Gradman W S, Bressman P, Sernaque J D
Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.
Ann Vasc Surg. 1994 Nov;8(6):549-56. doi: 10.1007/BF02017411.
Management of subclavian vein occlusive disease in persons with an ipsilateral arteriovenous fistula can be challenging. From July 1991 to May 1993, nine patients underwent direct exploration and repair of an obstructed subclavian vein following medial claviculectomy. Eight patients had polytetrafluoroethylene (PTFE) grafts; one patient had a Brescia-Cimino fistula. Intractable arm edema was the major symptom in five of eight. The site of the occlusive disease ranged from the midsubclavian vein to the proximal innominate vein. Pathology varied from a focal occluding web to a long segment of intimal fibroplasia. Five veins were occluded; four were stenotic. Surgical procedures consisted of endovenectomy and vein patch (four), endovenectomy and PTFE patch (one), resection of a focal stricture with end-to-end anastomosis (two), resection with PTFE interposition (one), and end-to-end internal jugular to subclavian vein transposition (one). Postoperative contrast venograms revealed a patent subclavian vein in eight of eight patients. One patient died postoperatively from unrelated causes; two patients died with a functioning fistula 8 and 12 months, respectively, after surgery. Two grafts were removed for infection and one deteriorated graft was abandoned because of repeated thrombosis. Only three of nine original grafts are currently in use, including one in which the ipsilateral subclavian vein rethrombosed. Although stent placement may now be the preferred treatment for subclavian vein stenosis, vein repair may still have a role in the treatment of subclavian vein occlusion, particularly in patients with a Brescia-Cimino fistula.
同侧动静脉内瘘患者锁骨下静脉闭塞性疾病的管理具有挑战性。1991年7月至1993年5月，9例患者在锁骨内侧切除术之后接受了阻塞性锁骨下静脉的直接探查和修复。8例患者使用了聚四氟乙烯（PTFE）移植物；1例患者有Brescia-Cimino内瘘。难治性手臂水肿是8例患者中5例的主要症状。闭塞性疾病的部位从中段锁骨下静脉到无名静脉近端。病理变化从局灶性闭塞网到内膜纤维增生的长段。5条静脉闭塞；4条狭窄。手术操作包括静脉内膜切除术和静脉补片（4例）、静脉内膜切除术和PTFE补片（1例）、切除局灶性狭窄并端端吻合（2例）、切除后用PTFE置入（1例）以及端端吻合的颈内静脉至锁骨下静脉转位（1例）。术后静脉造影显示8例患者中8例的锁骨下静脉通畅。1例患者术后因无关原因死亡；2例患者分别在术后8个月和12个月内瘘仍在发挥功能时死亡。2条移植物因感染被移除，1条恶化的移植物因反复血栓形成而被废弃。9条原始移植物目前仅3条仍在使用，其中1条同侧锁骨下静脉再次形成血栓。尽管支架置入现在可能是锁骨下静脉狭窄的首选治疗方法，但静脉修复在锁骨下静脉闭塞的治疗中可能仍有作用，特别是在患有Brescia-Cimino内瘘的患者中。
