Berguer R, Morasch M D, Kline R A, Kazmers A, Friedland M S
Division of Vascular Surgery, Wayne State University/Detroit Medical Center, Harper Hospital, Michigan, USA.
J Vasc Surg. 1999 Feb;29(2):239-46; discussion 246-8. doi: 10.1016/s0741-5214(99)70377-0.
The purpose of this study was to review 182 consecutive cervical reconstructions of supra-aortic trunks, which were performed over a 16-year period.
A total of 182 innominate, common carotid, or subclavian arteries were reconstructed with a cervical approach in 173 patients aged 23 days to 83 years. Indications included hemispheric (n = 79), vertebrobasilar (n = 56), upper extremity (24), and internal mammary/cardiac ischemia (n = 5), asymptomatic severe common carotid disease (n = 33), or other (n = 3). Primary atherosclerotic innominate (n = 6), common carotid (n = 84), and subclavian (n = 66) lesions underwent reconstruction. Thirty-one operations were performed for multiple trunk involvement, recurrent disease, arteritis, infection, dissection, coarctation, or aneurysm. There were 122 bypass grafting procedures (98 ipsilateral, 24 contralateral) and 60 arterial transpositions.
One death (0.5%) and 7 nonfatal strokes (3.8%) occurred, none in patients who were asymptomatic. Perioperative morbidity included four asymptomatic occlusions (2%), 6 myocardial infarctions (3%), 10 pulmonary complications (5%), and 2 graft infections (1%). Follow-up periods ranged from 1 to 190 months (mean, 53 +/- 5 months). Nineteen patients (10%) were lost to follow-up. Fifty-seven late deaths occurred, most from cardiac causes. Seven reconstructions necessitated late revision. The cumulative primary patency rate at 5 and 10 years was 91% +/- 2% and 82% +/- 5%, respectively. The survival rate at 5 years was 72% +/- 4% and at 10 years was 41% +/- 6%. The stroke-free survival rate was 92% +/- 2% at 5 years and 84% +/- 2% at 10 years.
Cervical reconstruction of symptomatic and asymptomatic supra-aortic trunk lesions carries acceptable death and stroke rates and provides a long-term patient benefit. This should be the preferred approach for asymptomatic lesions and for patients with significant comorbidity because it carries less morbidity than direct transmediastinal aortic-based reconstruction.
本研究旨在回顾16年间连续进行的182例主动脉弓上干颈部重建手术。
173例年龄从23天至83岁的患者共182条无名动脉、颈总动脉或锁骨下动脉采用颈部入路进行重建。适应证包括半球性（n = 79）、椎基底动脉性（n = 56）、上肢（24）和乳内动脉/心脏缺血（n = 5）、无症状严重颈总动脉疾病（n = 33）或其他（n = 3）。原发性动脉粥样硬化性无名动脉（n = 6）、颈总动脉（n = 84）和锁骨下动脉（n = 66）病变接受重建。31例手术用于多支血管受累、复发性疾病、动脉炎、感染、夹层、缩窄或动脉瘤。有122例旁路移植手术（98例同侧，24例对侧）和60例动脉转位术。
发生1例死亡（0.5%）和7例非致命性卒中（3.8%），无症状患者中无死亡和卒中发生。围手术期并发症包括4例无症状性闭塞（2%）、6例心肌梗死（3%）、10例肺部并发症（5%）和2例移植物感染（1%）。随访时间为1至190个月（平均53±5个月）。19例患者（10%）失访。发生57例晚期死亡，多数死于心脏原因。7例重建需要后期翻修。5年和10年的累积原发性通畅率分别为91%±2%和82%±5%。5年生存率为72%±4%，10年生存率为41%±6%。5年无卒中生存率为92%±2%，10年为84%±2%。
有症状和无症状的主动脉弓上干病变的颈部重建手术死亡率和卒中率可接受，且对患者有长期益处。对于无症状病变和有严重合并症的患者，这应是首选方法，因为它比基于直接经纵隔主动脉的重建手术发病率更低。
