第一部分 特殊类型的近段锁骨下动脉瘤（Kommerell憩室）的

开放与腔内微创外科疗效对比研究：基于研究水平的Meta分析

摘   要

背景及目的 Kommerell憩室是一种特殊类型的锁骨下动脉瘤，与迷走锁骨下动脉相伴发生，可引发吞咽困难、呼吸困难等临床症状，并且可能出现Kommerell憩室合并主动脉瘤样扩张、夹层或破裂等危及生命的并发症。随着医疗技术的不断进步，Kommerell憩室的治疗方法也在不断发展，包括传统的开放手术和近年来兴起的血管腔内微创治疗。然而，关于这两种治疗方法在症状缓解及临床结局方面可能存在差异，对于干预方式的选择仍存在争议，目前尚缺乏系统的研究和证据。本研究旨在通过荟萃分析，对开放手术和腔内微创手术在Kommerell憩室治疗中的疗效进行比较，以期为临床决策提供更为科学、合理的依据。

方法 本研究遵循系统评价和Meta分析优先报告条目(Preferred Reporting Items for Systematic Reviews and Meta-analysis，PRISMA)报告指南，检索Pubmed、the Cochrane Library、中国知识基础设施工程（CNKI）和万方医学网数据库，以相关检索词进行系统检索，收集各数据库自建库至2023年7月21日符合要求的关于Kommerell憩室或迷走锁骨下动脉的外科及腔内治疗的研究。使用“Newcastle-Ottawa Scale(NOS)”队列研究量表对纳入研究质量进行评估。使用软件R，version 4.3.0对纳入研究进行Meta分析。对于主要终点，使用计算比值比(odds ratio，OR)及其95%置信区间和p值表示。采用χ²和I²检验评估统计学异质性。对以下数据指标进行了敏感性分析：早期死亡、晚期死亡、症状缓解、再次干预、Kommerell憩室根部直径、Kommerell憩室顶端至对侧主动脉壁的距离。由于可纳入的研究较少难以进行亚组分析，故本研究仅以纳入文献的发表年份为自变量对异质性数据进行了Meta回归分析。

结果 共纳入6篇符合标准的文献。基线资料方面，“开放组”对比“微创组”患者手术年龄的标准化均数差（SMD）为-0.84岁，两组存在显著统计学差异。主要关注结局方面，“开放组”与“微创组”的早期死亡率（OR=0.4276）、再干预率（OR=0.7622）、术后吞咽困难症状缓解率（OR=1.7770），中晚期死亡率（OR=0.5096）相比均没有统计学意义。在次要关注指标中，“开放组”与“微创组”相比，两组的总体住院时长没有统计学差异（随机效应模型：0.5135天；95%置信区间：–1.1928，2.2198；P=0.5553）。“开放组”与“微创组”相比，两组的Kommerell憩室根部直径（随机效应模型：-1.0582cm；95%置信区间：-6.6425，1.5260；P=0.422）及Kommerell憩室顶端至对侧主动脉壁的距离（随机效应模型：-1.1210cm；95%置信区间：-3.2334，0.9915；P=0.2983）均没有统计学差异，但纳入的三个研究存在高度异质性，且Kommerell憩室根部直径的报告可能存在发表偏移（P=0.0184）。根据Meta回归分析，结果表明发表年份不是导致中远期死亡（P=0.2736）和住院时长（P=0.7056）异质性的显著影响因素。

结论 本荟萃分析评估了基于目前研究现状的Kommerell憩室患者的不同手术干预策略的预后结果，结果提示“开放手术”和“微创手术”都是安全和有效的。

第二部分 特殊类型的近段锁骨下动脉瘤（Kommerell憩室）及其相关主动脉疾病外科治疗的临床结果研究：

单中心回顾性队列研究

摘   要

背景与目的 Kommerell憩室是与迷走锁骨下动脉相伴的一种特殊类型的近段锁骨下动脉瘤。尽管大部分患者无临床症状，但存在较高的主动脉破裂和主动脉夹层风险。本研究通过单中心回顾性研究探讨特殊类型的近段锁骨下动脉瘤（Kommerell憩室）的临床特征、治疗策略及远期预后，为临床决策提供有力支持。

