跨中线经椎前间隙入路锁骨下动脉-颈总动脉血管旁路移植治疗颈总动脉闭塞

doi:10.11817/j.issn.1673-9248.2023.01.003

目的

总结跨中线经椎前间隙入路锁骨下动脉-颈总动脉血管旁路移植治疗颈总动脉闭塞的技术要点，评估其可行性和有效性。

方法

针对1例症状性的左侧颈总动脉闭塞患者，在全身麻醉下行右侧锁骨下动脉-左侧颈总动脉人工血管旁路移植术，经颈前间隙建立人工血管的经过通道，总结此手术技术治疗颈总动脉闭塞的技术要点及手术效果。

结果

该例患者的手术时间为205 min，术中出血量为30 ml。经椎前间隙入路行右侧锁骨下动脉-左侧颈总动脉人工血管旁路移植术后，左侧颈内动脉血流恢复通畅，术后无过度灌注综合征及其他脑血管并发症，无声音嘶哑、饮水呛咳及吞咽困难等颈部手术并发症。术后10 d患者康复出院，出院后随访3个月，建立的血管旁路及左侧颈内动脉系统通畅，左侧脑灌注较术前改善，未再发生头晕黑矇等脑缺血症状。

结论

跨中线经椎前间隙入路锁骨下动脉-颈总动脉血管旁路移植术技术可行，适用于治疗复杂慢性颈总动脉闭塞患者。

关键词: 颈总动脉, 动脉闭塞性疾病, 人工血管, 移植, 锁骨下动脉

Objective

To summarize the technical points of transmidline subclavian artery-common carotid artery bypass through the prevertebral space for the treatment of common carotid artery occlusion, and to evaluate its feasibility and effectiveness.

Methods

For a patient with symptomatic left common carotid artery occlusion, right subclavian artery-left common carotid artery artificial blood vessel bypass was performed under general anesthesia. The passage of artificial blood vessel was established through the cervical prevertebral space, and the technical points and surgical effects of this surgical technique for common carotid artery occlusion were summarized.

Results

The operative time of the patient was 205 min and the intraoperative blood loss was 30 ml. After the right subclavicular artery - left common carotid artery artificial vessel bypass through the prevertebral space approach, the left internal carotid artery blood flow was restored and unobtrusive, and there were no postoperative hyperperfusion syndrome and other cerebrovascular complications, and no postoperative complications of neck surgery such as hoarseness, drinking cough, and dysphagia. The patient recovered and was discharged from the hospital 10 days after surgery, and was followed up at 3 months after discharge. The established vascular bypass and left internal carotid artery system were unobstructed. The left cerebral perfusion was improved compared with that before surgery. No cerebral ischemia symptoms such as dizziness and amaurosis occurred again.

Conclusion

Transmidline subclavian artery-common carotid artery bypass through the prevertebral space is feasible and suitable for the treatment of complex common carotid artery occlusion.

Key words: Carotid artery, common, Arterial occlusive diseases, Artificial blood vessel, Transplantation, Subclavian artery

图1 颈总动脉闭塞患者术前影像学资料。图a：头颈CT血管成像；图b：CT灌注成像；图c：颈动脉高分辨磁共振成像注：L-ICA为左侧颈内动脉，L-ECA为左侧颈外动脉，L-VA为左侧椎动脉，L-SCA为左侧锁骨下动脉

图2 颈总动脉闭塞患者术前24 h颅脑磁共振弥散加权成像序列

图3 颈总动脉闭塞患者跨中线经椎前间隙入路锁骨下动脉-颈总动脉旁路移植术示意图注：RCCA为右侧颈总动脉，LCCA为左侧颈总动脉，C5为颈5椎体，artificial blood vessel为人工血管，jugular vein为颈内静脉，esophagus为食管，trachea为气管，thyroid gland为甲状腺，subclavian artery为锁骨下动脉，arcus aortae为主动脉弓

