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O p e rat i ve Te c h n i q u e s i n

6 Va sc u l a r S u rg e ry

A rc h a n d G re a t Ve s s e l R e c o n s t r u ct i o n w i t h
D e b ra n c h i n g Te c h n i q u e s 1 804
W. A n th o ny L e e a n d A lexa n de r Ku lik

Extrat h o ra c i c Reva s c u l a r i zat i o n


(Ca rot i d-Ca rot i d, Ca rot i d-S u b c l av i a n
B y p a s s a n d Tra n s p o s i t i o n ) 1810
Edwa rd Y. Wo o a n d Sco tt M. D a m ra u e r

Ca rot i d S u rg e ry :
I n t e r p o s i t i o n/E n d a rt e re cto m y
( I n c l u d i n g E v e rs i o n ) /L i g a t i o n 1818
Vin it N. Va ru a n d We i Zh o u

Ca rot i d S u rg e ry : B i f u rcat i o n Ste n t i n g w i t h


D i sta l P rotect i o n 1 82 1
Zh e n S . H u a n g a n d D a rren B . Sch n e ider

. .

Ca rot i d S u rg e ry : D i sta l E x p o s u re a n d
C o n t ro l Te c h n i q u e s a n d Co m p l i ca t i o n
M a n a g e m e nt 1 83 7
Ch e o n g J. L e e

Ve rt e b r a l Tra n s p o s i t i o n Te c h n i q u e s
a n d Ste n t i n g 1 843
Ma rk D . M o rasch

N e u ro g e n i c T h o ra c i c O u t l et S yn d ro m e
E x po s u re a n d D e co m p re s s i o n :
S u p ra c l a v i c u l a r 1 84 8
R o b e rt W. Th o mp s o n a n d Ch a n du Ve m u ri
N e u ro g e n i c T h o ra c i c O u t l et S y n d ro m e
E x po s u re a n d D e c o m p re s s i o n :
Tra n s a x i l l a ry 7 8 62
G e o rg e J. A rn a o u ta kis, Th o m a s R e ifsnyde r, a n d Julie A n n Fre ischlag

Ve n o u s a n d Arte r i a l T h o ra c i c O u t l et
S y n d ro m e 7 8 69
Ja s o n T. L e e

P rox i m a l to t h e Wr i st : U p p e r Extre m i ty
Reco n s t r u ct i o n/Revas c u l a r i za t i o n 7 877
M o h a m e d A . Zaye d a n d R o n a ld L . D a l m a n

U p p e r Extre m i ty A rte r i a l R e c o n st r u ct i o n
a n d Reva s c u l a r i za t i o n D i sta l
to t h e W r i st 7 894
Mich a e l G . Ga lvez a n d Ja m es Ch a n g

E x po s u re a n d O p e n S u rg i ca l
Reco n st r u ct i o n i n t h e C h e s t :
T h e T h o ra c o a b d o m i n a l A o rta 7 9 02
G e rm a n o M e lissa n o, Efrem Civilin i, En rico R i n a ldi,

a n d R o b e rto Chiesa

T h o ra c i c A o rt i c S t e n t - G raft R e p a i r fo r
A n e u ry s m . D i s s e ct i o n , a n d Tra u m a t i c
Tra n s e ct i o n 797o
B ra n t W. Ullery a n d Ja s o n T. L e e

E x po s u re a n d O p e n S u rg i ca l M a n a g e m e n t
at t h e D i a p h ra g m 7 92 7
Peter H. U. L e e a n d R a m in E. B eyg u i

R e t ro p e r i t o n e a l A o rt i c E x p o s u re 7 92 6
Ma tth e w M e l /

H y b r i d R e v a sc u l a r i za t i o n S t r a t e g i e s fo r
V i sce ra l/Re n a l A rte r i e s 7 93 1
B e nja m in W. S ta rn es
Snorkel/Chimney and Periscope Visceral
Revascularization During Complex
Endovascular Aneurysm Repair 1939
Jason T. Lee and Ronald L. Dalman

Branched and Fenestrated Endovascular


Stent Graft Techniques 1948
Gustavo 5. Oderich and Karina 5. Kanamori

Stenting, Endografting, and Embolization


Techniques: Celiac, Mesenteric, Splenic,
Hepatic, and Renal Artery Disease
Management 7959
Mohamed A. Zayed and Ronald L. Dalman

Visceral Reconstruction to Facilitate


Cancer Management: Celiac, Mesenteric,
Splenic, Hepatic and Renal Artery Disease
Management 1972
Mohamed A. Zayed and E. John Harris, Jr.

Hepatic- and Splenic-Based Renal


Revascularization 1986
Fred Weaver, Sung Wan Ham, and Grace Huang

. .

Advanced Aneurysm Management


Techniques: Open Surgical Anatomy
and Repair 7995
Elizabeth Blazick and Mark F. Conrad

Advanced Aortic Aneurysm Management:


Endovascular Aneurysm Repair-Standard
and Emergency Management 2006
Vinit N. Varu and Ronald L. Dalman

Advanced Aneurysm Management


Techniques: Management of Internal Iliac
Aneurysm Disease 2015
W. Anthony Lee
Occlusive Disease Management: Isolated
Femoral Reconstruction, Aortofemoral
Open Reconstruction, and Aortoiliac
Reconstruction with Femoral Crossover for
Limb Salvage 2024
Nathan /toga and E. John Harris, Jr.

Occlusive Disease Management:


Iliac Angioplasty and Femoral
Endarterectomy 2034
Venita Chandra

Management of the Infected


Femoral Graft 2044
Matthew Mel/

Surgical Exposure of the


Lower Extremity Arteries 2050
Luke X. Zhan and Joseph L. Mills, Sr.

Percutaneous Femoral-Popliteal
Reconstruction Techniques:
Reentry Devices 2061
Daniel/e E. Cafasso and Peter A. Schneider

Percutaneous Femoral-Popliteal
Reconstruction Techniques: Antegrade
Approaches 2068
F. Gallardo Pedrajas and Peter A. Schneider

Maximizing Vein Conduit for


Autogenous Bypass 2082
Gregory J. Landry

T ibial Interventions: Tibial-Specific


Angioplasty Considerations and
Retrograde Approaches 2092
Georges E. AI Khoury and Rabih A. Chaer
Perimalleolar Bypass and Hybrid
Techniques 2105
Geetha Jeyabalan and Rabih A. Chaer

Acute Iliofemoral Deep Vein Thrombosis


and May-Thurner Syndrome: Surgical and
lnterventional Management 2116
Sharon C. Kiang And Brian G. DeRubertis
-

Arch and Great Vessel


Chapter 1 Reconstruction with
I
Debranching Techniques
- ----------------------------------- � ----------------------------------------------------- �

W Anthony Lee Alexander Kulik

DEFINITION IMAGING AND OTHER DIAGNOSTIC


• An aortic arch aneurysm is defined as dilation of the aortic STUDIES
arch to greater than 5 em in diameter. Rarely occurring in • Although a routine chest x-ray may be the first imaging test to
isolation, aneurysms of the aortic arch are often extensions note an aortic arch abnormality, further imaging is necessary,
of aneurysms present in the ascending or descending aorta. including a CT scan of the aorta ( FIG 1 ) and an echocardiogram.
Causes of aortic arch aneurysms included atherosclerotic • An arterial phase CT angiogram should evaluate the entire
degeneration, cystic medial degeneration, aortic dissection, length of the aorta, from the level of the skull base proxi­
congenital aortopathy (i.e., bicuspid aortic valve), penetrat­ mally to the femoral heads distally, to ensure visualization of
ing aortic ulcer, previous traumatic transection (chronic the vertebral and iliofemoral arteries, respectively. The CT
pseudoaneurysm) , and previously repaired aortic coarcta­ images are then processed using 3D imaging software for
tion (postsurgical pseudoaneurysm) . Aortic arch aneurysms case planning and device selection. A magnetic resonance
have traditionally been repaired with graft replacement of imaging (MRI) or a noncontrast CT scan will not suffice.
the aorta, with or without an elephant trunk, using car­ • A transthoracic (2D) echocardiogram should be performed
diopulmonary bypass and deep hypothermic circulatory to assess left and right ventricular function and to exclude
arrest. With the advent of thoracic endovascular aortic re­ the presence of significant valvular heart disease.
pair (TEVAR), debranching of the brachiocephalic vessels • Strong consideration should be given to evaluating the
is a recently developed technique that takes advantage of anatomy of the coronary arteries in the preoperative period.
the reduced surgical trauma associated with stent grafting. 1 A CT coronary angiogram may be an option for younger
Debranching functionally extends the proximal landing patients or those with complex proximal aortic dissection.
zone by repositioning the inflow of the brachiocephalic ar­ However, if there is a strong suspicion of coronary disease,
teries toward the proximal ascending aorta. This facilitates then a preoperative conventional coronary angiogram
endovascular stent graft repair of the aortic aneurysm by should be performed, including those patients older than
allowing stent coverage across the ostia of the arch vessels, 40 years of age and those with a history of smoking.
producing a stable and fixed proximal landing zone in the
ascending aorta. SURGICAL MANAGEMENT

PATIENT HISTORY AND PHYSICAL Preoperative Planning

FINDINGS • Indications for repair of an aortic arch aneurysm include


large aneurysmal size ( > 5.5 em), rapid growth ( > 0.5 em per
• Aortic arch aneurysms are usually diagnosed as incidental
year), the presence of chest pain or back pain unexplained
findings noted on imaging studies, such as a chest x-ray or
by other causes, and compression of adjacent organs (esoph­
computed tomography ( CT) scan, to evaluate other concur­
agus, trachea, or left main bronchus).2
rent medical conditions.
• More aggressive size criteria may be applied for patients
• Most patients have no symptoms from their aneurysms.
with Marfan's syndrome (repair at 4.5 to 5 em) . However,
Symptoms, if they exist, may include chest or back pain from
stent graft outcomes appear less favorable in patients with
aneurysmal growth or those associated with compression of
adj acent structures (i.e., trachea, esophagus ) . Hoarseness
may develop from stretching of the left recurrent laryngeal
nerve (Ortner's syndrome) . Acute chest or back pain, with
or without signs of shock, should raise the suspicion of im­
pending aortic rupture and/or acute aortic dissection. Ad­
ditional details regarding a patient's past medical history
should be gathered, including a history of previous coronary
intervention, previous cardiac surgery, known valvular heart
disease, previous aneurysm surgery, or a family history of
aortopathy.
• The physical examination is often unremarkable. However,
attention should be directed to the presence of aortic valve
insufficiency ( diastolic murmur, widened pulse pressure) ,
previous surgical incisions, a n d the presence of concomitant FIG 1 • Preope rative c omputed tom ography (CT) a n g iogram of
peripheral vascular disease. an a o rtic a rch a n e u rysm .