方法 本研究通过病历系统采集了从2011年2月至2022年4月计算机断层扫描影像报告提示Kommerell憩室并在本院进行干预治疗的患者数据。本研究纳入18岁以上的成年Kommerell憩室患者共计76例，其中48例为合并主动脉夹层患者，28例为非主动脉夹层患者。本研究进行了标准化数据收集。对关注的术后早期结局变量及远期随访发生不良结局事件进行单因素及多因素logistic回归，每个模型计算比值比(odds ratio，OR)和95%置信区间(confidence intervals，CI)。对于合并主动脉夹层的患者进行了手术及术后情况的亚组分析。对纳入患者采用Kaplan-Meier法计算远期随访过程中的免于死亡率。

结果 本研究纳入病例的术后早期总死亡率为9.2%（7/76例），其中合并主动脉夹层组术后30天内死亡率为12.5%（6/48例），非合并夹层组术后30天内死亡率为3.6%（1/28例）。对于Kommerell憩室的两个评判指标（Kommerell憩室根部直径和Kommerell憩室至对侧主动脉壁距离）进行了不同的分组对比，发现夹层干预组的Kommerell憩室至对侧主动脉壁距离显著高于非夹层干预组（P=0.011），右位主动脉弓的Kommerell憩室大小明显大于左位主动脉弓（P=0.006）。左位主动脉弓更容易合并牛型主动脉弓的解剖变异（P=0.001）。右位主动脉弓组的迷走锁骨下动脉开口直径和迷走锁骨下动脉至对侧主动脉壁距离均显著高于左位主动脉弓组（P<0.001）。该研究纳入的全部患者的中位随访时间为4.0年。术前冠状动脉粥样硬化性心脏病被确定为是手术死亡相关的危险因素（OR=3.15，P=0.0163)。10例患者（13.2%）出现中枢神经系统并发症，4例患者（5.3%）出现呼吸系统并发症（其中合并夹层组包含的2例患者均因血管瘤压迫右主支气管导致肺部感染以及呼吸衰竭，最终导致术后30天内死亡）。合并主动脉夹层组术后3年、5年、7年的生存率分别为82.5%、79.7%、75.1%，非主动脉夹层组术后3年、5年、7年的生存率均为88.9%。术前迷走锁骨下动脉至对侧主动脉壁距离增加为发生随访期间不良终点事件的独立危险因素（OR=1.034，P=0.033)。

结论 对于这种特殊类型的近段锁骨下动脉瘤（Kommerell憩室）患者的治疗方案需要根据年龄、症状和影像表现等进行综合的评估，应注意右位主动脉弓合并Kommerell憩室患者的夹层动脉瘤与右主支气管的位置关系以及压迫情况。Kommerell憩室患者接受开放外科或血管腔内治疗后有可能因象鼻支架或膨大的瘤体压迫气管造成较差的治疗结局。发生主动脉夹层的Kommerell憩室患者的术后早期及远期随访生存率较低、术后并发症发生率较高。对于Kommerell憩室患者应考虑在主动脉夹层发生前尽早干预，一旦发生主动脉夹层需要根据患者自身因素，包括年龄、一般状况、夹层的类型和影像学特征进行个体化干预策略制定，以获得良好的结果。

第三部分 近段孤立性锁骨下动脉瘤的外科治疗结果：

单中心回顾性研究

摘   要

背景及目的 近段孤立性锁骨下动脉瘤（proximal isolated subclavian artery aneurysms, PISAAs）是一种极罕见的外周动脉瘤疾病，其发生率仅占外周动脉瘤的不到1%。其病因主要为动脉粥样硬化、创伤和继发于胸廓出口综合征的狭窄后扩张。以往的研究多以个案报道为主，目前缺乏系统性的临床研究和公认的治疗指南。本研究通过回顾性分析本中心8年来对于近段孤立性锁骨下动脉瘤治疗策略（经颈锁骨下动脉重建、经胸锁骨下动脉重建及腔内治疗）的经验，探讨PISAAs患者的手术治疗策略及临床预后。

方法 本研究回顾性分析了从2014年6月至2022年6月在我院接受不同治疗策略（经颈重建、经胸重建及血管腔内治疗）治疗的16例PISAAs患者。由于该疾病极为罕见，本研究为目前国际上有关近段孤立性锁骨下动脉瘤的最大样本量的临床研究。分类变量以频率和百分比表示，连续变量根据数据分布以平均值±标准差或中位数和四分位数间距（interquartile range：IQR 25%-75%）表示。连续变量采用t检验或Wilcoxon秩和检验，分类变量采用Fisher精确检验等统计方法，评估基线资料、手术相关资料、术后信息及长期随访情况。

