目的 总结颈动脉损伤患者救治的临床经验。 方法 2003年1月－2006年6月，抢救5例颈动脉损伤患者。男3例，女2例；年龄21～35岁。其中左右颈总动脉各1例，左锁骨下动脉2例，左椎动脉1例。合并损伤：左颈内静脉贯通伤1例，左胸导管及交感神经损伤1例，食道损伤1例，左锁骨骨折1例。受伤至入院时间20 min～3个月。受伤原因：刀刺伤3例，误食缝衣针伴感染1例，车祸伤1例。采用血管吻合修复颈总动脉及椎动脉3根、侧壁修补修复左锁骨下动脉1根、左颈内静脉1根及自体血管移植术修复左锁骨下动脉1根。术中输血量1 000～11 000 mL,平均3 800 mL。 结果 所有患者均抢救成功，伤口Ⅰ期愈合，经1～3年随访，无神经功能障碍。 结论 颈动脉损伤救治成功的关键在于尽早做出诊断，快速有效的急救及选择正确的治疗方法。
Objective To explore the effective surgical approaches in treating subclavian artery occlusion. Methods Between December 2005 and February 2010, 53 patients with subclavian artery occlusion were treated, including left subclavian artery occlusion (35 cases) and stenosis (5 cases), right subclavian artery occlusion (5 cases) and stenosis (4 cases), and bilateral subclavian artery occlusion (4 cases). There were 40 males and 13 females with an average age of 64 years (range, 22-77 years), including 49 cases of arteriosclerosis obl iterans and 4 cases of aortic arteritis. The disease duration was 15 days to 20 months (6.5 months on average). In 49 patients with unilateral subclavian artery occlusion, 39 cases compl icated by carotid or / and cerebral artery lesion underwent axillo-axillary bypass grafting, and 10 cases without carotid or /and cerebral artery lesion underwent carotid-subclavian bypass grafting. Ascending aorta to bisubclavian bypass graftings were performed on 4 cases with bilateral subclavian artery occlusion. After operation, patients received routine treatment with anticoagulant and antiplatelet agents. Results The operations were successfully performed in 52 cases with a successful rate of 98.11%. Thrombogenesis at anastomotic site occurred in 1 case of aortic arteritis after 48 hours. Two cases had brachial plexus crush injury and 4 had hematoma around the bilateral anastomosis after axillo-axillary bypass grafting, and all recovered with nonoperative therapy. A total of 52 patients were followed up 1-52 months (24.5 months on average). All patients survived and the symptoms of basilar and upper l imb artery ischemia disappeared. Doppler ultrasonography showed that the blood flow was patent through anastomosis and polytetrafluoroethylene graft, and the vertebral artery flow was normal. Pseudoaneurysm at anastomosis was found in 1 case after 18 months and treated by interventional embol ization. The postoperative graft patency rate was 100% at 1 year and at 2 years. Conclusion Both thoracic and extrathoracic surgical approaches are effective for treating subclavianartery occlusion. The reasonable surgical approach should be selected according to the arteriopathy and the patient’s condition. Perioperative treatment and strict intraoperative manipulation are important to guarantee the success of surgery.
Objective To explore the treatment of traumaticsubclavian artery. Methods From July 1990 to January 2006, 12 cases of traumatic subclavian artery were treated byusing of combined incision of superior-inferior clavian. All patients were male,aging 18-36 years(mean 22.6 years). The locations were section 1 of subclavianartery in 1 case, section 2 in 4 cases and section 3 in 7 cases. All patients had incomplete rupture and defect. Time from injury to operation was 3 hours to 1.5 months. The methods of vascular repair included primary repair, end-to-end anastomosis and artificial vascular prosthesis grafts. Results There was no death. Extremities survived in all cases and got good function in 10cases.All patients were followed up 2 months to 12 years (mean 5 yeras and 2 months). The pulse of radial artery restored to normal in 10 cases and did not be felt in 2 cases. The function of extremities restored to normal in 2 cases withpartial injury of brachial plexus nerve and did not improve in 2 cases with complete injury ofbrachial plexus nerve. 〖WTHZ〗Conclusion The exposure of subclavian artery is difficult because of its particular anatomy region. The repair and reconstruction of subclavian artery should be selected according to the type of vascular injuries. Combined superiorinferior clavian approach can satisfy the exposure and repair for the subclavian artery.
