保守治疗：锁骨下动脉狭窄是动脉硬化性疾病（颈动脉、冠状动脉和下肢动脉）的标志和进一步心血管事件的发生。发现锁骨下动脉狭窄意味着病人将从二期预防措施中获益。保守治疗是锁骨下动脉狭窄初期最好的治疗。包括
这些措施的潜在重要性，通过2420例周围血管疾病中位随访时间为8年的前瞻性队列研究所证实。他汀类药物、β受体阻滞剂、阿司匹林和血管紧张素转化酶抑制剂可以显著地减少长期死亡率。 症状性锁骨下窃血的治疗方法根据临床情况而不同。很多病人无需治疗随时间的推移症状会得到改善。无症状的锁骨下狭窄/阻塞通常不是干预治疗的适应症。没有其它明显心脑血管疾病的病人，其近端锁骨下动脉溃疡性狭窄性病变可伴有栓塞并发症，外科[2]可以考虑切除或清除锁骨下动脉病变。经皮血管成形术或支撑架植入术（栓塞保护装置）对于近端锁骨下病变相关栓塞的病人是最合适的，特别是短病变的病人。如果经皮治疗可能危及或损害椎动脉的功能，是否应该外科治疗是值得商榷的事。病人拒绝手术或解剖不合适介入治疗可以考虑抗血小板治疗（或者口服抗凝药物），至少目前没有人前瞻性比较这一观点的优效性。 外科治疗：作为顽固性症状的病人可以考虑外科治疗，例如颈动脉-锁骨下动脉旁路移植术，颈动脉移位（carotid trensposition）等解剖外血管再通手术是最常见方法。整体开通率，一年内开通率为95%，三年为86%，五年为73%[3]。用对侧锁骨下或腋动脉比起应用颈动脉作为供血血管的手术五年开通率要低的多（46% vs 83% p＜0.01）。高外科风险的患者腋-腋搭桥是一个选择[4]。外科治疗锁骨下窃血综合征同时伴有颈动脉狭窄的病例是有争论的。因为锁骨下窃血综合征往往有很大比例的病人伴有严重的颅外动脉动脉硬化性病变，首先进行颈动脉斑块切除术就有潜在改善症状的可能性[ 血管内治疗：尽管资料有限，没有随机对照研究。回顾性的观察研究提示经皮血管内治疗对于有选择的病例，如近端锁骨下动脉阻塞或狭窄段比较短患者广泛被认为是症状性病人的首选治疗的安全和有效的治疗。技术成功率为93%，技术失败通常和不能通过阻塞病变有关[5，6]。五年开通率大约85%[6~9]。单纯扩张的效果比支撑架植入的效果差，特别是锁骨下动脉阻塞的病例[10~12]。经皮治疗中风和死亡相关并发症为3.6%[10]。 大样本、前瞻性、随机对照研究需要比较外科手术与血管内治疗之间的长期开放率。 1. Feringa HH, van Waning VH, Bax JJ, Elhendy A, Boersma E, Schouten O, Galal W, Vidakovic RV, Tangelder MJ, Poldermans D. Cardioprotective medication is associated with improved survival in patients with peripheral arterial disease. J Am Coll Cardiol. 2006 Mar 21;47(6):1182-7. 2. Walker PM, Paley D, Harris KA, Thompson A, Johnston KW. What determines the symptoms associated with subclavian artery occlusive disease? J Vasc Surg. 1985 Jan;2(1):154-7. 3. Salam TA, Lumsden AB, Smith RB 3rd. Subclavian artery revascularization: a decade of experience with extrathoracic bypass procedures. J Surg Res. 1994 May;56(5):387-92. 4. Chang JB, Stein TA, Liu JP, Dunn ME. Long-term results with axillo-axillary bypass grafts for symptomatic subclavian artery insufficiency. J Vasc Surg. 1997 Jan;25(1):173-8. 5. Hadjipetrou P, Cox S, Piemonte T, Eisenhauer A. Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels. J Am Coll Cardiol. 1999 Apr;33(5):1238-45. 6. Wang KQ, Wang ZG, Yang BZ, Yuan C, Zhang WD, Yuan B, Xing T, Song SH, Li T, Liao CJ, Zhang Y. Long-term results of endovascular therapy for proximal subclavian arterial obstructive lesions. Chin Med J (Engl). 2010 Jan 5;123(1):45-50. 7. Nguyen NH, Reeves F, Therasse E, Latour Y, Genest J Jr. Percutaneous transluminal angioplasty in coronary-internal thoracic-subclavian steal syndrome. Can J Cardiol. 1997 Mar;13(3):285-9. 8. Hadjipetrou P, Cox S, Piemonte T, Eisenhauer A. Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels. J Am Coll Cardiol. 1999 Apr;33(5):1238-45. 9. Mahmud E, Cavendish JJ, Salami A. Current treatment of peripheral arterial disease: role of percutaneous interventional therapies. J Am Coll Cardiol. 2007 Aug 7;50(6):473-90. Epub 2007 Jul 23. 10. De Vries JP, Jager LC, Van den Berg JC, Overtoom TT, Ackerstaff RG, Van de Pavoordt ED, Moll FL. Durability of percutaneous transluminal angioplasty for obstructive lesions of proximal subclavian artery: long-term results. J Vasc Surg. 2005 Jan;41(1):19-23. 11. Catheter-based treatment of the subclavian and innominate arteries. Catheter Cardiovasc Interv. 2008 Jun 1;71(7):963-8. 12. Sixt S, Rastan A, Schwarzwälder U, Bürgelin K, Noory E, Schwarz T, Beschorner U, Frank U, Müller C, Hauk M, Leppanen O, Hauswald K, Brantner R, Nazary T, Neumann FJ, Zeller T. Results after balloon angioplasty or stenting of atherosclerotic subclavian artery obstruction. Catheter Cardiovasc Interv. 2009 Feb 15;73(3):395-403. 13. Smith JM, Koury HI, Hafner CD, Welling RE. Subclavian steal syndrome. A review of 59 consecutive cases. J Cardiovasc Surg (Torino). 1994 Feb;35(1):11-4. |