结果 16例患者共计18处PISAAs在我院接受治疗。以接受的治疗方式不同分为：经颈锁骨下动脉重建、经胸锁骨下动脉重建及腔内治疗组。三组间基线资料无有统计学意义的组间差异。16例患者中，术前无症状患者5例（31.25%），有症状患者11例（68.75%），有症状的患者中4例就诊主诉为头晕（36.36%）。锁骨下动脉重建在经颈重建、经胸重建和腔内治疗中的成功率分别为100%、100%和83.33%。对于受累椎动脉，经颈重建、经胸重建、血管内治疗的重建率分别为80%、80%、0%。经胸重建的术中出血量显著高于经颈重建和腔内治疗（P<0.05）。经胸重建和经颈重建的总手术时间明显长于腔内治疗（P<0.05）。在术后呼吸机使用时间、术后总引流量、术后总引流时间、ICU时间方面，经胸重建术和经颈重建术均显著多于腔内治疗（P<0.05）。经颈锁骨下动脉重建组的平均住院费显著低于其余两组。三组患者围术期均未出现脑梗死、心肌梗死或死亡等严重并发症。经颈锁骨下动脉重建组中的3例患者和经胸锁骨下动脉重建组中的1例患者出现一过性Horner综合征，随访期间均有不同程度改善。

结论 PISAAs患者术前应进行完善的影像学检查，根据患者一般情况、锁骨下动脉瘤大小及受累椎动脉是否需要重建，推荐不同的手术治疗策略。对于动脉瘤直径>50mm的患者，建议进行经胸锁骨下动脉重建术。对于动脉瘤直径较大的患者应谨慎考虑血管腔内治疗。对于动脉瘤直径较小且需要重建受累椎动脉的患者，建议进行经颈锁骨下动脉重建术。

Comparison of Open and Minimally Invasive Surgical Efficacy for Kommerell's Diverticulum, a Special Type of Subclavian Artery Aneurysm: A Meta-analysis Based on Research Level

Abstract

Background and Objectives: Kommerell's diverticulum is a specific type of subclavian artery aneurysm, often concurrent with aberrant right subclavian artery, which can lead to clinical symptoms such as dysphagia, dyspnea, and potentially life-threatening complications including aneurysmal dilatation, dissection, or rupture. With continuous advancements in medical technology, treatment modalities for Kommerell's diverticulum have evolved, including traditional open surgery and the emerging minimally invasive endovascular therapy. However, discrepancies may exist between these two treatment modalities regarding symptom relief and clinical outcomes, thus generating controversy in intervention selection, with a lack of systematic research and evidence. This study aims to compare the efficacy of open surgery and endovascular minimally invasive surgery in the treatment of Kommerell's diverticulum through a meta-analysis, aiming to provide a more scientific and rational basis for clinical decision-making.

Methods: This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. PubMed, the Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang Medical Online databases were systematically searched using relevant keywords to collect studies on surgical and endovascular treatments for Kommerell's diverticulum or aberrant right subclavian artery from inception to July 21, 2023. The quality of included studies was assessed using the Newcastle-Ottawa Scale (NOS) for cohort studies. Meta-analysis was conducted using R software, version 4.3.0. For primary endpoints, odds ratios (ORs) with 95% confidence intervals (CIs) and p-values were calculated. Statistical heterogeneity was assessed using χ2 and I2 tests. Sensitivity analyses were performed for early mortality, late mortality, symptom relief, re-intervention, Kommerell's diverticulum root diameter, and distance from Kommerell's diverticulum apex to the contralateral aortic wall. Due to limited studies available for subgroup analysis, meta-regression analysis was conducted using the publication year of included studies as the independent variable for heterogeneity data.

