Schaff H V, Brawley R K
Surgery. 1977 Aug;82(2):182-91.
A five year experience with 20 patients who had penetrating vascular injuries of the thoracic outlet was reviewed. A median sternotomy with extension into the right neck was used to explore six patients with right subclavian vascular injuries. With injuries to the origin of the left common carotid artery, repair was accomplished through a median sternotomy combined with a left anterior thoracotomy in one patient and through a left posterolateral thoracotomy in the other. Injury to the left subclavian vessels occurred in five patients and was exposed through a left anterolateral thoracotomy combined with a supraclavicular incision in four patients and through a supraclavicular incision with clavicular resection in one patient. Axillary vessel trauma generally was managed with an extrathoracic incision only. The two deaths in this series were due to postoperative respiratory complications (mortality rate of 10%). Twenty arteries were repaired and all were patent on follow-up examination. Associated neural and venous injury caused significant morbidity in 28% and 10% of patients, respectively. As a result of this experience we continue to recommend an extended median sternotomy for repair of right-sided cervicothoracic vascular injury. Anterior or posterolateral thoracotomy combined with a supraclavicular incision is advocated for trauma to left-sided vessels of the thoracic outlet. When possible, injured veins should be repaired rather than ligated.
回顾了20例胸廓出口穿透性血管损伤患者的五年治疗经验。6例右锁骨下血管损伤患者采用正中胸骨切开并延伸至右颈部进行探查。1例左颈总动脉起始部损伤患者通过正中胸骨切开联合左前外侧开胸进行修复，另1例则通过左后外侧开胸进行修复。5例患者发生左锁骨下血管损伤，其中4例通过左前外侧开胸联合锁骨上切口暴露，1例通过锁骨上切口并切除锁骨暴露。腋血管损伤一般仅通过胸外切口处理。该系列中有2例死亡，原因是术后呼吸并发症（死亡率为10%）。20条动脉得到修复，随访检查时均通畅。相关神经和静脉损伤分别导致28%和10%的患者出现严重并发症。基于这一经验，我们继续推荐采用延长正中胸骨切开术修复右侧颈胸段血管损伤。对于左侧胸廓出口血管损伤，主张采用前外侧或后外侧开胸联合锁骨上切口。如有可能，应修复而非结扎损伤的静脉。
