Alternative management of the left subclavian artery in thoracic endovascular aortic repair for aortic dissection: a single-center experience

Background

Since the new 2009 guidelines for left subclavian artery (LSA) management using thoracic endovascular aortic repair (TEVAR), a few studies have been published about alternative LSA management. The objective of this study was to present the follow-up results of covered or revascularized LSA during TEVAR.

Methods

From January 2010 to August 2012, 109 consecutive patients were treated with TEVAR at the Department of Vascular Surgery, Changhai Hospital, for aortic dissection extending near the LSA. After evaluating the bilateral vertebral arteries, fifty-two LSAs were covered and not revascularized (covered group), while 57 LSAs were preserved (revascularized group). Complications were stratified according to the time of occurrence after surgery.

Results

Emergency operations were more common (17.3 vs. 3.5 %, P = 0.017) and operation time was shorter (96.9 ± 16.3 vs. 135.3 ± 38.4 min, P < 0.001) in the covered group. Pulselessness and intermittent claudication of the left arm occurred in most patients in the covered group (P < 0.001). Incidence of stroke and cold shoulder feeling were higher in the covered group compared with the revascularized group (P = 0.026 and <0.001, respectively). There were five aorta-related deaths in the covered group and one in the revascularized group. Eight endoleaks were observed in the revascularized group (P = 0.006).

Conclusions

The results of this study suggest that due to occurrence of complications, LSA should be preserved or revascularized to reduce complications and to improve patients’ quality of life.     

Acute occlusion of the left subclavian artery with artery dissection

Subclavian steal syndrome is cerebral or brain stem ischemia resulting from diversion of blood flow from the basilar artery to the subclavian artery, which is caused by occlusive disease of either the subclavian artery or the innominate artery before they branch off at the vertebral artery. In the patients with subclavian steal syndrome the subclavian artery is fed by retrograde flow from the vertebral artery via the carotids and the circle of Willis. Clinical manifestations of the disease co…     

循证护理在预防锁骨下静脉穿刺置管术并发症中的作用

目的:将循证护理方法应用于解决锁骨下静脉穿刺置管术护理中出现并发症的实践过程。方法:对锁骨下静脉穿刺置管术护理中出现的问题进行汇总、筛选,应用计算机网络检索有关文献,对证据的真实性、可靠性、实用性做出评判和选择。结果:与常规护理相比,运用循证护理可以有效预防锁骨下静脉穿刺置管术并发症的发生,差异具有显著性(P<0.05)。结论:运用循证护理可以有效预防锁骨下静脉穿刺置管术并发症的发生,还可以培养护士的评判性思维,提高护士解决问题的能力和工作效率。     

Modification of the right subclavian vein catheterization and its anatomic basis and techniques

Background Several million subclavian-vein catheters are placed in patients each year to enable caregivers to administer chemotherapy, total parenteral nutrition, or long-term antibiotics or to manage preoperative fluids. Subclavian venipuncture requires the position of a deep vein to be identified with only surface landmarks. But the traditional right subclavian vein (RSV) catheterization (primitive procedures) is not the answer for all patients. The precise location of the vein is not known, and it is important to select the most appropriate method to achieve central venous access safely in any given patient. To modify the primitive procedures of the RSV catheterization for greater success and reduce the complications, anatomic studies and ultrasonography were conducted and clinical applications were validated. Methods Anatomical observation and measurement of the RSV and its adjacent structures were performed on 20 adult cadavers according to modified procedures. The RSV catheterization of 2900 cases was carried out by the modified procedure, 500 of these cases were observed by ultrasonography after the operation. Results The anatomical studies and clinical application showed that the insertion point differs from the bodily form of fatness or leptosome. The clinical data revealed that in the 2900 cases which were performed with the modified approach, the success rate was 98.90% (2868 cases), the failure rate was 1.10% (32 cases), and the complication rate is 0.79% (23 cases), and the catheterization time is (31.2±10.5) minutes. Five hundred and sixty cases of the RSV catheterization were carried out by the recommended insertion procedure; the results were compared with the modified approach and the traditional approach. The successful rate of the traditional approach was 73.0%, of which the complication rate was 6.1%; the two approaches were significantly different (successful rate: χ2=626.642, P&lt;0.01; complication rate: χ2=80.708, P&lt;0.01). Conclusions The modified RSV catheterization is characterized with a higher success rate and less complications, and the insertion procedure differs from the bodily form of fatness or leptosome.     