Results: Six eligible studies were included. The standardized mean difference (SMD) of surgical age between the "open group" and "minimally invasive group" patients was -0.84 years, showing significant statistical difference between the two groups. There were no statistically significant differences between the "open group" and "minimally invasive group" in early mortality rate (OR=0.4276), re-intervention rate (OR=0.7622), postoperative dysphagia symptom relief rate (OR=1.7770), and late mortality rate (OR=0.5096). The overall length of hospital stay did not differ significantly between the two groups (random-effects model: 0.5135 days; 95% CI: –1.1928 to 2.2198; P=0.5553). Additionally, there were no statistically significant differences between the "open group" and "minimally invasive group" in Kommerell's diverticulum root diameter (random-effects model: -1.0582 cm; 95% CI: -6.6425 to 1.5260; P=0.422) and distance from Kommerell's diverticulum apex to the contralateral aortic wall (random-effects model: -1.1210 cm; 95% CI: -3.2334 to 0.9915; P=0.2983). However, three included studies exhibited high heterogeneity, and publication bias might exist in reporting Kommerell's diverticulum root diameter (P=0.0184). According to the meta-regression analysis, publication year was not a significant factor influencing heterogeneity in mid-to-long-term mortality (P=0.2736) and length of hospital stay (P=0.7056).

Conclusion: This meta-analysis evaluated the prognostic outcomes of different surgical interventions for Kommerell's diverticulum patients based on current research status, indicating that both "open surgery" and "minimally invasive surgery" are safe and effective.

Treatment and prognosis of aortic diseases related to Kommerell diverticulum: single-center retrospective cohort study

Abstract

Background and Objective: Kommerell's diverticulum is a special type of proximal subclavian artery aneurysm that is associated with the aberrant subclavian artery. Although most patients are asymptomatic, there is a high risk of aortic rupture and aortic dissection. This study aimed to investigate the clinical characteristics, treatment strategies, and long-term prognosis of this specific type of proximal subclavian artery aneurysm (Kommerell's diverticulum) through a single-center retrospective study, providing valuable support for clinical decision-making.

Methods: Patient data were collected from the medical records system from February 2011 to April 2022 for patients who had computer tomography scan reports indicating Kommerell's diverticulum and underwent intervention at our institution. A total of 76 adult patients aged 18 years and above with Kommerell's diverticulum were included in this study, of which 48 had concomitant aortic dissection and 28 without. Standardized data collection was performed. Univariate and multivariate logistic regression analyses were conducted for postoperative early outcome variables of interest and adverse outcome events during long-term follow-up, calculating odds ratios (ORs) and 95% confidence intervals (CIs) for each model. Subgroup analysis of surgical and postoperative conditions was performed for patients with concomitant aortic dissection. Kaplan-Meier analysis was used to calculate the survival rate during long-term follow-up for all included patients.

Results: The overall early postoperative mortality rate for the included cases in this study was 9.2% (7/76 cases), with a 30-day mortality rate of 12.5% (6/48 cases) for the group with concomitant aortic dissection and 3.6% (1/28 cases) for the non-aortic dissection group. Different grouping comparisons were made for the two evaluation indicators of Kommerell's diverticulum (root diameter and distance to the opposite aortic wall), revealing a significantly higher distance to the opposite aortic wall（DAW）in the aortic dissection intervention group compared to the non-dissection intervention group (P=0.011). The size of Kommerell's diverticulum in the right-sided aortic arch was significantly larger than in the left-sided aortic arch (P=0.006). The left-sided aortic arch was more prone to anatomical variations with a bovine-type aortic arch (P=0.001). The diameter of the aberrant subclavian artery opening and the distance to the contralateral aortic wall were significantly higher in the right-sided aortic arch group compared to the left-sided aortic arch group (P<0.001). The median follow-up time for all included patients in this study was 4.0 years. Preoperative coronary artery atherosclerotic heart disease was identified as a risk factor associated with surgical mortality (OR=3.15, P=0.0163). Central nervous system complications occurred in 10 patients (13.2%), and respiratory system complications occurred in 4 patients (5.3%), with both cases in the group with concomitant aortic dissection resulting in postoperative death within 30 days due to compression of the right main bronchus by the aneurysm, leading to lung infection and respiratory failure. The 3-year, 5-year, and 7-year survival rates for the group with concomitant aortic dissection were 82.5%, 79.7%, and 75.1%, respectively, while the survival rates for the non-aortic dissection group were all 88.9%. An increased distance from the Kommerell's diverticulum to the opposite aortic wall distance was identified as an independent risk factor for adverse endpoint events during follow-up (OR=1.034, P=0.033).