1804
C h a p t e r 1 ARCH A N D G REAT V E S S E L R E C O N STRUCTI O N WITH D E B RA N C H I N G TEC H N I Q U E S 1805

connective tissue disease, and therefore, alternative surgical arch origin o f left vertebral artery, a n d a n aberrant right sub­
techniques ( such as conventional aortic replacement sur­ cia vi an artery.
gery) should be considered.2 • The ascending aorta is typically 6 to 7 em in length from the
• The presence of significant concurrent cardiac disease may sinotubular j unction to the innominate artery. Placement of
alter the surgical approach. Should significant coronary ar­ the proximal inflow anastomosis as low as possible on the
tery or valvular heart disease be identified in the preoperative ascending aorta (j ust distal to the sinotubular j unction) will
period, consideration may be given to performing concomi­ result in an optimal 3- to 4-cm proximal landing zone for
tant coronary artery bypass grafting ( CABG) or valve re­ the stent graft repair. The largest currently available thoracic
placement at the time of the aortic de branching procedure. stent grafts are 42 to 46 mm in diameter. To provide a safe
• During the second stage of the arch repair, stem graft deploy­ and durable proximal landing zone and avoid a proximal
ment in the distal ascending aorta may require the placement type I endoleak, we recommend replacement of an ascend­
of a guidewire across the aortic valve into the left ventricular ing aorta that is extremely short or if its diameter is 36 mm
cavity. The presence of a mechanical aortic prosthetic valve, or larger. Open replacement of the ascending aorta would
through which a guidewire and the delivery system cannot safely be performed at the time of the arch debranching procedure,
be placed, may require a single-stage approach with deployment with implantation of an aortic graft 34 mm or smaller.
of the stent graft at the time of debranching (see endovascular • The size of the iliofemoral arteries is worth noting on the pre­
second stage) . A bioprosthetic valve in the aortic position may operative CT study. The external iliac arteries need to be larger
allow for careful transvalvular introduction of devices, with than 7 mm in diameter to provide adequate vascular access
preference to bovine pericardia! valves over porcine valves. to deliver the stent graft devices during the second stage. An
• Selection of the ideal treatment strategy for repair of an aor­ iliac artery conduit may be needed if the iliofemoral arteries
tic arch aneurysm remains controversial and is dictated by are extremely small or in the presence of severe calcification
surgical experience and local area expertise. Aortic arch deb­ and occlusive disease. Alternatively, a single-stage antegrade
ranching and stent graft completion is an appealing repair introduction of the stent graft from the ascending aorta may
option that avoids a thoracotomy incision and may avert be performed (see endovascular second stage) to avoid access
the use of cardiopulmonary bypass and circulatory arrest. problems from a retrograde iliofemoral approach.
These types of hybrid procedures may be performed either as • The diameters of the brachiocephalic arteries are measured
single- or two-stage repairs. However, conventional open re­ on the preoperative CT scan to determine the interposition
placement of the entire aortic arch/·4 or replacement of the graft sizes for the debranching procedure. Most frequently,
ascending aorta and proximal arch with the creation of an the size of the graft chosen for the innominate artery branch
elephant trunk followed by stent graft completion/·5 should is 10 to 1 4 mm, with 6- to 8-mm grafts usually used for the
be considered as clinically indicated. left carotid and left subclavian arteries.
• Debranching of the aortic arch off the ascending aorta may • Cerebral oximetry monitoring may be helpful for the aortic
not be applicable for a patient with an aortic arch aneurysm debranching procedure to monitor brain perfusion before
who has previously undergone cardiac surgery and who is and after clamping of the brachiocephalic arteries. For the
too high-risk for consideration of redo sternotomy. In this second-stage endovascular procedure, cerebrospinal fluid
case, an alternative option would include extra-anatomic ( CSF) drains are placed preoperatively to reduce the risk of
debranching of the aortic arch (carotid-carotid, carotid­ spinal cord ischemia if a significant length of the descending
subclavian) followed by stent graft repair of the arch, with thoracic aorta is to be covered.
or without innominate artery chimney (snorkel) stenting.6
• The preoperative CT scan requires careful review before
Positioning
undertaking an aortic arch debranching operation. Arch
branch anatomy and appropriate landing zones need to be • For the arch debranching procedure, patients are positioned
identified proximal and distal to the arch aneurysm, with supine j ust as they are during standard cardiac surgical op­
criteria similar to those that apply for stent graft repair of a erations. Prepping is performed from the neck to the knees,
descending thoracic aortic aneurysm. Anatomic variations with draping higher than usual to strategically provide ac­
of the aortic arch anatomy may require modification of the cess to the lower neck. The head may be turned slightly to
debranching procedure. These include a bovine aortic arch the right to facilitate extension of the sternotomy incision
(common trunk of the innominate and left common carotid), proximally along the left sternocleidomastoid muscle.

AORTIC ARCH DE B RANCH I N G c l a m p . The space b etwe e n the l eft s i d e of the a o rta
and t h e p u l m o n a ry a rtery i s d i ssected, with s m a l l ves­
• Alth o u g h some a dvocate the use of a r i g ht tho racotomy sels cauterized o r c l i p p e d and d i v i d e d . The a sce n d ­
i n c i s i o n o r u p p e r h e m i sternotomy, we p refer to expose i n g a o rta i s m o b i l ized p roxi m a l l y d o w n to t h e l evel
the asce n d i n g a o rta through a convent i o n a l ste rnotomy of t h e a o rt i c root (si n otu b u l a r j u n ct i o n ) to e n a b l e
i n c i s i o n . This provides opti m a l visu a l ization and contro l . i d e ntificat i o n (a n d avo i d i n j u ry) to t h e r i g h t c o ro n a ry
T h e pericard i u m is i n c ised a n d retracted . a rte ry.
• T h e asce n d i n g a o rta is ca refu l l y m o b i l ized to fac i l itate • The brach ioce p h a l i c a rteries a re c i rcu mferentia l ly ex­
l ater p l a ce m e n t of a proxi m a l l y posit i o n e d s i d e - b i t i n g pose d . The i n n o m i nate ve i n is m o b i l ized a n d retracted
1806 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

with an u m b i l ica l tape to fac i l itate expos u re of the 8mm


a rch vessels (FIG 2) . U n common ly, the i n no m i nate
ve i n req u i res l i g ation and d ivision to aid i n a rch expo­
sure. The l eft s u bclavian a rtery i s often more poste rior
than expected, and exposu re of this a rtery may be d if­
ficult. In th ese circumstances, the ste rnotomy i n c ision
may be exte nded su periorly and l eftwa rd a long the
ste rnoc l e i domastoi d m u sc l e . Alternatively, i n no m i nate
and l eft caroti d d e b ra n c h i n g may be com b i ned with a
l eft carotid-s u bclavian bypa ss/transposition p roce d u re,
t h ro u g h a sta n d a rd s u p raclavicu l a r a p p roach, obviat i n g
the n e e d t o expose the l eft s u b c l a v i a n a rtery t h ro u g h t h e
ste rnotomy.
• Altho u g h a p reformed bifu rcated or m u lti l i m b g raft may
be used, th ese occ u py a l a rge footprint and reduce the
l e n gth ava i l a b l e for the asce n d i n g aortic l a n d i n g zone.
I nstead, we p refer to construct a Y-g raft by sew i n g a bev­
eled s m a l l e r Dacron g raft e n d -to-s ide to l a rger Dacron
g raft (FIG 3) . The g raft sizes a re sel ected based on the
measu red d i a m eters from the p reoperative CT sca n . Typ i ­
cal ly, a 1 0- or 1 2- m m g raft is u s e d f o r the i n nom i n ate a r­
tery, a n d a 6- or 8-mm g raft is used for the l eft caroti d
a rte ry.
• H e p a r i n is a d m i n i stered to a c h i eve a n a ctivated c l ot­
t i n g t i m e (ACT) of 200 secon d s . The b lood press u re FIG 3 • A Y-g raft i s constructed by sew i n g a beveled s m a l l e r
is lowe red to 90 m m H g systo l i c, a n d a n aort i c s i d e ­ Dacron graft (6 t o 8 m m ) e n d -to-s i d e t o l a rg e r Dacron g raft
b i t i n g c l a m p i s p l aced o n t h e r i g ht a ntero l atera l s i d e ( 1 0 to 1 2 m m ) .
(convexity) o f t h e asce n d i n g aorta, a s l o w as poss i b l e,
with care not to com p ro m i se t h e r i g h t coro n a ry a rte ry.

A ret raction s u t u r e i n t h e r i g h t atr i a l a p p e n d a g e m a y


be n e e d e d t o fa c i l itate p roxi m a l aort i c expos u re . C o n ­
s i d e ration m a y be g iven t o p e rfo rm i n g t h i s a n d s u b ­
seq u e nt ste ps i n t h e o p e r a t i o n with c a r d i op u l m o n a ry
bypass to p rov i d e opti m a l h e modyn a m i c control d u r­
i n g c l a m p a p p l ication a n d remova l a n d to i m p rove
b ra i n p rotect ion with syste m i c coo l i n g in the ra n g e of
32°C to 34°C.
• The p roxi m a l e n d of the l a rg e r (1 0 or 1 2 m m ) g raft is cut
to the a p prop r i ate l e n gth so the Y-g raft easily reaches
the a rc h vesse l s . The g raft is beve led and sewn e n d -to­
s i d e to the asce n d i n g aorta with a r u n n i n g 3-0 or 4-0
polypropy l e n e sutu re (FIG 4) . B ioG i u e may be a p p l ied
to f u rt h e r s u p port the a n a stomos is. The aort i c clamp i s
g e ntly released . A l a rg e c l i p may be p l aced a c ross the
h e e l of the a n a stomosis. T h i s wi l l help visu a l ize the ori­
gin of t h e d e b r a n c h i n g g ra ft from the asce n d i n g aorta
a n d precisely d efi n e the p roxi m a l l a n d i n g zone without
the need for contrast d u r i n g the seco n d -sta g e e n d ovas­
c u l a r p roced u re .
• The i n nom i n ate a rte ry is tra nsected, a n d the p rox i m a l
e n d is ove rsewn w i t h two l ayers o f 4-0 polypropy l e n e .
The d i sta l l a rg e e n d o f the Y-g raft is then t u n neled u n ­
derneath the i n no m i n ate ve i n a n d sewn end-to-e n d to
the i n nom i n ate a rtery with ru n n i n g 5-0 polypropylene
(FIG 5) .
FIG 2 • After ste rnotomy, the pericard i u m is i n cised
a n d retracte d . The asce n d i n g aorta is mob i l ized, a n d the
• N ext, t h e l eft com mon ca rot i d a rtery is transected, a n d
brach ioce p h a l i c a rteries a re ci rcumferentia l ly exposed. The the p rox i m a l e n d o f the ca rot i d a rtery is oversewn with
i n no m i nate ve i n is mobil ized a n d retracted with a n u m b i l i ca l 4-0 polypropy l e n e . The d i sta l s m a l l e r e n d of the Y-g raft
tape to fac i l itate expos u re of the a rch vesse l s . is t u n n e l e d u n d e rneath the i n nom i n ate ve i n a n d sewn
C h a p t e r 1 ARCH A N D G REAT V E S S E L R E C O N STRUCTI O N WITH D E B RA N C H I N G TEC H N I Q U E S 1807

FIG 4 • An aortic side-biti n g c l a m p is p l aced on the right FIG 6 • T h e l eft com mo n c a rot i d a rtery is tra n sected,
a nterol ate ral s i d e (convexity) of the ascen d i n g aorta, as low and t h e p rox i m a l end of the c a rot i d a rtery i s ove rsewn
as poss i b l e . The p roxi m a l end of the l a rg e r ( 1 0 or 1 2 mm) g raft with 4-0 polypropy l e n e . T h e d i st a l s m a l l e r end of the
is beve led a n d sewn e n d -to-si d e to the asce n d i n g aorta with a Y-g ra ft i s t u n n e l e d u n d e rn eath t h e i n nom i nate ve i n a n d
r u n n i n g 3-0 or 4-0 polypropylene suture. sewn e n d -to- e n d t o t h e ca rot i d a rtery w i t h r u n n i n g 5-0
polypropy l e n e .