右锁骨下动脉插管体外循环技术在主动脉弓部手术中的临床应用

目的　总结右锁骨下动脉插管体外循环技术在主动脉弓部手术中的临床应用价值。方法　在深低温 ,停循环时应用右锁骨下动脉插管的选择性脑灌注技术 ,手术治疗 2 0例累及主动脉弓的心血管疾病病人。结果　所有患者均于术后 4-6h清醒 ,无死亡及脑部并发症 ,平均体外循环时间 ( 10 3 .2 6± 3 2 .8)min ,脑部低流量平均时间( 2 6.0 6± 19.18)min。结论　以右锁骨下动脉插管建立体外循环行选择性脑灌注 ,可安全地延长停循环时限及有效防止脑部并发症。     

实时超声引导锁骨下静脉中心静脉置管穿刺术及其临床应用

目的 评估超声引导锁骨下静脉中心静脉置管的有效性、安全性.方法 总结2007 年9 月-2011 年11 月间行超声引导下锁骨下静脉置管97 例资料,并分析穿刺成功率、进针次数、置管穿刺所需时间及并发症发生率.结果 置管成功率100%,进针次数1-3(1.5±0.6) 次.操作时间15-30(19.2±5.5)min,2 例(2%) 中心静脉导管误入颈内静脉内,1 例(1%) 置管后41d 形成血栓,10 例(10%) 于置管后1-80(32.9±25.7)d 发生感染.结论 超声引导锁骨下静脉中心静脉置管是一种安全有效的方式.     

医源性锁骨下动脉损伤的诊断与治疗

目的探讨医源性锁骨下动脉损伤的诊断和有效治疗方法。方法对1997年7月至2009年1月,11例医源性锁骨下动脉损伤的救治进行回顾性分析,本组7例行血管修补,2例行人造血管移植,1例行大隐静脉桥接,l例行直接端-端吻合。结果手术修复成功10例,死亡1例。动脉修复术后l年随访,均可清晰地触及桡动脉搏动。其中1例并发臂丛神经损伤,术后1年随访未完全恢复。结论医源性锁骨下动脉损伤是一种严重而复杂的血管损伤,大多数医源性锁骨下动脉损伤是可以避免的,对血管损伤应做到诊断迅速,快速有效止血,及时补充血容量和纠正休克。手术修复应根据具体情况选择适当切口,选择合理的手术入路和适当的手术方法,是手术安全、成功的关键。     

经皮血管腔内成形术治疗锁骨下动脉近端闭塞性病变

利用经皮血管腔内成形术（ＰＴＡ）对３０例锁骨下动脉重度狭窄或闭塞患者进行治疗，并对其中２例锁骨下动脉重度狭窄并发急性血栓形成的患者进行溶栓及ＰＴＡ治疗，成功２７例（９０％），未发生与手术相关的严重并发病。除２例患者于术后８～１０个月发生再狭窄经重复ＰＴＡ再通外，随访６～１２个月均获得满意的效果。     

锁骨下动脉与椎动脉病变所致椎动脉反流超声鉴别诊断分析

目的 探讨不同病变部位引起推动脉(VA)反流时的血流动力学差异.方法 选取经彩色多普勒超声检查发现VA血流频谱出现反向血流,并准确诊断病变部位的125例患者.据病变部位不同分成锁骨下动脉(SA)病变组和VA病变组对比观察.结果 SA病变组81例,VA病变组44例,两组阃VA频谱类似者对比,SA组VA流速较VA组高(P＜0.05).SA组较VA组病变侧上肢动脉频谱改变发生率高;病变侧流速较健侧低,AT延长(P＜0.05).VA组双侧上肢动脉流速及AT差异无统计学意义(P＞0.05).束臂试验阳性率SA组较VA组高(P＜0.05).结论 VA反流可由锁骨下动脉或无名动脉或推动脉狭窄或闭塞引起,结合病变侧椎动脉流速、上肢动脉血流动力学变化及束臂试验,可提高鉴别诊断.     

