一、手术名称：锁骨下动脉狭窄/闭塞的血管内介入治疗
Endovascular therapy of stenosis/occlusion in subclavian artery
二、术者介绍
（一）术者姓名：杨宁 （Ning Yang）
（二）、术者单位：北京协和医院放射科
Department of Radiology，Peking Union Medical College Hospital
（三）、术者科室：介入放射学组 Division of Interventional Radiology
（四）、术者简历：
 从事介入放射学和血管影像学工作超过30年。现为北京协和医院放射科主任医师。《介入放射学杂志》 、《中国介入影像与治疗学》杂志编委。参与国家“九五”、“十五”、“十一五”和“十二五”科技攻关项目。参与发表论文30余篇。参与国家和省市级科技奖励3项。
The operater engaged in interventional radiology and vascular imaging over 30 years. The professor of Radiologic Department of Peking Union Medical College Hospital. The Editorial board of four kind of magazine related interventional radiology in China. Participant of national science and technology program. As a participant has won three national and provincial and municipal science and Technology Award.
二、锁骨下动脉狭窄/闭塞血管内治疗的适应症和禁忌症
Indications and contraindications of intravascular therapy for subclavian artery stenosis / occlusion
（一）适应症：症状性锁骨下动脉阻塞性疾病
Indication：Symptomatic occlusive disease of subclavian artery
1. 椎基底动脉供血不足
vertebro-basilar artery insufficiency
2. 患侧上肢缺血
ischemia of affected upper limb
3. 锁骨下动脉盗血综合征
subclavian steal syndrome
（二）禁忌症：
1. 无法纠正的凝血功能障碍者
uncorectable coagulopathy
2. 无法耐受手术或无法仰卧者
poor general conditions or inability to lie on back
3. 透析无效的严重肾功能不全者
Severe non-dialysis dependent renal insufficiency
4. 全身感染者
Current systemic infections
5. 伴有活动性大动脉炎者
uncontrolled subclavian arteritis
三、术前影像学检查
（一） CT血管造影（CTA）或 MR血管造影（MRA ）
（二）必要时血管造造影 Diagnostic arteriography when recanalization of subclavian artery is decided
四、手术设备与器材准备
（一）配有数字减影血管造影机的介入手术室
A standard room for angiography equiped with digital subtraction angiography machine.
（二）各种造影导管
Directional catheter
（三）超滑等各种类型导丝 Hydrophilic guide wires
（四）直径 8，10, 12及 15mm球囊导管
Angioplasty balloon
（五）自膨式血管内支架或球扩式血管内支架
Self-expanding stent or Balloon-mounted stent
（六）覆膜血管内支架
Covered stent
（七）心电血氧监测设备
Hemodynamic pressure monitor
五、术前准备
（一）术前化验包括正常的INR，血清肌酐，血小板计数和活化部分凝血活酶时间;
Check Normalize INR, serum creatinine, platelet count,acivated PTT. （二）术前六小时禁食水 A clear liquid diet is recommended for at least 6 hours before the procedure.
（二）术晨进行必要的镇静评估与治疗
On the morning of the procedure, preconscious sedation evaluatiion should be performed.
（三）建立外周静脉通路
Peripheral intravenous access is required before the procedure.
（四）双侧腹股股沟区备皮
Both groins are shaved and prepped..
（五）插尿管
A bladdder catheter is routinely placed in patients in whom intervention is anticipated.
（六）口服阿司匹林和波立维：术前3-7天口服阿司匹林100mg/天和波立维75mg/天，以减少支架血栓形成机会和病变部位内生性血栓的清除。
Aspirin puls clopidogrel is administered to any patient not already taking the medication. Aspirin 100mg/day plus clopidogrel 75mg/day X 3 to 7days prior to procedure to reduce chance of stent thrombosis, and to assist in endogenous clearing thomobus on lesion.