Innom inate vein

Innominate artery e n d -to-e n d to t h e c a rot i d a rtery with r u n n i n g 5-0 poly­


p ropy l e n e (FIG 6) .
• A t t h i s poi nt, a decision needs t o be made reg a rd i n g
t h e d e b ra n c h i n g strategy for t h e l eft subclavian a rte ry.
I n d ications for l eft subclavian revasc u l a ri zation a re
controve rsia l . Rout i n e versus sel ective strate g i es may
be adopte d .' If the l eft subclavian a rte ry needs to be
revasc u l a rized but can not safe ly be exposed, a ca rotid­
subclavian bypass can be performed as p reviously men­
tioned . If the subclavian a rtery can be exposed, the d i sta l
a n a stomosis is created fi rst u s i n g a 6- or 8-m m Dacron
g raft a n a stomosed either e n d -to-en d to the tra n sected
a rtery or end-to-s ide (fu n ction a l end-to-e nd) fol lowed by
l i g ation of the p roxi m a l a rtery in cont i n u ity. A side-biti n g
c l a m p is t h e n p l a ced a long the carotid g raft, a n d the s u b­
clavian g raft is sutu red e n d -to-side to the carot i d g raft
with 5-0 polypropy l e n e suture (FIG 7) .
• Prota m i n e is a d m i n istered t o reverse the h e p a r i n , a n d
hemostasis is e n s u re d . The g rafts shou l d l i e tension free
with i n the m e d i asti n u m . The perica rd i u m may be p a r­
tia l ly c losed ove r the g rafts, with care to avoid com p res­
sion of the g raft branches. Ch est tu bes a re positioned,
and the ste r n u m is c losed rout i n e ly. After the stern u m is
FIG 5 • The i n nom i nate a rte ry is tra nsected, a n d the p roxi m a l
e n d i s ove rsewn 4-0 polypropylene. T h e d ista l l a rg e e n d o f the c losed, the blood p ressure shou l d be assessed i n each a r m
Y-g raft is then t u n neled u n d e rneath the i n no m i nate ve i n and a n d cerebra l oxi m etry mon itored t o confi rm a d e q u ate
sewn end-to-e n d to the i n no m i nate a rtery with r u n n i n g 5-0 perfusion t h ro u g h the g raft branches a n d the a bsence of
polypropy l e n e . g raft com pression.
1808 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

FIG 7 • If the subclavian a rtery can be exposed, the d i sta l


a n a stomosis is created fi rst u s i n g a 6- or 8-mm Dacron g raft
a n a stomosed e n d -to-end to the tra n sected a rte ry. The
s u bclavian g raft is then sutu red e n d -to-s i d e to the caroti d
g raft w i t h 5 - 0 polypropylene suture.

E N D OVASCULAR SECO N D STAG E considered . The tech nical variations for these l ess com mon
situations a re beyond the scope of the present cha pter.
• The e n dovascu l a r second sta g e of the a rch repa i r is con - • The site of i n se rtion of the e n dovascu l a r g raft d e l ivery
d u cted i n a fairly s i m i l a r m a n n e r to that of stent g raft system is decided based on the size a n d q u a l ity of the ac­
repa i r of a descen d i n g thoracic aortic a n e u rysm, as de­ cess vessels. In g e n e ra l , the g rafts a re d e l ivered t h ro u g h
scribed i n Part 6, C h a pter 13 (Thora cic E n dog rafti n g ) . the com mon femora l a rte ry, whereas a n i l iac con d u it
• The t i m i n g of the e n dovascu l a r repa i r as a s i n g l e versus may be req u i red for very s m a l l or d iseased i l iofe mora l
sta ged a p p roach rem a i n s controversia l . We p refer to a rteries.
delay the second sta g e d e pe n d i n g on the c l i n ical see- • The d e l ivery g u idewire is p l aced i n the l eft ventri cle d u r­
n a rio. It can range from a few d ays (sa me hosp ita l i za­ i n g the e n dovascu l a r p roced u re to p rovide suffi cient
tion) to several weeks (sepa rate a d m ission) to a l low the p rox i m a l ra i l s u p port for the e n dovascu l a r g raft.
patient to recover from the fi rst p roced u re . T h i s red uces • The p rox i m a l ste nt g raft is deployed in the asce n d i n g
the overa l l physiolog ic stress on the patient. aorta j u st d ista l t o the orig i n o f the debranch i n g g raft.
• Althou g h we favor d e l ivery of the stent g raft in a retro­ D u ri n g d e p loyme nt, it is usefu l to lower the blood p res­
grade m a n n e r from the i l iofemoral a rteries, in cases of s u re u s i n g one of a va riety of p h a rmacolog i c, ventri c u l a r
a mech a n ical aortic va lve or severe i l iofemora l occ l usive paci n g or atri a l i n flow occ l u s ion tech n i q ues"
disease, s i n g le-stage a ntegrade deployment sho u l d be

PEARLS AND PITFALLS


I n d ications • The p reoperative CT a n g iog ram shou l d be reviewed in d eta i l to e n s u re the patient is a s u ita b l e
ca n d i d ate for aortic a rch repa i r w i t h d e b ra n c h i n g a n d ste nt g raft i n g , i n c l u d i n g a p p ropriate l a n d i n g
zones p roxi m a l ly a n d d i sta l l y a n d a d e q u ate vascu l a r access.
Proxi m a l type I endoleak • To optim ize the length of the p rox i m a l l a n d i n g zone and p revent a type I endoleak, the debra n c h i n g
g raft sho u l d be p l a ced as low as poss i b l e on the asce n d i n g aorta . Preem ptive replacement o f t h e
asce n d i n g aorta shou ld be performed if it is extremely short or i t s d i a m eter is > 34 m m .
Mech a n i ca l aortic • After aortic d e b ra n c h i ng, the e ndovasc u l a r g raft d e l ivery system may h a v e t o cross the aortic valve.
p rosthesis Althou g h transva lvu l a r p l acement of a l a rge sheath is relatively safe for n ative and bioprosthetic
va lves, it is contra i n d i cated for a m ec h a n ical aortic valve. Anteg rade ste nt g raft d e p loyment at the
time of debranch i n g shou l d be con s i d e red i n the p resence of a mech a n i c a l p rosthesis.
I nj u ry to r i g ht coro n a ry • Care shou l d be taken when a p p ly i n g the side-b iti n g clamp low on the asce n d i n g aorta to avoid
a rte ry occl usion or i nj u ry to the right coro n a ry a rte ry.
C h a p t e r 1 ARCH A N D G REAT V E S S E L R E C O N STRUCTI O N WITH D E B RA N C H I N G TEC H N I Q U E S 1809

Asce n d i n g aortic • The systo l i c blood p ress u re shou l d be lowe red to <90 m m H g when a p p l y i n g the side-biti n g c l a m p
d i ssection on the asce n d i n g aorta t o p revent i n j u ry a n d d issection o f a n a l ready fra g i l e a n d d i seased aorta .
Left subclavian a rtery • If the l eft subclavian a rtery is not easily access i b l e via the ste rnotomy i n cision ( l a rg e rotated
aortic a rch a n e u rysm), then debranch i n g of t h i s a rtery can be performed via ca rotid-subclavian
bypass.
Com p ression and k i n k i n g • I d e a l ly, the m a i n debranch i n g g raft shou l d l i e a long the r i g ht s i d e of the ascen d i n g aorta to avoid
o f d e b ra n c h i n g g rafts com p ression by the ste r n u m after chest closure. The g raft branches shou l d lie tension free, with care
taken to avoid kinking at the t i m e of perica rdia I a n d chest wa l l clos u re .

POSTOPERATIVE CARE debranching and stent graft repair was reported at 8 6 % . The
most common reason for technical failure was endoleak ( 9 % ) .1 0
• Following the de branching procedure, patients are monitored
in a cardiovascular surgical intensive care unit for 4 8 hours, COMPLICATIONS
with a focus on neurologic status, applying standard post­
operative cardiac surgery protocols. • Reopening for bleeding
• Chest tubes are typically removed 2 days after the debranch­ • Stroke or transient ischemic attack (TIA)
ing operation. • Spinal cord ischemic inj ury
• If a patient is recovering well after debranching without com­ • Ascending aortic dissection
plication and has stable renal function, then the stent graft • Endoleak
completion can be performed 3 to 5 days postoperatively. In • Iliofemoral artery injury
the event of a major complication requiring extended recovery, • Mortality
the patient may be discharged to a rehabilitation center. The
stent graft procedure can be delayed for a few weeks. However, REFERENCES
up to 25% of patients may not return for their second stage. 1. Lee CW, Beaver TM, Klodell CT Jr, et al. Arch debranching versus
• Following the second-stage stent graft procedure, the blood elephant trunk procedures for hybrid repair of thoracic aortic patholo­
pressure is augmented with fluid and vasopressor support to gies. Ann Thorac Surg. 2011;91(2):465-471.
achieve a target systolic blood pressure of 140 to 1 6 0 mmHg 2. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHNAATS/
ACRIASNSCNSCAIISIRISTS/SVM guidelines for the diagnosis and
for 48 hours to optimize spinal cord perfusion.
management of patients with Thoracic Aortic Disease: a report of the
• CSF drains are left open for 24 hours following stent graft­
American College of Cardiology Foundation/American Heart Asso­
ing. Drainage is limited to less than 15 mL per hour or less ciation Task Force on Practice Guidelines, American Association for
than 350 mL per day to avoid the potential risk of subdural Thoracic Surgery, American College of Radiology, American Stroke
hemorrhage. In the absence of spinal cord injury, CSF drains Association, Society of Cardiovascular Anesthesiologists, Society for
are then clamped for 12 hours and subsequently removed. Cardiovascular Angiography and Interventions, Society of Interven­
• Follow-up CT angiograms of the aorta are performed at tional Radiology, Society of Thoracic Surgeons, and Society for Vascu­
lar Medicine. Circulation. 2010;121(13):e266-e369.
1 and 6 months after the stent graft procedure, and then
3. Kulik A, Castner CF, Kouchoukos NT. Outcomes after total aortic
yearly thereafter. arch replacement with right axillary artery cannulation and a presewn
multibranched graft. Ann Thorac Surg. 2011;92(3):889-897.
OUTCOMES 4. Sundt TM 3rd, Orszulak TA, Cook DJ, et al. Improving results of
open arch replacement. Ann Thorac Surg. 2008;86(3):787-796; dis­
• In the authors' experience of 37 aortic arch debranching cussion 787-796.
procedures/ rates of spinal cord inj ury, stroke, and 3 0-day 5. Milewski RK, Szeto WY, Pochetrino A, er al. Have hybrid proce­
mortality were 0 % , 1 0 . 8 % , and 1 6 . 2 %, respectively. The dures replaced open aortic arch reconstruction in high-risk patients?
A comparative study of elective open arch debranching with endo­
incidence of proximal type I endoleak was 3. 7% at 1 and
vascular stent graft placement and conventional elective open total
1 2 months. Survival at 1 and 1 2 months was 8 6 . 5::+::5 . 6 % and distal aortic arch reconstruction. J Thorac Cardiovasc Surg.
and 7 1 . 6::+:: 8 . 5 % , respectively. Freedom from undergoing 2010;140(3):590-597.
any secondary surgical procedure after stent graft comple­ 6. Yang J, Xiong J, Liu X, et al. Endovascular chimney technique
tion at 1 and 12 months was 7 1 . 0::+::7 . 8 % and 5 2 . 8::+:: 1 0 % , of aortic arch pathologies: a systematic review. Ann Vase Surg.
respectively. 2012;26(7):1014-1021.
7. Matsumura JS, Lee WA, Mitchell RS, et al. The Society for Vascu­
• A recent systematic review of aortic arch debranching sum­
lar Surgery Practice Guidelines: management of the left subcla­
marized the clinical outcomes of 27 published studies in­ vian artery with thoracic endovascular aortic repair. J Vase Surg.
cluding a total of 642 patients.9 Reporting results similar 2009;50(5):1155-1158.
to those of the authors' experience1; the review noted rates 8. Lee WA, Martin TD, Gravenstein N. Partial right atrial inflow occlu­
of spinal cord inj ury, stroke, and 3 0-day mortality of 4 . 3 % , sion for controlled systemic hypotension during thoracic endovascular
7.3 % , and 1 1 .9 % , respectively. I n this review, a trend ex­ aortic repair. J Vase Surg. 2008;48(2):494-498.
9. Cao P, De Rango P, Czerny M, et al. Systematic review of clinical outcomes
isted between higher surgical volume and lower neurologic
in hybrid procedures for aortic arch dissections and other arch diseases. ]
complications, with stroke rates of 9 . 6 % and 6 . 5 % in low­
Thorac Gzrdiovasc Surg. 2012;144(6):1286-1300, 1300.e1-1300.e2.
volume and high-volume case series, respectively.9 10. Antoniou GA, El Sakka K, Hamady M, et al. Hybrid treatment of com­
• In anomer review article that included 1 8 studies and data from plex aortic arch disease with supra-aortic debranching and endovascu­
195 patients, the technical success rate following aortic arch lar stent graft repair. Eur ] Vase Endovasc Surg. 2010;39(6):683-690.
-