超声引导与触脉结合在桡动脉穿刺置管中的应用

目的 评估超声引导结合传统触脉定位行桡动脉穿刺置管的临床效果.方法 选取解放军第四一一医院准备择期手术患者60例,ASA Ⅰ或Ⅱ级,年龄32 ～ 87岁,采用数字表法随机分为U、C2组,每组30人.U组:采用传统触脉定位结合超声引导下穿刺置管;C组:采用传统触脉盲探法穿刺置管.记录2组患者定位及准备时间、置管成功时间、一次成功率、总成功率、穿刺次数、失败率及血肿并发症发生率.结果 与传统触脉定位法相比,传统触脉定位结合超声引导法置管成功时间显著缩短(P＜0.01),一次成功率显著提高(P＜0.01),穿刺次数显著减少(P＜0.01).结论 超声引导与触脉结合下行桡动脉穿刺置管,穿刺时间短,一次成功率高,并发症发生率低,安全可靠.     

体外受精-胚胎移植并发颈内静脉、锁骨下静脉及右头臂静脉血栓1例

探讨体外受精-胚胎移植(in vitro fertilization and embryo transfer,IVF-ET)并发颈内静脉、锁骨下静脉及右头臂静脉内血栓形成的诊治方法.报告1例IVF-ET并发颈内静脉、锁骨下静脉及右头臂静脉内血栓形成并获得顺利分娩病例的临床资料,讨论IVF-ET并发颈内静脉、锁骨下静脉及...     

21例锁骨下动脉瘤(SAA)腔内诊治经验

 目的  总结锁骨下动脉瘤(subclavicular artery aneurysm, SAA)患者腔内治疗的效果。方法  复旦大学附属中山医院血管外科2013年1月至2016年 6月共诊治SAA患者21例,男11例,女10例,平均年龄(39±9)岁。所有SAA患者均行腔内治疗,回顾分析围手术期和术后效果及不良事件。结果  技术成功率为100%。术中1例SAA患者支架植入后,近端Ⅰ型内漏明显,改行平行支架植入术;2例Ⅱ型内漏和2例SAA瘤腔巨大分别行侧支和瘤腔钢圈栓塞;中位随访时间19(6～42)个月。随访期间3例SAA患者发生支架内狭窄,1例右SAA患者在释放支架时未覆盖锁骨下动脉开口,在第2年出现支架近端严重狭窄;2例患者SAA位于锁骨下动脉第3段,左右各1例,分别在第2年和第3年出现支架远端严重狭窄。患者2年和3年支架通畅率分别为90.5%和85.7%。结论  腔内治疗SAA操作简单,效果明确;右SAA治疗中应在右锁骨下动脉和右颈总动脉分叉处的切线位角度,使分叉部位完全展开,尽量覆盖开口;对于短瘤颈平行支架植入效果较好;锁骨下动脉瘤位于第3段时,术后易出现支架内狭窄,要注意远期随访。     

经锁骨下静脉置入中心静脉导管进行肠外营养的并发症及预防

目的探讨经锁骨下静脉置入中心静脉导管进行肠外营养防治并发症的方法。方法回顾分析我科2005年1月~2010年12月经锁骨下静脉置入中心静脉导管进行肠外营养及并发症的临床资料。结果 1570例中52例（3.3%）并发症,其中气胸26例（1.7%）,血胸2例（0.13%）,发热34例（2.2%）,导管周围感染7例（0.45%）,导管脱出11例（0.70%）。结论采用预防性措施后,经锁骨下静脉置入中心静脉导管进行肠外营养技术的并发症可降低。     

经皮血管内支架植入术治疗锁骨下动脉狭窄的临床研究

目的：探讨经肱动脉路径行锁骨下动脉支架植入治疗重度锁骨下动脉狭窄和闭塞的疗效。方法：分析2005年9月至2008年3月采取经肱动脉逆行植入支架治疗锁骨下动脉重度狭窄和闭塞10例。术前诊断包括彩色多普勒超声检查和动脉造影确诊。结果：本组支架植入均获成功,支架植入满意,无移住。10例中随访8例,随访时间4-34个月,平均15个月。失访2例,随访率80％。随访期间8例病例均无上肢缺血症状及神经症状发生。结论：逆行锁骨下动脉支架植入是治疗锁骨下动脉重度狭窄和闭塞安全有效的方法。     

