Ligush J, Criado E, Keagy B A
Division of Surgical Sciences, Bowman Gray School of Medicine, Winston-Salem, NC 27157, USA.
Surgery. 1997 May;121(5):556-62. doi: 10.1016/s0039-6060(97)90111-2.
The purpose of this study was to review our experience with central vascular reconstruction for innominate artery occlusive disease. Eighteen patients underwent central reconstruction for innominate artery (IA) occlusive disease during an 8-year period (1986 to 1994). Mean age was 59 years (range, 36 to 77 years). Women outnumbered men 12 to 6. All patients had symptoms including amaurosis fugax 55%, transient ischemic attacks 44%, vertebrobasilar insufficiency 44%, and arm claudication 33%. The IA was occluded in three patients and stenotic in 15. Three patients underwent previous extrathoracic bypass procedures for IA lesions that failed.
Operations performed through a median sternotomy included aortocarotid bypass with reimplantation of the subclavian (n = 10) and aortoinnominate bypass (n = 7). Transection and oversewing of the IA was performed in all but one patient, in whom ligation of the IA was performed. One patient with severe chronic obstructive pulmonary disease and previous coronary artery bypass grafting underwent retrograde-transluminal IA angioplasty with endovascular stent placement via a carotid approach. Four patients underwent concomitant carotid endarterectomy). Two patients underwent concomitant coronary artery bypass grafting at the time of IA reconstruction.
There was one operative death from myocardial infarction. Perioperative morbidity included dysrrhythmia (three), respiratory insufficiency (three), subendocardial myocardial infarction (two), cerebrovascular accident with complete recovery (two), hemorrhage (one), and acute graft occlusion (one). All grafts remained patient at a mean follow-up of 21 months (range, 8 to 60 months). The only patient who underwent ligation of the IA required a subsequent revision of the IA to transection and oversewing for an embolic event at 4 months status-post aortocarotid bypass. The patient who underwent angioplasty remained asymptomatic with a patient IA at 12 months. Average length of stay for transthoracic repair was 14 days and for transluminal angioplasty 2 days.
Innominate artery bypass based on the ascending aorta is effective in providing relief of symptoms and has a high patency rate. Because of the significant morbidity, these procedures should be reserved for patients with symptoms. The IA should be transected and oversewn to prevent recurrent embolism. Transcarotid, retrograde angioplasty provides an alternative approach to stenotic lesions located in the IA or proximal common carotid artery. An aggressive approach directed at defining coronary artery disease is an invaluable adjunct to the proper treatment of this patient population.
本研究的目的是回顾我们对无名动脉闭塞性疾病进行中心血管重建的经验。在8年期间（1986年至1994年），18例患者因无名动脉（IA）闭塞性疾病接受了中心血管重建。平均年龄为59岁（范围36至77岁）。女性多于男性，比例为12比6。所有患者均有症状，其中55%出现一过性黑矇，44%出现短暂性脑缺血发作，44%出现椎基底动脉供血不足，33%出现上肢间歇性跛行。3例患者IA闭塞，15例患者IA狭窄。3例患者曾因IA病变接受胸外旁路手术但失败。
通过正中胸骨切开术进行的手术包括主动脉 - 颈动脉旁路移植术并重新植入锁骨下动脉（n = 10）和主动脉 - 无名动脉旁路移植术（n = 7）。除1例患者进行IA结扎外，所有患者均进行了IA横断和缝合。1例患有严重慢性阻塞性肺疾病且既往有冠状动脉旁路移植术的患者，通过颈动脉途径进行了逆行腔内IA血管成形术并置入血管内支架。4例患者同时进行了颈动脉内膜切除术。2例患者在IA重建时同时进行了冠状动脉旁路移植术。
有1例患者因心肌梗死手术死亡。围手术期并发症包括心律失常（3例）、呼吸功能不全（3例）、心内膜下心肌梗死（2例）、脑血管意外且完全康复（2例）、出血（1例）和急性移植物闭塞（1例）。所有移植物在平均随访21个月（范围8至60个月）时均保持通畅。唯一接受IA结扎的患者在主动脉 - 颈动脉旁路移植术后4个月因栓塞事件需要对IA进行后续修订，改为横断和缝合。接受血管成形术的患者在12个月时IA通畅且无症状。经胸修复的平均住院时间为14天，腔内血管成形术为2天。
基于升主动脉的无名动脉旁路移植术在缓解症状方面有效且通畅率高。由于并发症发生率较高，这些手术应仅用于有症状的患者。应横断并缝合IA以防止反复栓塞。经颈动脉逆行血管成形术为IA或近端颈总动脉的狭窄病变提供了一种替代方法。积极明确冠状动脉疾病的方法是对这一患者群体进行恰当治疗的宝贵辅助手段。