Chapter 2 Extrathoracic Revascularization


{Carotid-Carotid, Carotid­
Subclavian Bypass and
Transposition)
I

------------------------------------ -i ----------------------------------------------------- ....

Edward Y. Woo Scott M. Damrauer

DEFINITION IMAGING AND OTHER DIAGNOSTIC STUDIES


• Extrathoracic revascularization, including carotid-subclavian • Carotid duplex scanning should be used to identify patients with
and carotid---<:arotid bypass, involves the bypass of the proxi­ carotid artery stenosis prior to planned bypass procedures. Fail­
mal great vessels outside of the chest. Initially described for ure to identify and address stenoses at the carotid bifurcation
treatment of cerebrovascular and upper extremity occlusive may lead to postoperative steal phenomenon and neurologic se­
disease, these procedures are commonly now employed to cre­ quelae. Manipulation of the diseased carotid artery may also in­
ate a proximal seal zone for endovascular treatment of tho­ crease the risk of periprocedural stroke. In these circumstances,
racic aortic disease by " debranching" the aortic arch. concomitant or staged carotid intervention may be warranted.
• Carotid-subclavian bypass is accomplished by inserting a • Computed tomographic (CT) angiography of the aortic arch and
graft conduit between the mid-common carotid artery to the proximal carotid arteries provides the anatomic detail necessary
ipsilateral subclavian artery. to safely perform carotid-subclavian bypass, subclavian artery
• Subclavian artery transposition is a potential alternative to transposition, or carotid---<:arotid bypass. This study is comple­
carotid-subclavian bypass requiring division of the subclavian mentary to duplex scanning, as it provides anatomic rather than
artery proximal to the vertebral artery and transposing it to the hemodynamic assessment and images vessels equally well inside
ipsilateral common carotid artery. It is an efficient way to revascu­ and outside the chest. CT scanning also visualizes the course of
larize the subclavian artery without the use of prosthetic conduit. 1 the subclavian artery in relationship to the clavicle, as its course
• Carotid---<:arotid bypass provides flow from one common may also be distorted by a large arch aneurysm.
carotid artery to the contralateral common carotid artery.
• When carotid---<:arotid bypass is performed in a right-to-left SURGICAL MANAGEMENT
manner and in conjunction with carotid-subclavian bypass, the
Preoperative Planning
blood flow to the left brain can be preserved while allowing for
extension of the proximal thoracic endovascular aortic repair • Neuromonitoring is a useful adjunct to ensure adequacy of
(TEVAR) seal zone to cover the left common carotid artery. cerebral perfusion from the contralateral cerebral circulation
when the ipsilateral common carotid artery is clamped. Nu­
PATIENT HISTORY AND PHYSICAL FINDINGS merous modalities exist for neuromonitoring, including elec­
troencephalography (EEG), transcranial Doppler, near-infrared
• The history should focus on neurologic symptoms that may
spectroscopy, and stump pressure measurement. An indwelling
indicate the presence of symptomatic cerebrovascular dis­
carotid shunt may be placed to improve ipsilateral blood flow
ease. Previous head and neck or carotid surgery should be
when monitoring indicates cerebral perfusion is inadequate.
noted, as well as a history of head, neck, or upper chest re­
This problem occurs infrequently, as only the common carotid
gion external beam radiation therapy, as these may signifi­
is occluded, but preparations should be made for shunting pro­
cantly increase the complexity of the procedure.
cedures when indicated. Alternatively, as with carotid endarter­
• The directed physical exam should be focused on detection
ectomy (CEA), in the absence of neuromonitoring, shunts may
of underlying vascular disease that may complicate planned
be placed prophylactically to preserve carotid flow in all cases.
intervention. Bilateral upper extremity blood pressures
• Invasive continuous arterial pressure monitoring is routinely
should be obtained; a difference of greater than 10 mmHg
employed, with line placement dictated by the laterality of the
indicates the potential presence of preexisting occlusive dis­
procedure. Keeping in mind the potential need to occlude the
ease. Likewise, the presence of carotid bruits, delayed ca­
subclavian artery for the reconstruction, the arterial line should
rotid upstrokes, or abnormal upper extremity pulses suggests
be placed in the contralateral limb or in a femoral artery.
arterial occlusive disease that should be delineated prior to
extrathoracic reconstruction or bypass of the great vessels.
Positioning
• Special attention should be directed toward the cranial nerves
and voice, especially in patients with prior cervical surgical • The patient is positioned supine with the head rotated away
procedures. Indirect laryngoscopy should be performed preop­ from the operative side. A pneumatic pillow is placed under
eratively in patients with hoarseness or in whom a preexisting the shoulders to allow for neck extension. Careful attention
vocal cord or cranial nerve deficit has been noted. must be paid to achieve maximum neck extension while still
• Neck mobility and the presence of cervical spinal disease supporting the occiput. The bed is placed in a semi-Fowler's
should be assessed, as neck extension and rotation is essen­ position to reduce venous pressure and minimize bleeding.
tial for adequate operative exposure. Patients with relative • For carotid---<:arotid bypass, the head is positioned midline to
neck immobility may be poorly suited for these procedures. facilitate bilateral dissection.

1810
C h a p t e r 2 EXTRATHORACIC REVASC U LARIZAT I O N 181 1

CAROTI D-S U BCLAVIAN BYPASS


Exposure of the Subclavian Artery

• The i n cision is exte nded from the latera l aspect of the


c l avicu l a r head of the ste rnoc l e i domastoid (SCM) m u scle
l atera l ly across the s u p ra c l avicu l a r fossa. T h i s is f u rther
developed t h ro u g h the su bcuta neous tissue a n d pla­
tys ma with e l ectroca utery. If the exte r n a l j u g u l a r ve i n i s
encou ntered, it sho u l d be l i g ated a n d d ivided.
• Suffi cient clavicu l a r head of the SCM is d ivided to
a l low for a d e q u ate m ed i a l expos u re . U p to one- h a l f of
the ste r n a l head of the SCM can a l so be d ivided if a lso
needed, but t h i s is rarely n ecessa ry. The sca l e n e fat pad i s
then visua l i zed a n d d ivided . It is prefera b l e t o d ivide t h i s
near i t s i nferior borde r s o t h a t most o f the f a t pad can
be preserved a n d reclosed to cover the reconstruction.
Ca re m ust be taken to i d e ntify a n d p rese rve the phrenic
nerve as it cou rses ove r the a nterior sca lene m uscle deep
to the fat p a d . The thoracic d u ct is easily identified . If it i s
i n j u red or i n the way, it sho u l d be l i g ated t o p reve nt sig­
n ificant morb i d ity from a postoperative lym p h atic leak.
• Once the fat pad has been mob i l ized, the a nterior sca lene FIG 2 • The s u bclavian a rte ry a n d its branches a re
m uscle is d ivided to reveal the u nderlying subclavian artery circumferent i a l l y d i ssected a n d controlled with vessel loops.
(FIG 1 ). It is best to d ivide the m uscle slowly a n d in layers to
prevent i nj u ry to the u nderlying vessel . The subclavian a r­
Exposure of Carotid Artery
tery is dissected circu mferentia l ly a n d control led with vessel
loops. Care m ust be taken when m a n i p u lating this vessel, as • I n the m ed i a l aspect of the wou nd, the l atera l bord er
the subclavian a rtery is sign ificantly more fra g i l e a n d prone of the i ntern a l j u g u l a r ve i n is i d e ntified a n d sharply de­
to i nj u ry than lower extrem ity a rteries of com parable d ia m­ fined. The vein is retracted poste riorly and the ca rot i d
eter (e.g., femora l or pop l itea l). Depe n d i n g on the method sheath is entered from the latera l poste rior m a rg i n . Ca re
of reconstruction and location of the p l a n ned anastomosis, m u st be taken to ide ntify the va g u s n e rve early, as its
the thyrocervical tru n k, i nferior m a m m a ry, and vertebral u s u a l posterior position p l aces it i m med iately in the fi eld
a rteries may need to be controlled sepa rately (FIG 2). of d i ssection as the shea th is opened from t h i s a p p roac h .