可微创拔管的新型肺动脉插管方法的实验研究

目的　创建一种可以在术后微创拔管的新型肺动脉插管方法 ,用于右心辅助循环实验。方法　选用 7只成年犬 ,将 1个特制的可拆卸的人工血管 牛心包管“组件”(简称“组件”)的牛心包与主肺动脉吻合 ,作为肺动脉插管通道 ,组件的人工血管端及连接组件两段管道的连线经肋间小切口引到体外 ,经此途径插肺动脉灌注管到主肺动脉 ,再将组件上预置的打结 牵引线经另一肋间小切口引到体外并收紧 ;经皮切口插引流管到股静脉或颈外静脉建立右心辅助循环。停机后实施微创拔管 ,其关键步骤是依靠一种可经小切口向体内深部打结的简单方法 ,使用扩张管和打结器 ,将预置在“组件”上的滑线打结使牛心包管闭合 ,然后撤出“组件”上的牵引线、连接线和人工血管。结果　经此方法建立起的右心辅助的最大流量为 (6 4± 12 )ml·min-1·kg-1。微创拔管后活体开胸检查证实 ,除第 2例外 ,其他 6例牛心包管上的两组结 (各 8个 )均满意 ,主肺动脉吻合口和牛心包管残端均无出血。第2例第 2组的打结 牵引线被打进第 7个结中因抽不出来而部分残留。结论　该研究建立的这种可以在术后微创拔管的新型插管方法简单方便、安全有效 ,右心辅助的血流动力学效果满意 ,将来可为心外科医生在选择辅助循环时解除后顾之忧。     

锁骨下动脉损伤及创伤性假性动脉瘤的腔内治疗策略

目的:探讨锁骨下动脉损伤及创伤性动脉瘤腔内介入治疗的方法和经验.方法:对5例急性锁骨下动脉损伤伴出血性休克,2例外伤后锁骨下动脉闭塞,2例外伤性锁骨下假性动脉瘤,1例外伤性锁骨下动静脉瘘.实施了腔内支架治疗,成功实施9例,1例造影后发现血管完全断裂后立即转为开放手术.结果:所有患者均痊愈,随访4～30月,所有支架置人病例血管通畅,无严重狭窄及闭塞发生.结论:血管内支架技术治疗锁骨下动脉损伤,安全可靠,创伤小,并发症少,是一种崭新的、有效的治疗方法.     

胸主动脉夹层动脉瘤腔内隔绝术中左锁骨下动脉的处置

目的：探讨腔内隔绝术治疗Stanford B型胸主动脉夹层动脉瘤时左锁骨下动脉开口的处理原则。方法：对116例接受腔内隔绝术治疗的Stanford B型胸主动脉夹层动脉瘤患者进行回顾性分析。结果：116例患者中62例左锁骨下动脉开口受到干扰，其中2例完全遮蔽，19例有临床症状，而术前行颈外动脉－椎动脉旁路者，完全遮蔽左锁骨下动脉后无不适症状。结论：完全遮蔽左锁骨下动脉可引起左侧椎动脉的急性严重缺血造成严重的并发症，术前应根据夹层破口与左锁骨下动脉开口的距离，选择性实施左锁骨外动脉－左椎动脉旁路术。     

L-精氨酸联合右锁骨下动脉选择性顺行脑灌注对深低温停循环脑保护的实验研究

目的: 研究氧化亚氮(NO)前体L-精氨酸(L-arg)和经右锁骨下动脉选择性脑灌注(SCP)在深低温停循环(DHCA)中对脑组织的保护效果.方法: 实验兔随机分成DHCA组、SCP组和SCP L-arg组,分别予深低温停循环、停循环下顺行脑灌注及L-精氨酸静脉滴注,复温后开颅取脑组织检测超氧化物歧化酶(SOD)、丙二醛(MDA)及caspase-3蛋白表达进行组间比较.结果: SCP组和SCP L-arg组和DHCA组相比,SOD活性明显增强,MDA和caspase-3蛋白的表达均明显下降(P＜0.05,P＜0.01);SCP组和SCP L-精氨酸组间的MDA含量无统计学差异(P＞0.05),但是后者的SOD活性显著增加,caspase-3蛋白的表达明显下降(P＜0.05).结论: 选择性顺行脑灌注和L-精氨酸联合选择性顺行脑灌注在深低温停循环过程中对脑均有保护作用,L-精氨酸联合选择性顺行脑灌注对脑的保护作用更好.