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

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

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