Sternal head
sternocleidomastoid

Phrenic nerve

Anterior scalene

FIG 1 • The skin i n cision is p l aced


in the supraclavicu l a r fossa over the
Cut edge clavicular head clavicu l a r head of the SCM m uscle.
sternocleidomastoid The subclavian a rtery l i es d i rectly
beneath the a nterior sca lene m uscle.
Care m ust be taken to ide ntify and
preserve the phrenic nerve when
d i vi d i n g the a nterior sca lene m uscle.
1812 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

avoided, however, as their l o ng-term patency is i nferior to


p rosthetic in this location.3 We favor Dacron g iven the size
ra nges ava i l a b l e and the rel ative resista nce of the g raft to
k i n k i n g ove r the short d ista nce of the reco nstruct i o n .
• Prior to a rte r i a l c l a m p i ng, syste m i c a nticoag u l ation is
a c h i eved with i ntravenous heparin a d m i n istration. The
a ctivated clott i n g t i m e (ACT) should be m o n itored and
a d d i ti o n a l heparin a d m i n istered throughout the p roce­
d u re to m a i nta i n a d e q u ate anticoa g u lation.
• The subclavian a n a stomosis is perfo rmed fi rst. Arte r i a l
control (vesse l l o o p s o r c l a m ps) i s o bta i n e d a n d the vessel
is opened with a l o n g itud i n a l a rteriotomy. The a n asto­
mosis s h o u l d be fash ioned in the position m ost favora b l e
to the p l a n ned g raft. The g raft is beve l ed a n d t r i m m e d
so t h a t the g raft l i es at a n a p p roxi m ately GO-d eg ree
a n g l e to the a rtery. A r u n n i n g Pro l e n e suture is used to
perform the a n asto mosis with comp l et i o n of the back
wa l l fi rst. O n ce the a n asto mosis is co m p l ete, the g raft is
c l a m ped a n d f l ow restored to the a r m by u n c l a m p i n g the
FIG 3 • The carotid a rtery is d issected ci rcumferentia l ly after subclavian a rte ry. It is usefu l to flush through the g raft
ente r i n g the ca rotid sh eath from its poster i o r latera l m a rg i n . to remove a n y d e b ris pri or to open i n g to the a r m . The
T h e i ntern a l j u g u l a r vein c a n b e seen retracted o u t o f t h e way. g raft should a l so be flushed with h e p a r i n ized sa l i n e a n d
The va g u s n e rve is r u n n i n g p a ra l l e l to the a rtery between it c l a m ped n e a r the a n asto mosis t o avo i d a n y throm bosis
a n d the n e rve.
of the sta g n a nt b l ood co l u m n with i n the g raft. If repa i rs
a re needed, control is restored a n d pledgeted sutu res a re
• The c o m m o n ca rotid a rte ry is d issected ci rcu mferent i a l ly used to avo i d i nj u ry to the fra g i l e a rte ry.
(FIG 3) . O n ly 5 em of a rtery needs to be isolated i n order • The g raft is ta i l o red to the a p p ropri ate l e n gth to p revent
to o bta i n control a n d perform the a n asto mosis. The d is­ red u n d a n cy and k i n k i n g , and beve led so that the heel of
sect i o n s h o u l d stay proxi m a l to the ca rotid b u l b, which the a n asto mosis w i l l l i e prox i m a l ly o n the carotid a rte ry.
m i n i m izes risk of cere b ra l e m b o l ization a n d i n j u ry to As the c o m m o n ca rotid a rtery is c l a m ped, speci a l atten­
m o re proxi m a l n e rves. t i o n m u st be d i rected to n e u ro m o n ito r i n g ; s i g n ificantly
d i m i n ished cerebral perfusion, a lt h o u g h very u n com­
Bypass
m o n , m a n d ates s h u nt p l acement at t h i s sta g e of the p ro­
• Either Dacron or polytetrafl uo roethylene (PTFE) ca n be ced u re . A l o n g itu d i n a l a rteriotomy is perfo rmed and the
used as con d u its for extrathoracic bypass with no d i ffer­ prox i m a l a n asto m osis co m p l eted with r u n n i n g Pro l e n e
ence in o utco mes.2 Autogenous vei n g rafts shou l d be sutu re, a g a i n sta rti n g w i t h the back wa l l (FIGS 4 and S).

FIG 4 • After completing the d i sta l


a n a stomosis, the g raft a n d the subclavian
Subclavian a rtery a re all contro l led a n d the prox i m a l
art e ry a n astomosis is performed i n a r u n n i n g
fash i o n . T h e g raft can be t u n neled superfi c i a l
o r deep t o the i nternal j u g u l a r ve i n depe n d i n g
o n patient a n atomy a n d s u rgeon p reference.
C h a p t e r 2 EXTRATHORACIC REVASC U LARIZAT I O N 1813

After a few ca rdiac cyc l es, the d i sta l ca rotid c l a m p is a l so


remove d . The prox i m a l subclavian a rtery is then released
as we l l .
• When performed i n a ntici pat i o n of thoracic a o rtic stent
g raft i n g , the subclavian a rtery m ust be l i g ated p roxi m a l
t o t h e o r i g i n o f t h e verte bra l a rte ry. T h i s c a n i nvolve
d i ssection deep i nto the m e d i asti n u m and ca rries an i n ­
h e rent r i s k of catastro p h i c b l eed i n g . Alternative ly, t h e
p roxi m a l subclavian a rtery can be contro l l ed b y p l ace­
ment of an i ntra a rte r i a l occ l u s i o n device (e . g . , A m p­
l atzer), either d u r i n g the ca rotid-s u bclavian bypass or at
the t i m e of su bsequent ste nt g raft p l acement via a l eft
b rach i a l a p p roach 4

Closure

• If a p n e u m atic p i l l ow was used to p rovide exposu re, it is


d efl ated p r i o r to wo u n d closure i n order to red uce neck
extension and assist i n a l l ow i n g the wo u n d to be cl osed
without tensi o n .
FIG 5 • T h e co m p l eted bypass g raft can cou rse anterior o r
poste rior to the i nte r n a l j u g u l a r ve i n . The p h r e n i c n e rve is
• A c l osed suct i o n d r a i n is left i n the deep wound a n d
seen i n the l ower f i e l d . brought out t h r o u g h a sepa rate sta b i n c i s i o n .
• I n order to provide coverage for the g raft, the sca l e n e fat
pad is retu rned to its a n ato m i c l ocation a n d sutu red i n
• The f i n a l seq uence of c l a m p rem ova l is i m po rtant to p re­ p l a ce . T h e S C M is rea p p rox i m ated with r u n n i n g a bsorb­
vent e m b o l i s m to the b ra i n . Proxi m a l subclavian a rtery able sutu res.
control i s a g a i n o bta i n ed, and the c l a m p is rem oved from • The p l atysma a n d su bcuta neous tissues a re cl osed i n
the g raft. The prox i m a l ca rotid c l a m p is then removed to sepa rate l ayers i n a r u n n i n g fash i o n a n d t h e s k i n is reap-
a l l ow "flush i n g " d own the a rm rath e r t h a n to the b ra i n . p roxi m ated with a r u n n i n g d e r m a l suture.

SUBCLAVIAN ARTERY TRANSPOS ITION is l ost for a n y reason, the open a rte ry d oes not retract
i nto the m e d i asti n u m (FIG 6).
Exposure • The p roxi m a l subclavian a rtery is oversewn by exte n d i n g
• The subclavian a rte ry is exposed, as described i n the p re­ the stay sutu res across t h e stu m p . Hemostasis is confirmed
vious section, for ca rotid-s u bclavian bypass. The d issec­ by slowly releasing clamp contro l while m a i nta i n i n g trac­
tion m u st be carried p rox i m a l to the vertebral a rtery a n d tion o n the stay sutu res. Only once hem ostasis is rigorously
e n o u g h a rte ry m ust be exposed p roxi m a l ly t o a l low suf­ ensured a re the sutu res d ivided and the p roxi m a l subcla­
ficient length for the a n astomosis as we l l as control the vian a rtery a l lowed to retract i nto the mediasti n u m .
p roxi m a l stu m p . This can often be d iffi cult as a n a o rtic
a n e u rysm can occu py a s i g n ificant portion of the m e d i a s­ Carotid-Subclavian Anastomosis
t i n u m l i m it i n g vessel m a n i p u lati o n . • The subclavian a rte ry, having been freed ci rcu mferen­
• The carotid a rtery is exposed i n the same m a n n e r as t i a l ly, i s then m o b i l ized toward the carotid a rte ry. It may
described i n the p revi ous sect i o n . be t u n neled a nte rior o r poste rior to the i ntern a l j u g u l a r
ve i n d e pe n d i n g o n t h e l e n gth o f t h e a rtery a n d patie nt­
Division o f the Subclavian Artery specific a n atomy. The ca rotid a rtery is then c l a m ped
• Syste m i c h e p a r i n is a d m i n i stered, a n d maxi m u m a rte­ p roxi m a l ly and d i sta l ly and the a n asto mosis pe rfo rmed
r i a l l en gth is o bta i n e d by adva n c i n g a Coo ley c l a m p as in the sta n d a rd r u n n i n g fash i o n . Prior control of the sub­
deeply as possi b l e i nto the m e d i asti n u m a l o n g the sub­ clavian a rtery is m a i ntained (FIG 7) . As the a n a stomosis
clavian a rte ry. A d ista l atra u m atic c l a m p is then a p p l ied, i s com p l eted, the u n c l a m p i n g seq uence s h o u l d be re­
typ i ca l ly i n the m i dsubclavian a rte ry, with the m o re p rox­ peated as described i n the p reced i n g sect i o n to p revent
i n a dvertent a i r o r p a rticu l ate e m b o l i zation to the b ra i n .
i m a l branches i n d ivi d u a l ly contro l led with vessel loops.
There m ust be adeq u ate d i stance betwee n the p roxi m a l
Closure
c l a m p a n d t h e verte bral a rte ry t o a l low f o r p roxi m a l con-
tro l , transposition, a n d a n asto mosis. Prior to transection, • As descri bed in the section on ca rotid-subclavian bypass,
pledgeted 5-0 Pro l e n e stay sutu res a re p l a ced on each the wou n d is cl osed i n m u lti ple layers over a closed suction
side of the p roxi m a l a rtery to e n s u re that if c l a m p control d ra i n p l aced through a sepa rate sta b incision.
1814 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

F I G 6 • The s u bclavian a rtery a n d i t s branches


a re contro l l ed i n d ivid u a l ly with vesse l loops a n d
c l a m ps. A Cooley c l a m p is used prox i ma l ly o n
the s u bclavian a rte ry. Stay sutu res of 5 - 0 Pro l e n e
a re p l aced i n both ends of the s u bclavian a rtery
prox i m a l to the transection l i n e .

F I G 7 • T h e subclavian a rte ry i s m o b i l i zed so t h a t i t


may reach t o the carotid a rtery a n d the e n d-to-side
a n astomosis is performed i n the sta n d a rd r u n n i n g
fash ion, sta rt i n g a l o n g t h e b a c k wa l l . T h e thyrocervical
tru n k may be d ivided if necessary to fac i l itate
m o b i l izat i o n .

CAROTI D-CAROTI D BYPASS • The S C M is m o b i l ized latera l ly by c a r ry i n g t h e d i s­


sect i o n down towa rd the i nter n a l j u g u l a r ve i n ; t h i s
Exposure of the Bilateral Carotid Arteries exposes t h e c a r o t i d s h e a t h . Any b r i d g i n g ve i n s e n ­
• B i l atera l i ncisions a re m a d e ove r the a nterior border of cou ntered c a n be d iv i d ed; h oweve r, t h e e n t i re d i ssec­
the SCM at the base of the neck. The su bcuta neous tis­ t i o n s h o u l d be b e l ow t h e l evel of t h e faci a l v e i n , a s
sues and p l atysm a a re d ivided and the a nterior border of t h i s m a rks t h e c a r o t i d b i f u rcat i o n . F o r t h i s proce d u re,
the SCM is i d e ntifi e d . t h e re i s no need to risk i nj u ry to a d j a cent st r u ct u res by
C h a p t e r 2 EXTRATHORACIC REVASC U LARIZAT I O N 1815

expos i n g t h e carotid b i f u rcat i o n . T o o bta i n s u ffi c i e n t must be p a i d t o neuromonitoring a s t h e carotid a rtery i s


