Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
J Vasc Surg. 2023 Feb;77(2):642-649.e4. doi: 10.1016/j.jvs.2022.07.010. Epub 2022 Jul 15.
Aberrant subclavian artery (AScA) with or without associated Kommerell's diverticulum (KD) is the most frequently encountered anomaly of the aortic arch, it may be life threatening, especially when associated with aneurysmal degeneration. The best management is still debated and depends on many clinical and anatomical factors. A systematic review was conducted to assess the current evidence on the treatment options and their efficacy and safety for AscA and KD repairs.
A literature search in PubMed and Cochrane Library was performed, and articles that were published from January 1947 to August 2021 reporting on AscA and KD management were identified. Multicenter studies, single-center series, and case series with three or more patients were considered eligible in the present review. A comparison of outcomes of patients who underwent open surgery (OS), a hybrid approach (HA), and total endovascular repair (ER) (ie, 30-day mortality and stroke were analyzed when available and compared among the three groups (P < .05; Benjamini and Hochberg-adjusted P < .05; Bonferroni-adjusted P < .05). Titles, abstracts, and full texts were evaluated by two authors independently. Primary outcomes included survival rate, perioperative stroke, arm ischemia, and spinal cord ischemia. Endoleak, in the case of HA and ER, and reintervention rates were considered outcomes.
Three hundred thirty-one articles were initially evaluated and 30 studies, totaling 426 patients treated for AScA with 324 KD, were included. Of the 426 patients, 241 were male (56.5%), and the mean patient age was 57.9 ± 12.0 years. The approach was OS in 228 patients, HA in 147 patients, and ER in 51. Dysphagia was the most common presentation in 133 cases. Aortic rupture was observed in 16 of the 426 patients (3.8%), including 14 AScA/KD (3.3%) aneurysm rupture. KD maximum diameter varied widely from 12.6 to 63.6 mm. The overall 30-day mortality was 20 (4.7%) (OS group 8/228 [3.5%]; HA group 10/147 [6.8%]; ER 2/51 [3.9%]; P = NS). The overall stroke rate was 4.9% (21/426) (OS group 10/228 [4.4%]; HA group 6/147 [4.1%]; ER group 5/51 [9.8%]; P = NS), including nine transient and nondisabling neurological deficits. Overall secondary procedures for complications were reported in 36 of the 426 cases (8.4%), mostly owing to endoleak. Follow-up varied from 13 to 74 months.
This systematic review assessed the current outcomes of the three types of therapeutic management for AScA and KD and demonstrated that they are all relatively safe and effective, providing satisfactory early and midterm outcomes. Long-term outcomes are warranted, especially for total ERs since the long-term durability of stent grafts remains unknown.
异常的锁骨下动脉（AScA）伴或不伴 Kommerell 憩室（KD）是主动脉弓最常见的异常，它可能具有生命危险，尤其是在伴发动脉瘤样变性时。最佳治疗方法仍存在争议，取决于许多临床和解剖因素。进行了系统评价，以评估治疗 AScA 和 KD 的现有治疗方案及其疗效和安全性。
在 PubMed 和 Cochrane Library 中进行文献检索，确定了 1947 年 1 月至 2021 年 8 月期间发表的报告 AScA 和 KD 管理的文章。本综述考虑了多中心研究、单中心系列和 3 例或更多患者的病例系列。分析了接受开放手术（OS）、杂交方法（HA）和全腔内修复（ER）治疗的患者的结果（如果有，分析 30 天死亡率和卒中，并在三组之间进行比较（P <.05；Benjamini 和 Hochberg 调整 P <.05；Bonferroni 调整 P <.05）。两名作者独立评估标题、摘要和全文。主要结局包括生存率、围手术期卒中、手臂缺血和脊髓缺血。HA 和 ER 中的内漏和再介入率被认为是结局。
最初评估了 331 篇文章，纳入了 30 项研究，共 426 例 AScA 伴 324 例 KD 患者。在 426 例患者中，241 例为男性（56.5%），平均年龄为 57.9 ± 12.0 岁。228 例采用 OS 治疗，147 例采用 HA 治疗，51 例采用 ER 治疗。最常见的表现是 133 例吞咽困难。426 例患者中有 16 例（3.8%）发生主动脉破裂，包括 14 例 AScA/KD（3.3%）动脉瘤破裂。KD 最大直径范围很广，从 12.6 到 63.6mm。30 天总死亡率为 20 例（4.7%）（OS 组 8/228 [3.5%]；HA 组 10/147 [6.8%]；ER 组 2/51 [3.9%]；P = NS）。总卒中率为 4.9%（21/426）（OS 组 10/228 [4.4%]；HA 组 6/147 [4.1%]；ER 组 5/51 [9.8%]；P = NS），包括 9 例短暂性和非致残性神经功能缺损。426 例中有 36 例（8.4%）报告了继发性并发症手术，主要与内漏有关。随访时间从 13 到 74 个月不等。
本系统评价评估了 AScA 和 KD 三种治疗方法的当前结果，表明它们均相对安全有效，提供了满意的早期和中期结果。需要长期随访结果，特别是对于全腔内修复，因为支架移植物的长期耐久性尚不清楚。