图4 颈总动脉闭塞患者手术体位、切口设计（图a）及人工血管跨越中线图（图b）。箭头所示为右侧锁骨下动脉，白色虚线为颈前中线注：SCM为胸锁乳突肌

图5 颈总动脉闭塞患者术后颈部CT平扫图像注：Artificial blood vessel为人工血管，Thyroid gland为甲状腺，Trachea为气管，Esophagus为食管，C5 Vertebral body为第五颈椎椎体

图6 颈总动脉闭塞患者术后头颈CT血管成像+CT灌注成像。图a、b为术后CT血管成像血管三维图像，其中图a显示了人工血管和椎体之间的关系；图c为颈部血管冠状位重建图像，提示重建血流通畅；图d为术后CT灌注成像检查，提示术后左侧颈内动脉分布区脑灌注改善注：L-ECA为左侧颈外动脉，L-ICA为左侧颈内动脉，R-SCA为右侧锁骨下动脉，Artificial blood vessel为人工血管

图7 颈总动脉闭塞患者术后颅脑磁共振弥散加权成像序列

1	Belczak S, Mulatti GC, Abrao SR, et al. Common carotid artery occlusion: a single center experience in 40 cases [J]. Int J Angiol, 2016, 25(1): 39-43.
2	Klonaris C, Kouvelos GN, Kafeza M, et al. Common carotid artery occlusion treatment: revealing a gap in the current guidelines [J]. Eur J Vasc Endovasc Surg, 2013, 46(3): 291-298.
3	Hecht N, Wessels L, Fekonja L, et al. Bypass strategies for common carotid artery occlusion [J]. Acta Neurochir (Wien), 2019, 161(10): 1993-2002.
4	刘一人, 谷涌泉, 崔世军, 等. 锁骨下动脉-颈内动脉人工血管通路辅助颈内动脉支架置入术治疗复杂颈总动脉闭塞的效果 [J]. 中国普外基础与临床杂志, 2016, 23(6): 747-749.
5	Illuminati G, Pizzardi G, Calio FG, et al. Results of subclavian to carotid artery bypass for occlusive disease of the common carotid artery: a retrospective cohort study [J]. Int J Surg, 2018， 53: 111-116.
6	Catapano JS, Frisoli FA, Paisan GM, et al. Subclavian artery to internal carotid artery interpositional bypass for carotid artery occlusion: technical case report [J]. Oper Neurosurg (Hagerstown), 2020, 20(1): E66-E71.
7	Parker MH, Colpitts DK, Gilson GF, et al. Carotid-axillary bypass as an alternative to carotid-subclavian bypass following coverage of left subclavian artery during TEVAR [J]. Vasc Endovascular Surg, 2021, 55(3): 265-268.
8	Hass WK, Fields WS, North RR, et al. Joint study of extracranial arterial occlusion. II. Arteriography, techniques, sites, and complications [J]. JAMA, 1968, 203(11): 961-968.
9	姜林娣, 马莉莉, 薛愉, 等. 大动脉炎诊疗规范 [J]. 中华内科杂志, 2022, 61(5): 517-524.
10	Grubb RL, Derdeyn CP, Fritsch SM, et al. Importance of hemod-ynamic factors in the prognosis of symptomatic carotid occlusion [J]. JAMA, 1998, 280(12): 1055-1060.
11	Powers WJ, Clarke WR, Grubb RL, et al. Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the Carotid Occlusion Surgery Study randomized trial [J]. JAMA, 2011, 306(18): 1983-1992.
12	Brott TG, Halperin JL, Abbara S, et al. ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology,Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery [J]. Circulation, 2011, 124(4): e54-e130.
13	Berguer R. The short retropharyngeal route for arterial bypass across the neck [J]. Ann Vasc Surg, 1986, 1(1): 127-129.
14	McMillan W. Cross-over carotid bypass: customized operative approach to occlusive disease of the great vessels [J]. J Vasc Nurs, 1998, 16(3): 69.