p roxi m a l exposu re, t h e o m o h y o i d m u s c l e m a y n e e d t o clamped.
b e d i v i d e d b i l atera l l y. • O n ce the fi rst a n asto m osis is co m p l ete, the g raft is
• The ca rotid sheath is e ntered sharply on its a nte rior c l a m ped a n d ca rotid a rtery f l ow restored o n that si de.
su rface. The va g u s n e rve m ust be i d e ntified with i n the Prior to removi n g the d ista l ca rot i d a rtery c l a m p, the
ca rotid sheath a n d p rotected as the common carot i d d i sta l a rtery can be back-bled a n d the proxi m a l a rtery
a rtery is exposed a n d contro l l e d . f l u shed out the open g raft. As with the subclavian a rte ry,
the g raft s h o u l d be flushed with h e p a r i n ized sa l i n e a n d
c l a m ped c l ose t o t h e a n asto mosis t o avo i d a l o n g stag ­
Graft Tunneling and Anastomosis
nant col u m n of blood with i n the p rosthetic g raft.
• O n ce the b i l atera l c o m m o n ca rotid a rteries a re suffi­ • The contra l atera l a n astomosis is then performed in the
ciently exposed and contro l l ed, the a p p ro p riate g raft same fash i o n (FIG 9) . The g raft should be flushed with
t u n n e l ca n be create d . Tu n n e l i n g is a c h i eved via b l u nt f i n ­ h e p a r i n ized sa l i n e a n d the g raft, p roxi m a l ca rotid a rte ry,
g e r d i ssection f r o m both s i d es of the n e c k . The g raft m a y a n d d ista l carotid a rtery shou l d be vi gorously flushed
be t u n neled e i t h e r between the trachea a n d eso p h a g u s pri or to completion.
o r b e h i n d the eso phag us, d e pe n d i n g o n patient h a b itus
a n d s u rgeon p refe rence (FIG 8). Care m u st obviously
Closure
be taken to avo i d i n j u ries to th ese critica l struct u res.
P l a cement of an orogastric or nasogastric tube p rio r to • H e m osta s i s is obta i n e d . The neck wo u n d s a re c l osed
creati o n of the d i ssection p l a n e can be h e l pf u l for identi­ in l aye rs, fi rst ta k i n g ca re to rea p p roxi m ate t h e SCM
fyi n g the eso p h a g u s . in its a n ato m i c posit i o n with i nterru pted a b s o r b a b l e
• O n ce the t u n n e l has been deve l o ped, the g raft is passed sutu res .
and patient syste m i ca l ly a nticoa g u lated with i ntrave- • A cl osed suct i o n d r a i n is l eft i n each wo u n d .
n o u s h e p a r i n a d m i n istrat i o n . • The p l atysma a n d su bcuta neous tissues a re cl osed with
• T h e a nastomoses a re performed i n t h e sta ndard r u n n i n g r u n n i n g a bsorba b l e sutu res and the skin rea p p roxi m ated
fashion; either one m a y b e performed fi rst. Careful attention with a r u n n i n g deep d e r m a l suture.

Common

I nternal
jugular
vein

FIG 8 • After iso l ati n g both com m o n ca rot i d a rteri es, a


retro p h a ryngeal t u n n e l is fash ioned u s i n g b l u nt f i n g e r
d i ssect i o n . The p l acement of a nasog astric o r orogastric t u b e
a l l ows for easy i d e ntification a n d p rotection of the eso p h a g u s .
1816 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

Internal

vein

Common
carotid
artery

FIG 9 • The d istal a nastomosis is performed in the


standard ru nning fash ion starti ng with the back wa l l . Prior
to completing the anastomosis, the carotid a rteries and graft
should be back-bled and fl ushed with heparin ized sa l i ne.

PEARLS AND PITFALLS


Positi o n i n g • When i nflating the p n e u m atic p i l l ow, care m u st be taken to e n s u re that the occ i put is adeq uately
s u p po rted. Fa i l u re to a d e q u ately s u p p o rt the head may result i n cervical spine and n e u ro l o g i c
i n j u ries.
Thoracic d u ct • G reat care m ust be taken to avo i d i n j u r i n g the thoracic d uct when expos i n g the subclavian a rte ry.
A l l lymphatic tissue encou ntered s h o u l d be l i g ated before b e i n g d ivided as the ensu i n g lymphatic
leak ca n be q u ite tro u b lesome for the patient a n d the surgeon.
S u bclavian a rtery control • The s u b c l a v i a n a rtery c a n be contro l l e d e i t h e r with vesse l l o o p s o r with atra u m at i c vascu l a r
c l a m ps, d e p e n d i n g o n w h i c h h e l ps t o better d e l iver t h e a rte ry i nto t h e wo u n d w i t h o u t u n d u e
tensi o n .
S u bclavian a rtery • T h e subclavian a rte ry is exceed i n g l y fri a b l e a n d s h o u l d be h a n d led ca refu l ly. G iven t h e exposu re, it
a n asto mosis may be easier to parach ute the a n asto mosis rath e r than fix the suture l i n e at the heel of the
a n asto mosis.
Position i n g vis-a-vis the • Depe n d i n g o n the h a b itus of the i n d ivid u a l patie nt, the g raft may lie better t u n neled either a bove
i ntern a l j u g u l a r ve i n o r below the i nte r n a l j u g u l a r ve i n . It i s p r u d e nt to explore both options pri or to creat i n g a n d com­
p l et i n g the ca rot i d a n a stomosis.
Proxi m a l subclavian con­ • The use of stay sutu res o n the proxi m a l s u bclavian a rtery i n subclavian a rte ry transposition is cru­
trol d u r i n g transposition cia l . Once the stay sutu re o n the prox i m a l e n d of the a rtery is released, the a rtery retracts deep
i nto the m e d i asti n u m a n d is not retrieva b l e . U n contro l led b l eed i n g may be d i sastro us a n d lead to
fata l co m p l i cations. As such, the proxi m a l oversewed subclavian a rtery m ust be hem ostatic prior
to rel ease of the stay sutu res. Stay suture safety i s ensu red by p l acement of pledgeted sutu res at
either end of the subclavian closure .
Common ca rot i d a rtery • It is n ot n ecessa ry a n d n ot advisa b l e to expose o r m a n i p u late the ca rotid b u l b o r b i f u rcation i n per­
expos u re form i n g a ny of these reco nstructions u n l ess a concomitant CEA is n ecessa ry or the bifurcati o n is situ­
ated l ow i n the neck. These p roced u res a re performed o n the common ca rotid a rtery, and expos i n g
the b i f u rcati o n o n l y i n c reases the r i s k of cra n i a l n e rve i n j u ry a n d stro ke.
Closure • The pneu matic p i l l ow should be deflated prior to closure to assist i n bri n g i n g the tissue together
without tension.
C h a p t e r 2 EXTRATHORACIC REVASC U LARIZAT I O N 1817

POSTOPERATIVE CARE this complication is beyond the scope of this text; however,
• Careful attention should be paid to both systolic and mean it should be mentioned that reexploration of the wound in
arterial blood pressure in the postoperative period. Invasive the early period is relatively straightforward and may repre­
arterial monitoring is usually maintained for the first sent the best way to resolve the problem. Late reexploration
24 hours. When carotid-subclavian bypass or subclavian can be fraught with difficulty finding the leak as the tissue
artery transposition is performed, blood pressure should be becomes fixed. A muscle flap may then be needed to close
monitored in the contralateral arm. the space. The main concern with a persistent leak is the
• Neurologic status and distal pulses should be followed potential for graft infection. Unfortunately, early wound re­
closely in the postoperative period. Any pulse changes need exploration significantly increases the risk of prosthetic graft
to be rigorously investigated as they may indicate the pres­ infection as well.
ence of either graft occlusion or distal embolization. • The vagus, phrenic, and recurrent laryngeal nerves, as well
• When carotid-subclavian bypass, where the proximal sub­ as the brachial plexus, can all be injured as a result of carotid
clavian artery is not ligated, is performed as a debranching and subclavian artery exposure. Most injuries are due to
procedure prior to thoracic aortic stent grafting, the timing traction rather than transection, and conservative therapy
of the endovascular procedure is important. In these patients will generally resolve symptoms over the course of months
who tend not to have concomitant occlusive disease, there is to a year. In the case of a staged bilateral subclavian revascu­
competitive flow via the native circulation, putting the newly larization, it is important to ensure that any vagus or phrenic
placed graft at risk of thrombosis. In the absence of compli­ nerve injury has resolved prior to contralateral intervention,
cations or other mitigating circumstances, the endovascular as bilateral inj uries can lead to tracheal obstruction and
aortic procedure should be performed within 3 to 5 days of acute respiratory failure.
the debranching bypass. • Although uncommon, significant bleeding from the wound
• Patients should be placed on aspirin therapy and followed at should mandate reexploration. More commonly, minor
regular intervals with duplex ultrasonography. wound hematomas may develop that can be observed.
Judgment regarding the need for reexploration of a neck
OUTCOMES hematoma is similar to that required during any other neck
procedure.
• Recent review of the American College of Surgeons National • Infection of the wound can be devastating if prosthetic is
Surgical Quality Improvement Program (ACS-NSQIP) data­ involved. Local cellulitis should be treated aggressively with
base from 2005 to 2 0 1 0 demonstrates that extrathoracic early institution of antibiotics in order to prevent deeper
revascularization carries a 3 . 5 % risk of stroke and 3 . 3 % infection. Upon removal of the drain, it is important that
risk o f death i n the immediate perioperative period.5 Over the drain site does not continue to leak, as continued leak­
this time period, 9 1 8 procedures were performed, with 1 0 % age may act as an entry point for bacterial contamination.
o f them a s part o f a staged approach t o thoracic aortic stent Simple suture closure should resolve this. Prosthetic graft
grafting. infection necessitates graft removal, which is extremely dif­
• Carotid-subclavian bypass has excellent durability. In a ficult and beyond the scope of this chapter.
series of 284 consecutive patients, Takach and colleagues2 • Although uncommon, stroke is a complication of any carotid
reported 5-, 1 0-, and 1 5 -year primary patency rates of procedure. Taking the precautions outlined previously in
9 4 % , 8 8 % , and 8 6 % , respectively. These results have sub­ this chapter should minimize these risks.
sequently been replicated by other large, multiple-decade
series.6 Subclavian artery transposition has similarly out­
REFERENCES
standing long-term patency, with rates as high as 9 9 % re­
ported at 5 years.6•7 1. Morasch MD. Technique for subclavian to carotid transposition, tips,
• Symptom-free survival following revascularization is like­ and tricks. J Vase Surg. 2009;49(1):251-254.
wise excellent, with long-term results approaching 8 8 % to 2. Takach TJ, Duncan JM, Livesay JJ, et al. Contemporary relevancy
of carotid-subclavian bypass defined by an experience spanning
9 9 % at 5 years.6•7
five decades. Ann Vase Surg. 20 1 1;25(7):895-901.
3. Ziomek S, Quinones-Baldrich WJ, Busuttil RW, et al. The superiority
COMPLICATIONS of synthetic arterial grafts over autologous veins in carotid-subclavian
bypass. J Vase Surg. 1986;3(1 ):140-145.
• The thoracic duct lies at the medial aspect of the field of
4. Woo EY, Bavaria JE, Pochettino A, et al. Techniques for preserving
dissection when dissecting in the supraclavicular fossa. This
vertebral artery perfusion during thoracic aortic stent grafting requir­
can be easily inj ured and remain undetected during the ing aortic arch landing. Vase Endovaseular Surg. 2006;40(5):367-373.
course of the operation. Continued or milky drainage is a 5. Madenci AL, Ozaki CK, Belkin M, et al. Carotid-subclavian bypass
clear sign of duct injury. The oral administration of cream and subclavian-carotid transposition in the thoracic endovascular aor­
can be used to promote chyle flow, and if a leak is pres­ tic repair era. } Vase Surg. 20 1 3;57(5):1275-1282.
ent, will promptly increase drain output. When this occurs, 6. Cina CS, Safar HA, Lagana A, et al. Subclavian carotid transposition
and bypass grafting: consecutive cohort study and systematic review.
the closed suction drain should be left in place, the patient
J Vase Surg. 2002;35(3):422-429.
kept fasting, and parenteral nutrition instituted. With con­ 7. Berguer R, Morasch MD, Kline RA, et al. Cervical reconstruc­
servative management, some of these inj uries may close tion of the supra-aortic trunks: a 16-year experience. J Vase Surg.
without further intervention. The complete management of 1 999;29(2):239-246; discussion 246-248.
-

