主动脉开放手术与血管腔内手术中左锁骨下动脉的处理

文献信息

中文摘要

背景： 主动脉弓手术中左锁骨下动脉（LSA）的处理因其解剖位置深在及潜在病理改变而较为复杂，可带来卒中、脊髓损伤和喉返神经损伤等风险。方法：本综述评估了当代主动脉弓开放手术与血管腔内治疗选择，以及由此涉及的LSA处理。结果：LSA血运重建在多种临床情形下至关重要，以维持椎动脉、脊髓和上肢的充分灌注，尤其适用于存在解剖变异、既往旁路手术或缺血风险增高的患者。在胸主动脉腔内修复（TEVAR）中覆盖LSA而不进行血运重建会显著增加卒中和脊髓缺血发生率。结论：冷冻象鼻（FET）、血管腔内策略（分支型和开窗型TEVAR）以及新兴的混合装置均为有价值的治疗方式，各有其优势和局限性，需加以理解以实现最佳的患者-假体匹配。基于病理、紧急程度和患者因素的个体化治疗选择对于优化结局至关重要。这一不断演变的范式整合了开放手术与血管腔内技术，以改善复杂主动脉弓疾病患者的诊疗。

英文摘要

Management of the left subclavian artery (LSA) during aortic arch surgery is complex due to its deep anatomical location and potential pathological alterations, posing risks such as stroke, spinal cord injury, and recurrent laryngeal nerve damage. Revascularization of the LSA is critical in various clinical scenarios to maintain adequate perfusion to the vertebral arteries, spinal cord, and upper limb, especially in patients with anatomical variations, prior bypass surgeries, or increased risk of ischemia. Coverage of the LSA during thoracic endovascular repair (TEVAR) without revascularization significantly increases stroke and spinal cord ischemia rates. We provided a narrative review, evaluating contemporary open and endovascular options for the treatment of the aortic arch, and consequently of the LSA. Frozen elephant trunk (FET), endovascular strategies (branched and fenestrated TEVAR), but also emerging hybrid devices, are all valuable treatments with respective strengths and limitations to be understood to obtain the best patient-prosthesis match. Individualized treatment selection based on pathology, urgency, and patient factors is essential to optimize outcomes. This evolving paradigm integrates open and endovascular techniques to enhance patient care in complex aortic arch disease.