Azakie A, McElhinney D B, Higashima R, Messina L M, Stoney R J
Division of Vascular Surgery, University of California, San Francisco, USA.
Ann Surg. 1998 Sep;228(3):402-10. doi: 10.1097/00000658-199809000-00013.
Symptomatic atherosclerotic occlusive disease of the innominate artery is a threatening disease pattern that offers a major challenge in achieving definitive surgical repair. To assess the evolution of treatment strategies and their outcomes for this disease, the authors undertook a review of the cumulative experience for more than 3 decades at one institution.
Between 1960 and 1997, 94 patients (mean age, 62 years) underwent direct innominate artery revascularization for occlusive atherosclerotic disease to relieve neurologic (n = 85) and/or right upper extremity (n = 26) symptoms or asymptomatic critical stenosis (n = 3). The pattern of atherosclerotic involvement revealed by angiography included critical stenosis (n = 77), complete occlusion (n = 10), and moderate stenosis with plaque ulceration (n = 7). A common brachiocephalic trunk was present in five patients. Transsternal (n = 68) or transcervical (n = 4) innominate endarterectomy was performed in 72 patients and bypass grafting in 22. Forty-one patients underwent concomitant endarterectomy or bypass of innominate branches or adjacent arch vessels, and 3 had coronary bypass grafting.
There were three perioperative deaths (3%), all due to cardiac causes. Postoperative morbidity included four strokes (three resolved), two myocardial infarctions, two transient ischemic attacks, and one sternal dehiscence. Follow-up ranged from 8 months to 20 years. Postoperative actuarial survival rate was 96% at 1 year, 85% at 5 years, and 67% at 10 years. Freedom from recurrence requiring reoperation was 100% at 1 year, 99% at 5 years, and 97% at 10 years.
Innominate artery reconstruction is safe and durable when either endarterectomy or prosthetic bypass is used. The anatomic variation and disease distribution permit endarterectomy for most patients. The technique of innominate endarterectomy can be extended safely to outflow and adjacent vessels.
无名动脉症状性动脉粥样硬化闭塞性疾病是一种具有威胁性的疾病类型，在实现确定性手术修复方面面临重大挑战。为评估该疾病治疗策略的演变及其结果，作者回顾了一家机构30多年来的累积经验。
1960年至1997年间，94例患者（平均年龄62岁）因闭塞性动脉粥样硬化疾病接受了直接无名动脉血运重建术，以缓解神经症状（n = 85）和/或右上肢症状（n = 26）或无症状严重狭窄（n = 3）。血管造影显示的动脉粥样硬化累及模式包括严重狭窄（n = 77）、完全闭塞（n = 10）和伴有斑块溃疡的中度狭窄（n = 7）。5例患者存在共同头臂干。72例患者接受了经胸骨（n = 68）或经颈部（n = 4）无名动脉内膜切除术，22例接受了旁路移植术。41例患者同时接受了无名动脉分支或相邻主动脉弓血管的内膜切除术或旁路手术，3例接受了冠状动脉旁路移植术。
围手术期死亡3例（3%），均为心脏原因。术后并发症包括4例中风（3例恢复）、2例心肌梗死、2例短暂性脑缺血发作和1例胸骨裂开。随访时间为8个月至20年。术后1年、5年和10年的精算生存率分别为96%、85%和67%。无需再次手术的无复发率1年时为100%，5年时为99%，10年时为97%。
使用内膜切除术或人工血管旁路术时，无名动脉重建是安全且持久的。解剖变异和疾病分布使大多数患者能够接受内膜切除术。无名动脉内膜切除术技术可安全扩展至流出道和相邻血管。
