陳文有　楊鋒彬　簡(jiǎn)紫微　李華芳　鄒耀祥

[摘要] 目的 探討鎖骨下動(dòng)脈瘤治療策略。 方法 回顧性分析解放軍第一七五醫(yī)院2015年6—12月右鎖骨下動(dòng)脈瘤患者2例，1例行腔內(nèi)動(dòng)脈瘤栓塞隔絕（患者A），1例行雜交手術(shù)（患者B），并學(xué)習(xí)相關(guān)文獻(xiàn)。 結(jié)果 2例動(dòng)脈瘤均血栓化，解決了動(dòng)脈瘤破裂出血的風(fēng)險(xiǎn)。行栓塞隔絕的患者A術(shù)后初期因?yàn)檠┎蛔闩几杏疑现αΓ纫粤嘀匚飼r(shí)明顯，半年后癥狀消失；患者B既解除了動(dòng)脈瘤破裂的警報(bào)，同時(shí)保證了右上肢及右椎動(dòng)脈的血供。 結(jié)論 右鎖骨下動(dòng)脈瘤的治療方式應(yīng)因人而異，根據(jù)患者的病情選擇適宜的治療方案，同時(shí)盡可能保證患肢及患側(cè)椎動(dòng)脈血供。

[關(guān)鍵詞] 右鎖骨下動(dòng)脈瘤；彈簧圈栓塞；腔內(nèi)隔絕；雜交手術(shù)

[中圖分類號(hào)] R445 [文獻(xiàn)標(biāo)識(shí)碼] A [文章編號(hào)] 1674-0742（2017）09（b）-0095-03

[Abstract] Objective This paper tries to investigate the subclavian artery aneurysm treatment strategy. Methods A retrospective analysis of the right subclavian artery aneurysm in 2 cases from June to December 2015 in this hospital was carried out， 1 case with endovascular embolization of aneurysms （patient A）， the other case with hybrid operation （patient B）， and related literature was studied. Results Two cases of aneurysms became thrombosis， solving the risk of aneurysm rupture. Patient A with right upper extremity with embolization felt weakness in early times after the operation due to insufficient blood supply， especially when lifting the heavy objects， 6 months later， the symptoms disappeared. Hybrid operation for patient B with aneurysms not only released the rupture alert， but also ensured blood supply of the right arm and right vertebral artery. Conclusion The treatment of aneurysm of the right subclavian should differ from person to person， according to the patients illness， the suitable treatment plan should be chosen. At the same time， blood supply of the limb and ipsilateral vertebral artery should be ensured as far as possible.

[Key words] Right subclavian artery； Embolism with spring coil； Isolated intracavity； Hybrid operation

鎖骨下動(dòng)脈瘤是一種外周動(dòng)脈瘤，以動(dòng)脈粥樣硬化、創(chuàng)傷為常見(jiàn)病因，分為真性動(dòng)脈瘤和假性動(dòng)脈瘤，假性動(dòng)脈瘤以右側(cè)鎖骨下動(dòng)脈較為多見(jiàn)，多為醫(yī)源性穿刺損傷造成。平時(shí)無(wú)特殊表現(xiàn)，若瘤內(nèi)血栓形成、栓子脫落造成上肢或腦動(dòng)脈栓塞以及動(dòng)脈瘤破裂或者壓迫周圍組織則可出現(xiàn)相應(yīng)臨床表現(xiàn)。若血栓脫落可引起肢體缺血、腦動(dòng)脈栓塞；動(dòng)脈瘤破裂則發(fā)生大出血，死亡率較高；若動(dòng)脈瘤壓迫臂神經(jīng)可出現(xiàn)上肢疼痛、功能障礙，壓迫喉返神經(jīng)則出現(xiàn)聲音嘶啞。故鎖骨下動(dòng)脈瘤一旦明確，應(yīng)及時(shí)處理。由于其特殊的解剖關(guān)系，常規(guī)開(kāi)放手術(shù)創(chuàng)傷較大。鎖骨下動(dòng)脈瘤選擇什么樣治療方式較為合適，以下就2015年6—12月該院2例右鎖骨下動(dòng)脈瘤患者進(jìn)行分析，現(xiàn)報(bào)道如下。

1 資料與方法

1.1 一般資料

病例1：吳某某，男，33歲，因“右頸部脹痛伴咳嗽、聲音嘶啞1月余”入院。查體：雙側(cè)橈動(dòng)脈搏動(dòng)正常，右鎖骨上可聞及血管雜音。入院后查CTA提示右鎖骨下動(dòng)脈瘤，動(dòng)脈瘤直徑約5.5 cm，距離右鎖骨下動(dòng)脈開(kāi)口約2 cm。

病例2：蔡某某，女，61歲，因左側(cè)肢體無(wú)力入院，既往有腦梗病史21年余，入院診斷為：復(fù)發(fā)性腦梗。入院后查CTA提示右鎖骨下動(dòng)脈瘤，動(dòng)脈瘤直徑約5 cm，距離右鎖骨下動(dòng)脈開(kāi)口約1.5 cm，雙側(cè)頸內(nèi)動(dòng)脈硬化閉塞，右側(cè)椎動(dòng)脈纖細(xì)，左側(cè)椎動(dòng)脈代償，明顯增粗。

1.2 治療方法

（1）患者A采取了右側(cè)鎖骨下動(dòng)脈彈簧圈栓塞（動(dòng)脈瘤遠(yuǎn)端）+頭臂干-右頸總動(dòng)脈腹膜支架植入術(shù)，具體步驟如下：①常規(guī)消毒，鋪無(wú)菌巾，局部麻醉下穿刺右股動(dòng)脈，置入5F導(dǎo)管鞘。②引入5F RH肝管至胸主動(dòng)脈。在0.035in黑泥鰍導(dǎo)絲引導(dǎo)下將5.0F 豬尾巴導(dǎo)管選入主動(dòng)脈造影：右側(cè)鎖骨下動(dòng)脈起始部見(jiàn)假性動(dòng)脈瘤，大小約為約5 cm×6 cm，距右鎖骨下動(dòng)脈開(kāi)口約2 cm，左側(cè)椎動(dòng)脈優(yōu)勢(shì)、顯影良好，開(kāi)口未見(jiàn)狹窄。交換超硬導(dǎo)絲，將10 mm×6 cm覆膜支架覆蓋于右側(cè)鎖骨下動(dòng)脈開(kāi)口。造影見(jiàn)：右鎖骨下動(dòng)脈瘤未顯示，且無(wú)內(nèi)漏。右頸內(nèi)動(dòng)脈血流通暢，右鎖骨下動(dòng)脈通過(guò)右椎動(dòng)脈倒流可見(jiàn)顯影。右上肢皮溫正常。③穿刺右肱動(dòng)脈，置入5F短鞘，置入單彎導(dǎo)管，將導(dǎo)管置右鎖骨下動(dòng)脈造影示：右側(cè)鎖骨下動(dòng)脈顯示，血流明顯減慢，鎖骨下動(dòng)脈遠(yuǎn)端血管通暢。密切透視下將5枚彈簧圈釋放于右鎖骨下動(dòng)脈瘤遠(yuǎn)端，再次造影：右側(cè)鎖骨下動(dòng)脈瘤未顯影。endprint