大隐静脉重建颈动脉在头颈部恶性肿瘤手术治疗中的应用

目的探讨大隐静脉在颈动脉重建手术中的应用以及对恶性肿瘤侵犯颈动脉的患者行颈动脉重建手术的临床疗效和安全性。方法回顾性研究。纳入中国医学科学院肿瘤医院头颈外科2017年11月—2019年9月18例行肿瘤切除颈动脉重建的恶性肿瘤患者,其中男10例、女8例,年龄47~72(58.8±6.6)岁;甲状腺乳头状癌11例,头颈部鳞癌7例,其中5名患者在术前接受过放射治疗。完成综合术前检查后,术中完整切除肿物及受侵的部分颈动脉,并以自体大隐静脉重建颈动脉。观察患者术前颈部超声及颈部CT提示肿瘤包绕角度、下肢静脉超声所提示的大隐静脉情况及距汇入股静脉远心端5 cm处内径,手术时间、术中出血量、移植大隐静脉侧别、供体大隐静脉长度、术中颈动脉阻断时间、肿瘤包绕颈动脉角度、受体颈动脉吻合处内径,术后病理组织学检查结果、患者住院时间、重建血管的通畅情况、有无出现神经系统及下肢供区并发症,随访期间有无局部复发及远处转移病例。结果术前超声探查及颈部CT示,18例患者大隐静脉在距汇入股静脉远心端5 cm处内径(0.53±0.14)cm;颈部CT扫描见肿瘤对颈动脉的包绕角度均超过180°,其中超过270°15例、全部包绕颈动脉9例。术中大隐静脉取材长度(7.3±1.1)cm,取用左侧大隐静脉9例、右侧大隐静脉9例。颈动脉近心端吻合处均为颈总动脉,内径(0.74±0.06)cm;远心端吻合处位于颈总动脉14例,颈内动脉4例,内径(0.71±0.17)cm。术中颈动脉阻断时间(640±117)s。术中观察颈动脉受侵角度190°~360°(317°±56°),与术前影像学检查一致。18例患者手术时间4~6 h,术中出血200~500 mL,住院时间7~28 d(平均13.13 d)。术后病理提示侵犯颈动脉血管壁组织13例。术后随访时间3~24个月,平均11.06个月。18例中,死亡2例、局部复发1例,余15例无瘤生存;术后颈动脉CT血管成像示重建血管均通畅,未见移植血管破裂、感染、狭窄及假性动脉瘤形成,供区下肢均未见水肿、跛行等血液循环障碍并发症。结论在头颈部肿瘤患者的颈动脉重建手术中,大隐静脉具有易于取材、移植物感染率低等优势,同时该手术能在低神经系统并发症风险下安全、完整地切除肿瘤,值得推广应用。

Reconstruction of carotid artery with the great saphenous vein in the surgery of head and neck malignancy

Objective To investigate the efficacy and safety of the great saphenous vein in carotid resection for malignant tumor invasion.Methods This retrospective study included patients who underwent head and neck surgery at the Cancer Hospital of the Chinese Academy of Medical Sciences from November 2017 to September 2019. In particular, this study focused on 18 patients of carotid artery malignant tumor invasion, including 10 males and 8 females, aged 47-72(58.8±6.6)years. Among the patients, 11 patients had papillary thyroid cancer and seven patients had squamous cell carcinoma of head and neck, where five of them underwent radiation therapy before surgery. Combined with a comprehensive preoperative examination, the surgeries comprised the complete removal of the tumor and part of the carotid artery and the reconstruction of the vessel with the autologous saphenous vein. Low-molecular-weight heparin was given after surgery, and computed tomography (CT) angiography and CT were regularly reviewed. The patients were observed with preoperative cervical ultrasound and CT prompt neck round Angle, lower limb venous ultrasound prompted by the great saphenous vein and far away from hui in vein heart to carry 5 cm in diameter, operation time, intraoperative blood loss, not by the side of great saphenous vein transplantation, donor great saphenous vein length, tumor and carotid artery block time package RaoGeng Angle, receptor carotid arterial anastomosis inner diameter, histologic examination results, patients' length of hospital stay, postoperative reconstruction flow situation of the blood vessels, presence of complications in the nervous system and the lower limbs for area, with or without local recurrence and distant metastasis patients during the follow-up period.Results Preoperative ultrasound exploration and neck CT showed that the internal diameter of the great saphenous vein in 18 patients was (0.53±0.14) cm at 5 cm from the distal end of the portal vein. CT scan of the neck showed that the wrapping angle of the tumor to the carotid artery were more than 180°, among which 15 patients were more than 270°, and 9 patients were all wrapped around the carotid artery. The length of saphenous vein was (7.3±1.1) cm. Nine patients were selected from the left great saphenous vein and 9 patients from the right. The proximal carotid anastomosis sites were all common carotid arteries with an internal diameter of (0.74±0.06) cm. The distal anastomosis was located in the common carotid artery in 14 patients and the internal carotid artery in 4 patients, with the internal diameter (0.71±0.17) cm. The time of intraoperative carotid artery occlusion was (640±117) s. The intraoperative invasion angle of carotid artery was observed at 190°- 360° (317°±56°), which was consistent with the preoperative imaging examination. The operation time of 18 patients ranged from 4 to 6 hours, the intraoperative hemorrhage ranged from 200 to 500 mL, and the hospitalization time ranged from 7 to 28 days (mean 13.13 days).Postoperative pathology indicated 13 patients of invasion of carotid vascular wall tissue. The average follow-up time was 11.06(3-24) months. Among the 18 patients, 2 died, and 1 experienced local recurrence, and the remaining 15 survived without tumor. Postoperative carotid artery CT angiography showed that all the reconstructed vessels were unobstructed. No graft vessel rupture, infection, stenosis, and pseudoaneurysm formation were found in all patients during the follow-up period. No edema, claudication, and other complications of blood circulation disorders were observed in the lower limbs of the donor area. Conclusions The autologous great saphenous vein can be used as a donor for carotid artery reconstruction in the surgical treatment of head and neck malignant tumors. Therefore, it is suitable to be widely used because of its easy sampling, low graft infection rate, and low risk of neurological complications.