Chapter 3 Carotid Surgery:


Interposition/Endarterectomy
{Including Eversion)/Ligation
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - · - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ·

Vinit N. Varu Wei Zhou

DEFINITION is not recommended to detect asymptomatic disease in the


general population; patients with appropriate risk factors,
• Stroke is the leading cause of disability in the United States or those with a bruit on physical exam should be evaluated
and Western Europe and the third leading cause of death when clinical circumstances warrant.
behind coronary artery disease and cancer. • Carotid duplex ultrasound provides a reliable and accu­
• Pivotal studies have shown the efficacy of carotid endarter­ rate noninvasive tool to identify predicted stenosis and is
ectomy ( CEA) in stroke prevention in both symptomatic and the initial diagnostic study of choice. Peak systolic veloc­
asymptomatic patients with internal carotid artery (ICA) ity (PSV) higher than 125 em per second predicts angio­
stenosis versus medical therapy alone. 1•2 graphic stenosis more than 5 0 % and higher than 230 em
• CEA is defined as the surgical excision of atherosclerotic per second predicts more than 70% stenosis. However, a
lesions of the intima and tunica media of the carotid artery. combination of PSV, end diastolic velocity, and the PSV
• Occasionally, ICA ligation and/or interposition bypass may ratio of ICA to CCA is more accurate in estimating sig­
be indicated for stroke prevention. nificant carotid stenosis. In general, end diastolic veloc­
ity higher than 1 0 0 em per second correlates to more than
PATIENT HISTORY AND PHYSICAL 8 0 % carotid stenosis.
FINDINGS • When duplex imaging is not definitive, as is the case in the
setting of extensive carotid bifurcation calcification, addi­
• Patients may be entirely asymptomatic and still benefit from
tional cross-sectional imaging (computed tomography angi­
carotid intervention to prevent long-term stroke. In the
ography [CTA] or magnetic resonance angiography [MRA] )
United States, most CEA procedures are performed on
may be necessary to quantify the degree of stenosis. When
asymptomatic patients. Symptoms of cerebroembolic dis­
accurate velocity information is obtainable, duplex imaging
ease originating from the carotid bifurcation, when present,
provides the most accurate and physiologically relevant esti­
may include dysarthria, dysphasia, aphasia, hemiparesis,
mates of percent diameter reduction.
or hemisensory deficit or amaurosis fugax. Symptoms that
resolve within 24 hours are defined as transient ischemic SURGICAL MANAGEMENT
attacks (TIAs) regardless of severity; symptoms that persist
past the first day constitute a stroke. Indications
• For patients at risk for cerebroembolic disease, a thorough
Endarterectomy
vascular history is obtained including modifiable risk factors
such as smoking, hyperlipidemia, hypertension, and diabe­ • The Society for Vascular Surgery recommends that neu­
tes management. Prior to surgery, single-agent antiplatelet rologically symptomatic patients with greater than 5 0 %
therapy is initiated and continued indefinitely following stenosis o r asymptomatic patients with greater than 6 0 %
intervention. Blood pressure control at or below 140 mmHg stenosis should be offered CEA t o reduce risk of recurrent
systolic and 90 mmHg diastolic is the single most impor­ or initial stroke, respectively. Endarterectomy is appropriate
tant medical intervention to reduce stroke risk. 3 Sufficient for patients with at least a 3- to 5-year life expectancy with
13-blockade to stabilize resting heart rate at 60 bpm is also perioperative stroke/death rates less than 3 % . In all other
instituted prior to surgery to limit perioperative myocardial circumstances, optimal medical therapy is preferred.5
oxygen demand unless contraindicated.4 • Surgical endarterectomy is the procedure of choice for
• Cervical auscultation is performed in both the supraclavicu­ good-risk surgical patients with normal cervical anatomy.
lar and mandibular regions. Bruits appreciated at the man­ For selected high-risk patients, such as those with tracheal
dibular angle usually indicate ICA or bifurcation disease. stoma, previously radiated neck, prior cranial nerve inj ury,
More proximal bruits may indicate common carotid artery or lesions proximal to the clavicle or distal to C2 vertebral
( CCA) disease or radiating heart sounds. body, transcatheter angioplasty and stenting is generally the
• A full neurologic assessment including mental status, speech, preferred approach. 5 Indications and technical guidelines for
facial symmetry, and extremity strength must be obtained carotid angioplasty and stenting procedures are discussed in
and documented prior to surgery. Part 6, Chapter 4 .
Carotid Artery Interposition Bypass
IMAGING AND OTHER DIAGNOSTIC
• Reconstruction for extensive bifurcation disease, injury to
STUDIES
the bifurcation during endarterectomy, or aggressive reste­
• All patients exhibiting symptoms of carotid territory isch­ nosis following previous intervention (endarterectomy or
emia need appropriate vascular imaging studies. Screening stem placement} is best accomplished by carotid resection

1818
C h a p t e r 3 CAROT I D S U R G E RY: I nterpos i t i o n/Endarterectomy ( I n c l u d i n g Evers i on)/L i g a t i o n 1819

and interposition grafting. Other indications include the


following:
Significant diffuse CCA and ICA disease
Radiation-induced stenosis or other forms of arteritis
involving long arterial segments
Aneurysms (degenerative or traumatic) and invasive carotid
body tumors.

Ligation

• Ligation and resection of the proximal ICA may be indicated


in the setting of carotid stump syndrome, when persistent
distal embolization from the " cul-de-sac" of the occluded
ICA may reflux into collateral pathways, such as through
the ophthalmic artery into the distal ICA.

Preoperative Planning

• Similar outcomes are achieved with general anesthesia or


regional anesthesia.
• Use of shunt during CEA is dependent on operator prefer­
ence. Most surgeons either shunt selectively or use a shunt
FIG 1 • Reco m m e n d e d patient position for a CEA p roced u re.
for all cases. Some surgeons never shunt.6 Surgeons should
develop the methods they feel most comfortable with to opti­
mize outcome. Obj ective measures that may influence shunt can be flexed with the head in relative extension to aid in
usage include stump pressure measurement, electroencepha­ positioning ( FIG 1 ) .
lographic monitoring, and transcranial Doppler assessment. • Arterial blood pressure monitoring i s necessary for optimal
Data supporting use of these adjuvants is inconsistent, and anesthetic management. Bladder catheterization is performed
none is considered standard of care nationally. if the procedure is expected to extend beyond 2 hours. If end­
• Optimal neck extension is obtained by placing a towel or arterectomy is performed with regional anesthesia, an audi­
gel roll behind the scapula. The head is rotated contralat­ ble squeeze device is placed in the patient's contralateral hand
eral to the operative side. In older patients, often with lim­ for indirect neurologic monitoring. Preoperative antibiotics
ited neck movement or prior cervical fusions, padding and are administered routinely.
shay positioning must be sufficient to support the neck to • Aspirin therapy is initiated well in advance of surgery and
prevent hyperextension inj ury. The chin, angle of the man­ continued throughout the perioperative period. Evidence
dible, lower earlobe, and sternal angle are prepped and pre­ suggests that statin therapy, initiated preoperatively, reduces
liminarily draped within the operative field. The bed itself postoperative neurologic events and mortality.7

CAROTI D E N DARTERECTOMY­ • F o l l o w i n g fasc i a l i ncision, the fa c i a l ve i n i s identified a n d


secu rely l i g ated . T h i s ve i n u s u a l ly transverses t h e CCA
PATCH AN G I OPLASTY
n e a r the bifu rcati o n . Fa i l u re to adeq uately secu re this
Incision ve i n may lead to bleed i n g a n d a i rway co m p ro m i se d u r­
i n g postoperative co u g h spe l l s or Va lsa lva m a n e uvers.
• The s k i n i ncision is opti m a l ly p l aced a l o n g the a nte rior • With i n the ca rotid sheath, the va g u s n e rve usua l ly ex­
border of the sternocleidomasto i d m uscle. This s h o u l d be te nds poste rior to, and p a ra l l e l with, the a rtery and ve i n .
cu rved poste rol atera l ly near the a n g l e of the m a n d i b l e H oweve r, t h i s posit i o n rel ative t o t h e oth e r contents of
t o avoid d i ssection i nto the pa rot i d g l a n d . the ca rotid sheath may va ry, a n d the va g u s s h o u l d a lways
• Alternatively, a m o re transverse i n c i s i o n can be m a d e at be i d e ntified and p rotected in the cou rse of the d i ssec­
the level of the ca rotid bifu rcati o n . Alth o u g h p rovi d i n g t i o n . The a nsa cervi ca l is n e rve is co m m o n l y m uch s m a l l e r
a n i m p roved cosmetic resu lt, expos u re o f t h e d i stal I CA t h a n the va g u s a n d r u n s a nte rior t o the carotid bi furca­
may be compromised with t h i s a p p roach (FIG 2) . tion. When co m p l etely iso l ated, the p roxi m a l a nsa a rises
from the i p s i l atera l hypog l ossa l (XI I ) cra n i a l n e rve. The
Carotid Exposure and Control
a nsa cervica l is can be d ivided to i m p rove exposure if n ec­
• As the i ncision is extended through the p l atysm a m u scle, essa ry o r m o b i l ized suffi ciently to be gently retracted out
the a nterior border of the sternocleidomasto i d m uscle of the ope rative f i e l d .
is visual ized a n d retracted poste rol atera l ly. The g reater • T h e CCA is circu mferentially d issected from surround­
a u ri c u l a r n e rve s h o u l d be i d e ntified and p rotected at the i n g structu res i n sufficient length to provide adequate
s u pe rior exte nt of the i n c i s i o n . exposure for proxi m a l clamping a n d contro l . The CCA is
1820 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

External carotid artery

Line of incision

Cornman carotid artery

Sternal head of
sternocleidomastoid
muscle

FIG 2 • The i n c i s i o n a l o n g the a nte rior border of sternocleidomasto i d (SCM) m uscle is the
m ost co m m o n l y used incision for a CEA proce d u re. A tra nsverse incision along a s k i n crease
in the vici n ity of the ca rotid b i f u rcation is an a lternative i n c i s i o n for a bette r cosmetic resu lt.
CCA, common ca rot i d a rte ry; I CA, i nte r n a l ca rotid a rte ry; ECA, exte r n a l ca rotid a rte ry.

