谨慎覆盖：创伤性胸主动脉腔内修复术中左锁骨下动脉的处理
Cover with caution: Management of the Left Subclavian Artery in TEVAR for trauma.
作者信息
Romagnoli Anna Noel, Paterson Jeanette, Dua Anahita, Kauvar David, Saqib Naveed, Miller Charles, Starnes Benjamin, Azizzadeh Ali, DuBose Joseph
机构信息
From the Division of Endovascular Trauma, R Adams Cowley Shock Trauma Center (A.N.R.), Baltimore; Division of Trauma and Acute Care Surgery Walter Reed National Military Medical Center (A.N.R., J.P.), Bethesda, Maryland; Division of Vascular and Endovascular Surgery, Massachusetts General Hospital (A.D.), Boston, Massachusetts; Division of Vascular Surgery, Denver Health Medical Center, Denver, Colorado (D.K.); Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston (N.S., C.M.), Houston, Texas; Division of Vascular Surgery, University of Washington Medical Center (B.S.), Seattle, Washington; Division of Vascular Surgery, Cedars Sinai Medical Center (A.A.), Los Angeles, California; and Division of Vascular Surgery, Dell University School of Medicine, University of Texas (J.D.B.), Austin, Texas.
出版信息
J Trauma Acute Care Surg. 2023 Mar 1;94(3):392-397. doi: 10.1097/TA.0000000000003832. Epub 2022 Nov 29.
BACKGROUND
Elective Thoracic Endovascular Aortic Repair (TEVAR) with left subclavian artery coverage (LSA-C) without revascularization is associated with increased rates of ischemic stroke. In patients with blunt thoracic aortic injury (BTAI) requiring TEVAR, LSA-C is frequently required in over one-third of patients. This study aimed to evaluate outcomes of TEVAR in BTAI patients with and without LSA-C.
METHODS
The largest existing international multicenter prospective registry of BTAI, developed and implemented by the Aortic Trauma Foundation, was utilized to evaluate all BTAI patients undergoing TEVAR from March 2016 to January 2021. Patients with uncovered left subclavian artery (LSA-U) were compared with patients who had left subclavian artery coverage with (LSA-R) and without (LSA-NR) revascularization.
RESULTS
Of the 364 patients with BTAI who underwent TEVAR, 97 (26.6%) underwent LSA-C without revascularization, 10 (2.7%) underwent LSA-C with revascularization (LSA-R). Late and all ischemic strokes were more common in LSA-NR patients than LSA-U patients ( p = 0.006, p = 0.0007). There was no difference in rate of early, late, or overall incidence of paralysis/paraplegia between LSA-NR and LSA-U. When compiled as composite central nervous system ischemic sequelae, there was an increased rate in early, late, and overall events in LSA-NR compared with LSA-U ( p = 0.04, p = 0.01, p = 0.001).
CONCLUSION
While prior studies have suggested the relative safety of LSA-C in BTAI, preliminary multicenter prospective data suggests there is a significant increase in ischemic events when the left subclavian artery is covered and not revascularized. Additional prospective study and more highly powered analysis is necessary.
LEVEL OF EVIDENCE
Therapeutic/Care Management; Level III.
背景
选择性胸主动脉腔内修复术（TEVAR）中覆盖左锁骨下动脉（LSA-C）且不行血管重建与缺血性卒中发生率增加相关。在需要TEVAR的钝性胸主动脉损伤（BTAI）患者中，超过三分之一的患者经常需要LSA-C。本研究旨在评估有和没有LSA-C的BTAI患者接受TEVAR的结局。
方法
利用由主动脉创伤基金会开发并实施的现有的最大规模国际多中心BTAI前瞻性注册研究，评估2016年3月至2021年1月期间所有接受TEVAR的BTAI患者。将未覆盖左锁骨下动脉（LSA-U）的患者与行（LSA-R）和未行（LSA-NR）血管重建的左锁骨下动脉覆盖患者进行比较。
结果
在364例接受TEVAR的BTAI患者中，97例（26.6%）接受了未行血管重建的LSA-C，10例（2.7%）接受了行血管重建的LSA-C（LSA-R）。LSA-NR患者的晚期和所有缺血性卒中比LSA-U患者更常见（p = 0.006，p = 0.0007）。LSA-NR和LSA-U之间在早期、晚期或总体瘫痪/截瘫发生率方面没有差异。当汇总为复合性中枢神经系统缺血性后遗症时，LSA-NR与LSA-U相比，早期、晚期和总体事件发生率均增加（p = 0.04，p = 0.01，p = 0.001）。
结论
虽然先前的研究表明LSA-C在BTAI中相对安全，但初步的多中心前瞻性数据表明，当左锁骨下动脉被覆盖且未行血管重建时，缺血性事件显著增加。需要进一步的前瞻性研究和更有说服力的分析。
证据水平
治疗/护理管理；三级。
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