6%. In addition, 6% to 10% of vertebral arteries terminate in a posterior inferior cerebellar artery, increasing the risk of stroke if not revascularized. Few series of aLVA to carotid transposition have been reported. The aim of this study was to evaluate the outcomes of patients who underwent aLVA to carotid transposition for the management of aortic disease.
A retrospective review of all aLVA-carotid transpositions performed for the management of thoracic aortic dissection or aneurysm at a single center from 2018 to 2021 was performed. The primary outcomes were postoperative stroke and patency of the transposed aLVA. Secondary outcomes were spinal cord ischemia, postoperative cranial nerve injury, and Horner's syndrome.
Seventeen patients underwent aLVA to carotid transposition as an adjunct to management of aortic disease during the study period. Most were men (n = 14) and the mean age was 54 ± 16 years. The primary indication for aortic repair was dissection in 10, aneurysm in 6, and Kommerell diverticulum in 1. Nine patients underwent zone 2 thoracic endovascular aortic repair, seven received open total arch repair, and there was one attempted total endovascular arch repair that was aborted owing to unfavorable anatomy. Twelve transpositions were performed before or concomitant with planned aortic repair owing to high-risk cerebrovascular anatomy (three posterior inferior cerebellar artery termination, six dominant aLVA, four intracranial LVA stenosis), and two were performed postoperatively for treatment of type II endoleak. LVA diameter ranged from 2 to 6 mm (mean, 3.3 mm). The mean operative time for transposition was 178 ± 38 minutes, inclusive of left subclavian artery revascularization, and the mean estimated blood loss was 169 ± 188 mL. No patients experienced 30-day postoperative spinal cord ischemia, stroke, or mortality. There were two cases of postoperative hoarseness, presumably owing to recurrent laryngeal nerve palsy, both of which resolved within 4 months. There were no cases of Horner's syndrome. At follow-up (mean, 306 days; range, 6-714 days), all transpositions were patent.
Vertebral-carotid transposition is a safe and effective adjunct in the management of aortic disease with anomalous origin of the LVA.
在胸主动脉腔内修复术（TEVAR）的 2 区，通过将左椎动脉（LVA）移位或旁路到左锁骨下动脉，通常可以保留 LVA 的顺行血流。左椎动脉异常（aLVA）直接发自主动脉弓，是一种常见的弓部变异，报道的发生率为 4%至 6%。此外，6%至 10%的椎动脉终止于小脑后下动脉（PICA），如果不进行血运重建，中风的风险会增加。只有少数关于 aLVA 到颈动脉转位的系列报道。本研究的目的是评估在单一中心接受 aLVA 到颈动脉转位治疗主动脉疾病的患者的结果。
回顾性分析了 2018 年至 2021 年期间因胸主动脉夹层或动脉瘤在单一中心接受 aLVA 到颈动脉转位治疗的所有患者。主要结果是术后中风和转位 aLVA 的通畅性。次要结果是脊髓缺血、术后颅神经损伤和霍纳氏综合征。
在研究期间，17 名患者接受 aLVA 到颈动脉转位作为主动脉疾病治疗的辅助手段。大多数是男性（n=14），平均年龄为 54±16 岁。主动脉修复的主要指征是夹层 10 例、动脉瘤 6 例、Kommerell 憩室 1 例。9 例患者接受了 2 区 TEVAR，7 例患者接受了开放全弓修复，1 例患者因解剖结构不利而尝试全腔内弓修复失败。由于高风险的脑血管解剖结构（3 例 PICA 终止，6 例优势 aLVA，4 例颅内 LVA 狭窄），12 例转位在计划的主动脉修复前或同时进行，2 例在术后因 II 型内漏而行治疗性转位。LVA 直径为 2 至 6mm（平均 3.3mm）。转位的平均手术时间为 178±38 分钟，包括左锁骨下动脉血运重建，平均估计出血量为 169±188ml。无患者发生 30 天术后脊髓缺血、中风或死亡。有 2 例术后声音嘶哑，可能是喉返神经麻痹，均在 4 个月内缓解。无霍纳氏综合征病例。随访（平均 306 天；范围 6-714 天）时，所有转位均通畅。
在治疗 LVA 异常起源的主动脉疾病时，椎动脉-颈动脉转位是一种安全有效的辅助治疗方法。
