Nehler M R, Taylor L M, Moneta G L, Porter J M
Department of Surgery, Oregon Health Sciences University, Portland, USA.
Arch Surg. 1997 May;132(5):527-32. doi: 10.1001/archsurg.1997.01430290073015.
To describe our experience with surgical therapy for upper extremity ischemia incident to emboli from aneurysms of the subclavian artery.
Retrospective review case series.
Vascular surgery practice at a university hospital-based tertiary referral center.
All patients treated for upper extremity ischemia caused by embolism from a subclavian artery aneurysm from January 1, 1990, to July 31, 1996.
All patients underwent detailed history and physical examination, screening for immunologic and hypercoaguable disorders, noninvasive vascular laboratory evaluation, and arteriography of the aortic arch in both arms and hands. Surgical treatment consisted of rib excision or fracture plating, aneurysm excision, and interposition vein grafting, with additional saphenous vein bypasses to brachial or forearm arteries as needed to provide uninterrupted circulation to the wrist.
Twelve patients (6 males; mean age, 37 years) were treated. All had episodic upper extremity ischemia with an initial misdiagnosis of primary vasospastic disorder. Rest pain and/or ischemic ulceration developed in 3. Duration of symptoms before correct diagnosis averaged 7 months (range, 1-36 months). All patients had bony abnormalities of the thoracic outlet (8 cervical ribs, 3 abnormal first ribs, and 1 unstable clavicular fracture). All aneurysms contained intraluminal thrombus, and all patients had multiple ipsilateral distal arm, forearm, and/or hand arterial occlusions indicating chronic and repeated embolization. All patients underwent aneurysm excision and interposition vein grafting, with additional vein bypass to the brachial (3 patients) and/or forearm arteries (5 patients). Mean follow-up was 18 months (range, 2 weeks to 63 months). Eleven patients had complete symptomatic relief, and 1 patient improved. All subclavian interposition grafts remained patient. Two distal bypass grafts occluded in patients with preoperative arteriograms demonstrating no patient forearm arteries. There has been no limb loss.
Hand ischemia caused by embolization from a subclavian artery aneurysm occurs in young patients without atherosclerosis and is frequently misdiagnosed as vasospasm. Despite advanced disease and multiple chronic distal arterial occlusions, surgical treatment by resection of bony abnormalities, aneurysm excision and grafting, and distal bypass grafting produces excellent results.
描述我们对锁骨下动脉瘤栓子所致上肢缺血进行外科治疗的经验。
回顾性病例系列研究。
一所大学医院附属三级转诊中心的血管外科。
1990年1月1日至1996年7月31日期间，所有因锁骨下动脉瘤栓子导致上肢缺血而接受治疗的患者。
所有患者均接受了详细的病史和体格检查、免疫和高凝疾病筛查、无创血管实验室评估以及双臂和双手的主动脉弓动脉造影。手术治疗包括肋骨切除或骨折钢板固定、动脉瘤切除以及静脉移植，必要时额外进行大隐静脉旁路移植至肱动脉或前臂动脉，以确保手腕部血液循环不间断。
共治疗12例患者（6例男性；平均年龄37岁）。所有患者均有发作性上肢缺血，最初被误诊为原发性血管痉挛性疾病。3例出现静息痛和/或缺血性溃疡。正确诊断前症状持续时间平均为7个月（范围1 - 36个月）。所有患者均有胸廓出口的骨质异常（8例颈肋、3例第一肋骨异常和1例不稳定锁骨骨折）。所有动脉瘤均有腔内血栓形成，所有患者均有多发性同侧上肢远端、前臂和/或手部动脉闭塞，提示慢性反复栓塞。所有患者均接受了动脉瘤切除和静脉移植，另外3例患者进行了静脉旁路移植至肱动脉，5例患者进行了静脉旁路移植至前臂动脉。平均随访18个月（范围2周至63个月）。11例患者症状完全缓解，1例患者症状改善。所有锁骨下移植血管均保持通畅。术前动脉造影显示无前臂动脉的2例患者，其远端旁路移植血管闭塞。无肢体丢失情况。
锁骨下动脉瘤栓子导致的手部缺血发生在无动脉粥样硬化的年轻患者中，常被误诊为血管痉挛。尽管病情严重且存在多处慢性远端动脉闭塞，但通过切除骨质异常、切除动脉瘤并进行移植以及远端旁路移植等手术治疗仍可取得良好效果。