目的 了解喉不返神经临床解剖特点，总结甲状腺手术中预防其损伤的经验。方法 分析2例喉不返神经临床资料，结合文献讨论甲状腺手术中预防其损伤的有关问题。结果 本组2例经手术证实，喉不返神经均位于右侧； 右喉返神经缺如，术中未损伤。结论 甲状腺手术中发现横行于颈动脉鞘和喉之间任何索状结构或探查喉返神经缺如，须显露迷走神经(颈段)以避免损伤喉不返神经。
ObjectiveTo investigate the clinical value of cervical vascular color Doppler ultrasound for dignosis of nonrecurrent laryngeal nerve before thyroid surgery. MethodsThere were 1931 cases of thyroid patients treated between January 2010 to Jule 2014, group these patients according to the results of preoperative chest radiograph examination, the chest radiograph shows abnormal vessels image were group A (45 cases), no abnormalities were group B (1886 cases). Before operaton, made patients of group A to have routine carotid duplex ultrasound to identify whether the right subclavian artery abnormalities. All patients were exposed to conventional methods of recurrent laryngeal nerve during surgery. ResultsThe 45 patients of group A, chest angiography showed 17 cases with right subclavian artery abnormalities, they were confirmed that all the 17 patients were nonrecurrent laryngeal nerve by surgery, no damage cases. The other 28 cases showed a normal right subclavian artery and no cases of nonrecurrent laryngeal nerve. The 1886 patients in group B, surgical exploration found four cases with nonrecurrent laryngeal nerve, injury in 1 case. The 21 patients whose nonrecurrent laryngeal nerve were on the right side, there were no left side with nonrecurrent laryngeal nerve and no co-exist cases of nonrecurrent and recurrent laryngeal nerve. The average exposure time of nonrecurrent laryngeal nerve in patients of group A (17 cases) was significantly shorter than that group B[(4.28±1.08) min vs. (15.50±2.08) min, t=-15.978, P=0.000]. ConclusionsThe cervical vascular color Doppler ultrasound examination before thyroid surgery can be adjuvant used, if there is the right subclavian artery abnormalities, it showes that there is the right side nonrecurrent laryngeal nerve. So as to effectively prevent the damage of nonrecurrent laryngeal nerve during thyroid surgery.
ObjectiveTo summarize our experience and clinical effect of surgical treatment of Stanford type A aortic dissection (TAAD) involving an aberrant right subclavian artery (ARSA). MethodsFrom March 2009 to January 2016, 14 patients with TAAD involving an ARSA (acute TAAD, n=10; chronic TAAD, n=4) underwent operation under hypothermic cardiopulmonary bypass combined with selective antegrade cerebral perfusion in our center. There were 11 male and 3 female patients with a mean age of 46.07±8.45 years. A total of 13 patients (13/14, 92.86%) underwent stented elephant trunk procedure combined with total arch replacement (Sun's procedure). The remaining patient (1/14, 7.14%) underwent partial aortic arch replacement combined with Bentall procedure without ARSA revascularization. ResultsThe average operation time, cardiopulmonary bypass time, aortic cross-clamping time and selective cerebral perfusion time was 7.89±1.80 h, 208.43±28.84 min, 117.64±23.30 min, and 30.50±10.15 min, respectively. No operation-related deaths occurred. However, two (14.29%) patients died on postoperative 5 d, 7 d, respectively in hospital. One patient required repeat thoracotomy for bleeding, one suffered temporary renal dysfunction and one renal failure (this patient had renal failure before surgery). The mean follow-up was 28.42±22.52 months with a follow-up rate of 100.00% (12/12). One patient died of heart failure and renal failure at 64 months after operation. The others were free from any aortic complications during follow-up. ConclusionsTAAD involving an ARSA should be clearly diagnosed before surgery, and treated by the optimal arterial cannulation and cerebral perfusion during operation. Repair of aortic dissection with Sun's procedure and revascularization of the ARSA can obtain satisfactory clinical outcomes in patients with TAAD involving an ARSA.
Objective To evaluate the short- and middle-term outcomes of surgical treatment for distal aortic arch lesions using stented elephant trunk implantation combined with transposition of left subclavian artery to left common carotid artery. Methods The clinical data of 14 patients with distal aortic arch lesions undergoing stented elephant trunk procedure with left subclavain artery transposition under hypothermic cardiopulmonary bypass (CPB) with antegrade selective cerebral perfusion from May 2009 to November 2015 in our hospital were retrospectively reviewed. All of them were males with a mean age of 52±14 years ranging from 20 to 69 years. Hypertension was observed in nine patients, coronary artery disease in five and prior cerebral infarction in one. History of percutaneous coronary intervention was noted in one patient, history of Bentall operation in one, ligation of patent ductus arteriosus in one and endovascular aneurysm repair in one. Results There was no hospital death. Concomitant procedures included coronary artery bypass grafting in two patients and plasty of the ascending aorta replacement in one. Mean duration of mechanical ventilation and ICU stay was 21±7 h and 43±19 h, respectively. All patients survived and were discharged. One patient was lost to follow-up and no patient died during the follow-up. Postoperative computed tomography revealed good patency of the anastomotic site between the left subclavian artery and the left common carotid artery. Conclusion Stented elephant trunk procedure with left subclavain artery transposition obtains satisfactory surgical results in patients with distal aortic arch lesions.