（七）胰岛素依赖的糖尿病患者术晨应用胰岛素的的剂量为平时用量的一半。
Insulin-dependent diabetic should take half off their dose of insulin the morning of their procedure.
（八） 为预防造影剂肾病可于术前2-12 小时开始用生生理盐水以 1 mL/kg/hr 的用量进行水化，持续 24 小时。
Hydration with 0.9 % saline at 1 mL/kg/hr for 24 hours beginning at 2 to 12 hours before the procedure to protect the patients from contrast nephropathy.
（九）为预防造影剂过敏可于术前 12 小时及 2 小时口服甲甲基泼尼松龙龙 32 mg。 Oral methylpred nisolone 12 and 2 hours before contrast agent administration has been recommended to protect the patient from contrast allergy.
六、解剖要点
（一） 评估狭窄/ 闭塞病变的位置、范围和程度
evaluation the location, extent of stenosis and/ or occlusion
（二） 评估病变的性质，如是否有钙化及溃疡斑块等。
evaluation etiology of affected arteries and wether calcification of ulcerative plaque exists
七、手术体位及麻醉方式
（一）仰卧位 Supine
（二）麻醉方式：局部皮肤麻麻醉 Dermal anesthesia
八、手术步骤及方法
（一）入路选择：除非有动脉闭塞性病变或穿刺部位皮肤病变，通常选择右侧股动脉为最常用穿刺入路。或经股动脉路径未能建立锁骨下动脉扩张和支撑架植入通道时，可在超声引导下穿刺患侧肱动脉，建立逆行入路。
（一）Right common femoral artery access is most desirable excepting arterial or cutaneous lesions of puncture site. When the channel of subclavian artery dilation or stent implantation could not be created by the femoral artery approach, puncture of the ipsilateral brachial artery guided by ultrasound for establishment of retrograde path.
（二）诊断性血管造影 Diagnostic Arteriography
应用Pigtail造影导管进行全主动脉弓造影。为了显示整个病变及狭窄程度，造影时左侧锁骨下动脉病变需要左前斜30°~45°右侧锁骨下动脉需右前斜至少＞60°以上，特别是右锁骨下动脉开口病变。
A diagnostic arteriogram of the thoracic aorta is obtained via a pigtail catheter. In order to display the entire lesion and degree of stenosis, left anterior oblique 30°~45°projections may be helpful for the left subclavian artery lesions and right anterior oblique Greater than 60°at least or more for right subclavian artery, especially proximal lesion.
（三）过闭塞性病变技术
（1） 一旦决定进进行介入治疗疗应立即给予予充分肝素化化
Full anticoagulation is accomplished with intravenous heparin, as soon as the determination for endovascular treatment course is made.
（2） 应用方向可调导管及260cm超滑、超硬导丝开通通狭窄/ 闭塞塞段
Recanalization of stenosis/occlusion with directable catheters and 260-cm hydrophilic stiff guidewires.
（3）在猎人头导管支持下260-cm超滑超硬导丝通过锁骨下锁骨下动脉阻塞段后，5F导管经导丝也通过狭窄段进行血管造影以证实导管在远端锁骨下动脉真腔。
After headhunter catheter- based recanalization of the occlusive segment of subclavian artery with 260-cm hydrophilic guidewire，the 5F headhunter catheter is advanced over the guidewire and angiography is performed to approve the catheter is in true lumen of distant subclavian artery.
（4）5F导管经260-cm 导丝交换为8F 引导导管，并达到病变近端。
Exchange 5F catheter with 8F guiding catheter over 260-cm guidewire to proximal lesion.
（四） 球扩式支架置入入术 Stenting and balloon dilation
导丝通过阻塞病变后，在透视监视下，8-10mm直径，30-40mm长球扩支撑架沿导丝前进到病变处，并覆盖整个病变，然后经引导导管注射造影加以证实。
After the occlusion is traversed with a guidewire, under X-ray fluoroscopy 8mm diameter and 20mm long balloon-mounted stent which advanced over guidewire is properlly positioned to cover the entire lesion, after then the right place of stent should be proven by injection of contrast medium through guiding catheter.
