腔内修复抢救胸主动脉创伤伤员时封闭左锁骨下动脉的可行性分析

Feasibility of Intentional Occlusion of the Left Subclavian Artery during Endovascular Aortic Repair for Thoracic Aortic Trauma

目的探讨腔内修复术(endovascular aortic repair,EVAR)中抢救胸主动脉创伤(thoracic aortic trauma,TAT)伤员时封闭左锁骨下动脉(left subclavian artery,LSA)的可行性,从而为临床快速、简便、有效地急救TAT提供依据。方法对因EVAR中锚定区(landing zone,LZ)不足的19例TAT伤员进行颈动脉、椎基底动脉及大脑动脉环(Willis环)检查。如颈动脉、椎基底动脉血流通畅及Willis环完整则在EVAR时直接完全封闭LSA开口。术后行电子计算机断层扫描(computed tomography,CT)或/和CT血管造影(computed tomography angiography,CTA)复查、随访,观察脑及上肢缺血并发症发生情况。结果 4例(4/19)伤员因近端LZ不足,均选择了在EVAR术中直接完全封闭LSA开口,均获得了手术成功。术后复查提示LSA远端无前向性血流1例、少量血流1例、中等量血流1例、正常血流1例。出院后平均随访21.2个月,随访期间2例伤员完全没症状;1例左上肢皮色稍苍白,皮温较对侧低,左上肢运动轻微减少,短暂性麻木、针刺感;1例阵发性眩晕,左上肢间歇性肌力减弱。所有症状表现轻微,无需再次手术以减轻症状。结论在明确颈动脉、椎基底动脉血流通畅及Willis环完整后,应用EVAR救治TAT伤员时因锚定不足而直接完全封闭伤员的LSA开口是安全、可行的。进一步的论证需要多中心、大样本的临床实验。

Objective To investigate the feasibility of intentional occlusion of the left subclavian artery （LSA） dur- ing endovascular aortic repair （EVAR） for thoracic aortic trauma （TAT）, so as to supply reference for the rapid and first aid of TAT with EVAR. Methods The carotid artery, vertebral basilar artery and circle of Willis of 19 cases with TAT and insufficient landing zone （LZ） were examined before EVAR. The patients with good blood pathway in the vertebral artery and carotid artery, and whole Willis circle underwent direct LSA closure in EVAR. They were reexaminated after surgery by computed tomography （CT） and/or computed tomography angiography （CTA） and followed up. The ischemic symptoms and complications of the brain and upper limb were observed. Results Four cases with insufficient proximal LZ underwent successful direct LSA closure in EVAR. The reexamination after surgery indicated that one case had no an- tegrade flow in the distal LSA, one case had minimal flow, one case had moderate flow and one case had normal flow. During the follow-up of meanly 21.2 months, two cased had no symptoms, one case had pale skin, lower temperature, slightly reduced movement, transient paresthesias and tingling of the left arm, and one case had paroxysmal dizziness and intermittent exercise-induced weakness of the left arm. All symptoms were mild and no secondary surgery was needed. Conclusion Once it is confirmed that the carotid artery and vertebral basilar artery have good blood flow and whole Willis circle, LSA closure in EVAR is safe and feasible for TAT patients with insufficient LZ. More clinical trials in multiple centers and large samples are needed.