[1]	谢迎东, 孙帼, 徐超丽, 杨斌, 孙晖, 戴云. 超声造影定量评价不同生存期移植肾血流灌注的临床价值[J]. 中华医学超声杂志（电子版）, 2023, 20(07): 749-754.
[2]	罗旺林, 杨传军, 许国星, 俞建国, 孙伟东, 颜文娟, 冯志. 开放性楔形胫骨高位截骨术不同植入材料的Meta分析[J]. 中华关节外科杂志(电子版), 2023, 17(06): 818-826.
[3]	顾娟, 孙擎擎, 胡方方, 曹义娟, 祁玉娟. 子宫内膜容受性检测改善胚胎反复种植失败患者妊娠结局的临床应用[J]. 中华妇幼临床医学杂志(电子版), 2023, 19(05): 582-587.
[4]	刘林峰, 王增涛, 王云鹏, 钟硕, 郝丽文, 仇申强, 陈超. 足底内侧皮瓣联合甲骨皮瓣在手指V度缺损再造中的临床应用[J]. 中华损伤与修复杂志(电子版), 2023, 18(06): 480-484.
[5]	陈永沛, 仲海燕, 陈勇, 王慜, 王倩, 邹鸣立, 袁斯明. 数字减影血管造影在腓动脉穿支皮瓣移植中的应用[J]. 中华损伤与修复杂志(电子版), 2023, 18(06): 507-510.
[6]	韩李念, 王君. 放射性皮肤损伤治疗的研究进展[J]. 中华损伤与修复杂志(电子版), 2023, 18(06): 533-537.
[7]	刘竹影, 周年苟, 李泳祺, 周丽斌. 空心环钻联合手术导板用于自体牙移植牙槽窝备洞[J]. 中华口腔医学研究杂志(电子版), 2023, 17(06): 418-423.
[8]	严庆, 刘颖, 邓斐文, 陈焕伟. 微血管侵犯对肝癌肝移植患者生存预后的影响[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 624-629.
[9]	廖梅, 张红君, 金洁玚, 吕艳, 任杰. 床旁超声造影对肝移植术后早期肝动脉血栓的诊断价值[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 630-634.
[10]	李秉林, 吕少诚, 潘飞, 姜涛, 樊华, 寇建涛, 贺强, 郎韧. 供肝灌注液病原菌与肝移植术后早期感染的相关性分析[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 656-660.
[11]	吕垒, 冯啸, 何凯明, 曾凯宁, 杨卿, 吕海金, 易慧敏, 易述红, 杨扬, 傅斌生. 改良金氏评分在儿童肝豆状核变性急性肝衰竭肝移植手术时机评估中价值并文献复习[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 661-668.
[12]	王孟龙. 肿瘤生物学特征在肝癌肝移植治疗中的意义[J]. 中华肝脏外科手术学电子杂志, 2023, 12(05): 490-494.
[13]	何吉鑫, 杨燕妮, 王继伟, 李建国, 谢铭. 肠道菌群及肠道代谢产物参与慢性便秘发生机制的研究进展[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 495-499.
[14]	郭晓磊, 李晓云, 孙嘉怿, 金乐, 郭亚娟, 史新立. 含生长因子骨移植材料的研究进展和监管现状[J]. 中华老年骨科与康复电子杂志, 2023, 09(06): 373-378.
[15]	王丁然, 迟洪滨. 自身免疫甲状腺炎对子宫内膜异位症患者胚胎移植结局的影响[J]. 中华临床医师杂志(电子版), 2023, 17(06): 682-688.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Treatment of common carotid artery occlusion by transmidline subclavian artery - common carotid artery bypass through the prevertebral space

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Treatment of common carotid artery occlusion by transmidline subclavian artery - common carotid artery bypass through the prevertebral space