ObjectiveTo report a simple and safe method for in situ fenestration of left subclavian artery in thoracic endovascular aortic repair (TEVAR).MethodsTwenty-eight patients received in situ fenestration of left subclavian artery in TEVAR from June 2018 to May 2019 in our center, including 23 males and 5 females at an average age of 57.7±9.6 years. Among them, 12 patients used adjustable sheath or guiding catheter (a group A) and 16 patients used "J. D"technique (a group B). The clinical efficacy of the two groups was compared.ResultsIn the group A, 1 patient failed to receive fenestration and was transferred to the chimney technique. In the group B, 1 patient due to the traction system shift during operation, was completed by traditional adjustable sheath puncture. The group B had shorter alignment-perforation time and trigger time and less complications. There was no significant difference in endoleak during short-term follow-up between the two groups.ConclusionThe "J. D" technique is simple, safe and easy to obtain materials. It effectively reduces the risk caused by difficult sheath alignment during the in situ fenestration of the left subclavian artery. Although the results of recent follow-up are not significantly different from traditional methods, it still needs to accumulate the cases to observe the possible risks and difficulties.
ObjectiveTo investigate the efficacy of subclavian-carotid transposition (SCT) in treating patients with proximal subclavian artery occlusive diseases who were unable to be intervened, such as failure of intervention, congenital malformation and unwillingness to intervention.MethodsA retrospective review of 19 patients with proximal subclavian artery occlusion who underwent SCT from May 2016 to December 2018 was done. There were 14 males and 5 females with an average age of 54.05±17.34 years. The advantages and disadvantages of SCT in the treatment of proximal subclavian artery occlusion were analyzed.ResultsAll patients achieved immediate remission of symptoms after surgery. The stenosis degree of the proximal subclavian artery decreased from 100.0%±0.0% to 12.7%±10.1% after surgery. The average blood pressure difference between the unaffected side and the affected side decreased from 11.95±10.60 mm Hg to 0.89±5.75 mm Hg (P<0.01). Peripheral nerve injury occurred in 7 (36.8%) patients. The in-patient cost of subclavian artery occlusion patients who received subclavian artery interventional therapy in our hospital during the corresponding period was 3 392.12 yuan higher than that of the SCT group in average (if eliminating the patients whose cost was far from the average value, the cost of interventional therapy was 4 812.01 yuan higher than that of the SCT group in average). During 1-3 years' follow-up, 6 patients with neurological complication relieved. One- and three-year patency rates were 100.0%. No perioperative stroke, death or re-operation happened.ConclusionSCT is an ideal process for the patients with subclavian artery occlusion who cannot accept subclavian artery interventional therapy.
ObjectiveTo evaluate the early and mid-term safety of transcatheter aortic valve replacement via transfemoral (TF), transapical (TAp) and transsubclavian (TSc) approaches by meta-analysis.MethodsWe systematically searched the clinical comparative trials published from inception to June 2019 from PubMed, Web of Science, EMbase and The Cochrane Library, to evaluate the safety of transcatheter aortic valve replacement through TF, TAp or TSc approaches. The information of all-cause mortality at 30 days, 1 year, 2 years and the incidence of common complications at 30 days after operation (including pacemaker-dependent block, major vascular complications, severe bleeding events, acute renal injury and stroke) were exacted, and a meta-analysis was conducted by RevMan 5.3 software.ResultsThis study included 11 literatures, with a total of 7 833 patients, among whom 5 348 patients were treated by TF TAVR, 1 796 patients by TAp TAVR and 689 patients by TSc TAVR. The results of the meta-analysis were as follows: (1) at 30 days after operation, the mortality of TF and TSc approaches were lower than that of the TAp approach (TF vs. TAp: OR=0.57, 95%CI 0.39-0.84, P=0.004; TSc vs. TAp: OR=4.12, 95%CI 1.93-8.79, P=0.000 3). There was no statistical difference between the TF and TSc approaches (TF vs. TSc: OR=0.98, 95%CI 0.38-2.51, P=0.97); at 1 year, there was no statistical difference in mortality among the three approaches (P>0.05); at 2 years, there was no statistical difference between TSc and TF or TAp approaches (TF vs. TSc: OR=1.21, 95%CI 0.95-1.54, P=0.13; TSc vs. TAp: OR=1.02, 95%CI 0.76-1.36, P=0.91). (2) The incidence of acute kidney injury after TF approach was lower than that of the TAp approach (OR=0.30, 95%CI 0.22-0.41, P<0.000 01). (3) There was no statistical difference in major vascular complications between TSc and TF or TAp approaches (TF vs. TSc: OR=0.75, 95%CI 0.38-1.49, P=0.41; TSc vs. TAp: OR=1.37, 95%CI 0.56-3.32, P=0.49). (4) There was no statistical difference in severe bleeding events between TF and TSc (OR=0.97, 95%CI 0.53-1.76, P=0.92). (5) There was no statistical difference in the incidence of postoperative stroke, pacemaker dependent block among the three approaches (P>0.05).ConclusionTAp and TSc approaches are safe and effective. They are not only an alternative to TF approach, but also the first choice in some patients with poor condition of iliofemoral artery.