Conclusion: The treatment approach for patients with this specific type of proximal subclavian artery aneurysm (Kommerell's diverticulum) should be based on comprehensive evaluation including age, symptoms, and imaging findings. Attention should be paid to the relationship and compression of the aortic dissection with the right main bronchus in patients with Kommerell's diverticulum and a right-sided aortic arch. Adverse outcomes may occur due to tracheal compression by the elephant trunk stent graft or an enlarged aneurysm. Patients with Kommerell's diverticulum who develop aortic dissection have lower early and long-term survival rates and higher rates of postoperative complications. Early intervention should be considered for patients with Kommerell's diverticulum before the occurrence of aortic dissection. Once aortic dissection occurs, individualized intervention strategies should be formulated based on patient factors, including age, general condition, type of dissection, and imaging characteristics, to achieve favorable outcomes.

Surgical outcome of proximal isolated subclavian artery aneurysms:

A single-center retrospective observational study

Abstract

Background and Objectives: Proximal isolated subclavian artery aneurysms (PISAAs) are an extremely rare peripheral arterial disease, accounting for less than 1% of peripheral artery aneurysms. The etiology primarily includes atherosclerosis, trauma, and post-stenotic dilatation secondary to thoracic outlet syndrome. Previous studies have mainly relied on case reports, lacking systematic clinical research and recognized treatment guidelines. This study aims to explore the surgical treatment strategies and clinical outcomes of PISAAs patients through a retrospective analysis of the treatment experience for PISAAs over 8 years at our center, including neck subclavian artery reconstruction, chest subclavian artery reconstruction, and endovascular treatment.

Methods: This retrospective study analyzed 16 patients with PISAAs who underwent different treatment strategies (neck reconstruction, chest reconstruction, and endovascular treatment) at our hospital from June 2014 to June 2022. Due to the extreme rarity of this disease, this study represents the largest clinical study sample size of PISAAs currently available internationally. Categorical variables were expressed as frequencies and percentages, while continuous variables were presented as means ± standard deviations or medians with interquartile ranges (IQR 25%-75%) depending on data distribution. Continuous variables were analyzed using t-tests or Wilcoxon rank-sum tests, and categorical variables were assessed using statistical methods such as Fisher's exact test, evaluating baseline data, surgical-related information, postoperative details, and long-term follow-up.

Results: A total of 16 patients with 18 PISAAs were treated at our hospital. They were categorized into groups based on different treatment modalities: neck subclavian artery reconstruction, chest subclavian artery reconstruction, and endovascular treatment groups. There were no statistically significant intergroup differences in baseline data. Among the 16 patients, 5 (31.25%) were asymptomatic preoperatively, while 11 (68.75%) presented with symptoms, with dizziness being the chief complaint in 4 symptomatic patients (36.36%). The success rates of subclavian artery reconstruction in neck, chest, and endovascular treatments were 100%, 100%, and 83.33%, respectively. The reconstruction rates for affected vertebral arteries in neck, chest, and endovascular treatments were 80%, 80%, and 0%, respectively. Intraoperative blood loss was significantly higher in chest reconstruction than in neck reconstruction and endovascular treatment (P < 0.05). Total surgical time for chest and neck reconstructions was significantly longer than for endovascular treatment (P < 0.05). Regarding postoperative ventilator use time, total drainage volume, total drainage time, and ICU stay, both chest and neck reconstructions were significantly longer than endovascular treatment (P < 0.05). The average hospitalization cost in the neck subclavian artery reconstruction group was significantly lower than in the other two groups. There were no occurrences of severe complications such as stroke, myocardial infarction, or death in any of the three groups perioperatively. Three patients in the neck subclavian artery reconstruction group and one patient in the chest subclavian artery reconstruction group experienced transient Horner's syndrome, all showing varying degrees of improvement during follow-up.

Conclusion: Patients with PISAAs should undergo comprehensive imaging examinations preoperatively. Different surgical treatment strategies are recommended based on patient's general condition, aneurysm size, and the need for reconstruction of affected vertebral arteries. For patients with aneurysm diameter >50mm, chest subclavian artery reconstruction is recommended. Endovascular treatment should be cautiously considered for patients with larger aneurysms. Neck subclavian artery reconstruction is recommended for patients requiring reconstruction of affected vertebral arteries.