开通成功后立即置入血管管内支架来覆覆盖整个病变变血管段并向球囊导管注射造影剂展开支撑架。
a stent is properlly positioned to cover the entire lesion and stent is unfolded by injection of contract median to balloon catheter applying high pressure.
（七）血管造影 Completion Angiogram
支架置入及球囊扩张后应进行血管造影影评估。评估内容包括动脉血流情况及是否有有远端动脉栓塞。注意加硬支撑导丝在手术结束前应始终保持跨越病变血管段。
After angioplasty or stent placement, a completion angiogram is mandatory to evaluate tthe result of revascularization of aorto-iliac artery and to exclude distal embolization. As in any case of endoovascular interventions, a guiidewire should be keept across the treated vessel until a satisfactory completion angiogram is obtained.
（八）拔出出导管及血管管鞘，加压包包扎或应用血血管缝合器器对血管入路路进行止血处处理。
On completion of the procedure, catheters and sheaths should be removed. Then hemostasis is performed by compression or blood vessel suture instrument.
九、手术并发症防范 锁骨下动脉支撑架植入术的并发症分为入路并发症，局部病变并发症和远处并发症。 Complication of stent implantation for subclavian artery include access, local lesion and remote complication. （一）入路并发症 access complication 相关入路并发症包括穿刺部位血肿，动脉的血栓、动脉瘤及动静脉瘘形成。穿刺局部并发症的表现从轻到重，整体发生率为2%-9%。严重病例需要外科手术。 Complication related to access include hematomas, thromboses, aneurysm and AVF. Access complications can present as multiple symptoms, from mild to severe. overall rate can range from 2 to 9%，with the most severe requiring possible operative intervention. （二）病变局部并发症：病变局部并发症包括动脉破裂和支架内急性血栓形成。 The target vessel complication of the lesion include , arterial rupture and acute thromboses in-stent. 当发生动脉破裂的时候，立即充盈球囊覆盖整个病变部位临时止血，然后植入覆膜支撑架永久止血。如果没效进行紧急外科手术。 When arterial rupture occurs, reinflation of the balloon cover the entire lesion should be performed immdiately in an attempt to temporarily tamponade the bleeding,then placement of a covered stent is done to stop the hemorrhage permanently. Surgery may be need urgently as it does not work. 支架内血栓形成非常罕见。术中充分抗凝以避免其发生。 Incidence of in-stent thrombosis after theprocedure is rare. Full anticoagulation should be accomplished during the procedure to avoid in-stent thrombosis. （三）远处并发症主要为病变处栓子脱落导致上肢动脉栓塞或椎动脉栓塞。Distal embolization Stroke can occur secondary to aortic arch or subclavian artery manipulation (transcatheter therapy to the right subclavian artery at a higher risk) or embolization/dissection of the vertebral artery. Gental traversal of guidewire is mandatory to avoid distal embolization. 十、术后处理要点 （一）绝对卧床至少6小时，密切观察病人生命和神经症状体征。 Under careful observation of vital and neurologic signs，Patients should be at least 6 hours in bed after procedure， （二）观察穿刺局部有无血肿和远端动脉搏动情况。测量双上肢血压，与术前和对侧比较 Check access site , peripheral Pulse and hematomas should carefully monitored。Bilateral arm BP and compare （三）测量双上肢血压，对患侧血压进行术前术后比较，并与对侧进行比较 BP measuring bilateral arm，and the arm which treated by stent implantation should be compared with the preoperation and contalateral side. （四）恢复双抗治疗和饮食 Resume or initiate dual antiplatelet regimen，and diet can be restart with clear liquids. （五）术后3个月，1年和2年定期随访观察 regular follow-up visits are repeated at 3, 12, 24 months. |