opti m a l ly contro l led by p lacement of an a ppropriately • C l a m p i n g of I CA is performed fi rst, fo l l owed by control of


sized, atra u m atic vascu l a r cl am p such as a G regory pro­ the exte r n a l a n d c o m m o n ca rotid a rteries. This seq uence
funda c l a m p . The ratchet should be engaged o n ly to the is fo l l owed to m i n i m ize e m b o l ization risk associ ated with
m i n i m a l a m o u nt necessa ry to control bleed i n g to prevent cla m p i n g . When n ecessa ry, measurement of ICA stu m p
intimal injury and dissection at the site of c l a m p p l acement. p ressu re is o bta i n e d a t t h i s j u nctu re b y ca n n u lation of
• F o l l o w i n g co m m o n carotid control, the d issect i o n i s ex­ the ca rotid b i f u rcat i o n a n d sel ective remova l of the i n ­
tended cra n i a l ly and poste riorly a l o n g the poste rol at­ te r n a l carotid c l a m p .
e r a l border of the I CA. Deve l o p ment of the d i ssect i o n
p l a n e postero latera l l y a l o n g the proxi m a i i CA m i n i m izes
risk of hypogl ossa l n e rve i n j u ry. This d issect i o n is a l so
performed with m i n i m a l d is p l a cement a n d i nstr u m e nta­
tion of the ICA to red uce i ntraoperative e m b o l ization
risk (FIG 3) .
• To co m p l ete the n ecessa ry exposu re, the exte r n a l ca rot i d
a rtery (E CA) is d issected a n d m o b i l ized to at least the l evel
of the superior thyro i d a l a rte ry. The superior l a ryngeal
n e rve may a l so be encou ntered poste rior to the ca rot i d
b ifurcation i n t h i s a re a .
• F o l l o w i n g d i ssection, a n d p r i o r to c l a m p p l ace m e nt, suf­
ficient u nfract i o n ated h e p a r i n is a d m i n istered i ntrave­
nously to o bta i n an activated c l ott i n g t i m e (ACT) of more FIG 3 • Exposure o f ca rotid bi furcat i o n . Va g us n e rve a n d
than 200 seco nds. With n o r m a l c i rc u l ation t i m es, t h i s is hypog l ossa l n e rve a re most co m m o n ly encou ntered n e rves
usu a l ly acco m p l ished with i n 2 o r 3 m i n utes of i nject i o n . d u ri n g ca rotid d i ssect i o n .
C h a p t e r 3 CAROT I D S U R G E RY: I nterpos i t i o n/Endarterectomy ( I n c l u d i n g Evers i on)/L i g a t i o n 182 1

Conventional Endarterectomy res i d u a l m ed i a l e l e m e nts. These a re best rem oved with


fine forceps u n d e r m a g n ificat i o n . Co m p l ete remova l is
• The a rteriotomy is i n itiated in a soft, u n i nvolved prox i m a l fa c i l itated by conti n u ous i rrigation to identify m o b i l e
seg ment of the CCA a n d exte nded ce p h a l a d w i t h Potts m ed i a l e l e m ents. I nteg rity o f the d i sta l a n d p roxi m a l
scissors. It sh o u l d be positioned on the a nte r i o r- l atera l e n d p o i nts is a lso verified u s i n g t h i s tech n i q u e .
su rface of the I CA to avo i d the f l ow d i v i d e r. (FIG 4A) .
• When an i n d we l l i n g s h u nt is i n d i cated or req u i red, the
Patch Placement
d i sta l tapered e n d is ca refu l ly i n se rted i nto the I CA u n d e r
d i rect visi o n . W e p refer the Pru itt- l n a h a ra s h u nt, whi c h • An appropriately sized bovine pericard ia I or Finesse Dacron
has p i lot b a l loons at b o t h ends to m a i nta i n s h u n t posi­ kn itted po lyester patch is selected a n d trimmed as neces-
t i o n and hem ostasis. Once the d i stal e n d is i n se rted, the sa ry for closu re-assisted a n g ioplasty. Both bovi ne pericar­
d ista l b a l loon is i n f l ated with l ess t h a n 1 m l of air u n t i l d i a ! a n d po lyester patches have chiral ity considerations;
the " po p-off" ba l l oo n i nfl ates o n the p i lot tube. Fa m i l ­ one su rface is preferred for l u m i n a l a pposition. Please con­
i a r ity with t h i s s h u n t p rio r t o i nsertion is esse ntial; if the sult the accompanying i nstructions for use prior to i m plan­
i nflation override cuff covers the " po p-off" b a l loon o n tation. Closu re is secu red with running 6-0 polypropylene
t h e p i lot tu be, overi nflation may i nj u re o r r u pt u re t h e suture i n itiated at the cephalad extent of the a rteriotomy
d i sta l I CA. F o l l o w i n g d ista l I CA ca n n u lation a n d b a l loon and conti nued proxi m a l ly a long the long axis of the patch.
i nflation, the s h u nt is back-bled to confirm l u m i n a l p l ace- • After 9 0 % o r m o re of the c i rcu mference of the patch is
ment a n d decant a i r. With the s h u nt actively back- b l eed- secu red, fl ush i n g is acco m p l ished by seq uentia l c l a m p
ing, the p roxi m a l e n d is i nserted i nto the CCA fo l l owed rem ova l a n d l u m i n a l i rrigation with h e p a r i n ized sa l i n e .
by p rox i m a l c l a m p rem ova l i nto the u n o bstructed l u m e n . C l o s u re is then co m p l eted pri or to resto ration of fl ow.
T h e p roxi m a l p i l ot t u b e is i n f l ated w i t h the p rovi ded sy- • The decl a m p i n g seq uence is of critica l i m po rtance. The
r i n g e u n t i l the cuff is p a l p a b l e in the CCA, after whi c h CCA is rel eased fi rst, fo l l owed by the ECA c l a m p . After
a p repositioned R u m e l to u r n i q uet is gently cinched seve r a l card i a c cyc les have ensued, the d ista l I CA is
a r o u n d the a rte ry. When performed q u ick ly, with concur- released (FIG 4C) .
rent d i g ita l control of the CCA fo l l ow i n g c l a m p rem ova l • W e perform i ntraoperative comp l et i o n d u p lex i m a g i n g
a n d p r i o r to s h u nt i nsertion, m i n i m a l b l eed i n g ensues. of the e n d a rte rectomy site as we l l as the proxi m a l a n d
When sa l i n e is a p p l ied to the s h u nt tubing, p u lsati l e flow d i sta l ca rotid a rteri es, with p u rpose-des i g n ed, m i n iatur­
is a p p reci a b l e with h a n d h e l d D o p p l e r i nsonati o n . ized 7 M H z probes. Comp leti o n d u p lex sca n n i n g is q u i ck,
• At the site of maxi m a l atherosc l e rot ic d isease in the CCA, efficie nt, h i g h l y re p ro d u c i b le, a n d effective at identify­
the Penfi e l d k n i fe is e m p l oyed to i d e ntify a n d deve l o p i n g s i g n ificant res i d u a l l u m i n a l d efects. Deta i l ed descrip­
the a p p rop riate e n d a rterectomy p l a n e with i n the m ed i a l t i o n of the cha racte ristics of s i g n ificant l u m i n a l d efects
l ayer. W h e n t h e correct p l a n e is i d e ntified, t h e p l a q u e i s i d e ntified by co m p l etion u ltraso n o g raphy a re beyo n d
easily a n d ra p i d ly e l evated f r o m the u n d e r l y i n g adven­ the scope of t h i s cha pter. I ntraoperative i nsonation i s
titi a . I n a reas conta i n i n g i ntra p l a q u e hemorrhage, i n ­ n ot poss i b l e t h ro u g h extruded po lytetrafl u o roethy l e n e
f l a m mation may i n crease a d h e rence of the p l a q u e t o t h e (ePTFE) patches a n d s h o u l d n o t be attem pted .
adventitia, a n d ca re s h o u l d be taken n o t t o exte n d t h e
d i ssect i o n p l a n e i nto the adventitia itse lf.
Closure
• At the d ista l extent plaque, sufficient exposure should be
present to create a defined endpoint, a l lowi ng p lacement • Following adequate d u plex i m a g i n g a n d endpoint de-
of tacki ng sutu res if necessa ry, ensuring that no further po­ termi nation, a nticoa g u l ation is reversed with prota m i n e
tentially mobile plaque rem a i ns. It is essential to "feather" sulfate. S o m e p ractitioners a re re l u ctant t o reverse a ntico­
the plaque at the d ista l endpoint to m i n i m ize risk for d ista l a g u lation due to u n certa i nty regarding thrombogenicity
dissection or thrombus accu m u lation . If the plaque extends at the endarterectomy site. In o u r experience, tech n ical
past the point where feathering is feasib le, a d ista l endpoint issues at the endarte rectomy site a re most p red ictive of
should be determi ned a n d created sharply with scissors or a postoperative n e u rologic events, a n d these a re efficiently
no. 1 5 blade (FIG 48). Tacking sutu res, placed circu mferen­ identified a n d corrected, when p rese nt, with com p l etion
tial ly, ca n control d ista l plaque at the transection site. Care u ltrasonography. Following reversa l, the entire wou n d is
should be taken, however, to place the m i n i m a l n u mber of inspected for venous o r a rterial bleed i n g . The enti rety of
sutu res necessa ry to prevent dissection, or consider extend- the patch a ngioplasty suture l i n e is reinspected for period­
ing the a rteriotomy a n d endarterectomy to identify a more icity of suture p lacement a n d potential leaks. Rei nforci n g
suitable term i nation site. Successful sutu re placement re­ sutu res a re a p p l ied l i bera l ly as needed to ensure hemo­
q u i res circu mferentia l dissection and opti m a l visu a l ization. stasis, but with expe rience a n d even suture spacing, the
• O n ce the d i sta l e n d point is determ i n ed, resi d u a l p l a q u e need for additional sutu res should be rare. B leed i n g lymph
is rem oved f r o m the E C A b y eve rs i o n i nto the C C A a n d nodes should be sutu red a n d removed from the operative
c i rcu mferent i a l d i ssection a n d tract i o n . S uffi cient back­ field. Confirmation of hem ostasis, the pl atysma is reap­
bleed i n g is perfo rmed to remove a n y l u m i n a l debris proxim ated with r u n n i n g a bsorba b l e suture fo l l owed by
with i n the ECA. skin closure. We usua l ly a lso perform a Va lsa lva m a neuver
• D i rect visua l i zation of the e n d a rterectomy bed fo l l ow­ to identify occult venous inju ries that may not be apparent
i n g p l a q u e rem ova l com m o n ly identifies l oosely attached with positive p ressure venti lation prior to closu re.
1822 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

I ntimal tacking
suture

Line of incision

FIG 4 • Arte riotomy is exte nded from the a nte rior


su rface of CCA to the a nterior su rface of I CA d i stal to
the lesion (A) . I n t i m a l f l a p is tacked down to e n s u re
sm ooth d i stal e n d po i nt (B) . Arte riotomy is cl osed with
a patch (C) . c
C h a p t e r 3 CAROT I D S U R G E RY: I nterpos i t i o n/Endarterectomy ( I n c l u d i n g Evers i on)/L i g a t i o n 1823

CAROTI D E N DARTERECTOMY-EVERS I O N p l a q u e is su bseq uently removed by the Pe nfield kn ife


as i n d i cate d . The p roxi m a l CCA a rteriotomy may be ex­
Incision tended as n eeded to e n s u re co m p l ete rem ova l .
• See sect i o n under Ca rotid E n d a rterectomy-Patch
• Co m m o n a n d exte r n a l carotid p l a q u e is su bse q u e ntly re­
A n g i o p l asty. m oved by the Penfi e l d kn ife as i n d icate d . The prox i m a l
CCA a rteriotomy may be exte nded as poss i b l e to e n s u re
Dissection and Control of the Carotid Artery co m p l ete remova l (FIG SB) .

• See sect i o n u nder Ca rotid E n d a rterectomy-Patch Anastomosis


A n g i o p l asty.
• The I CA is reve rted a n d a n a stom osed e n d -to-e n d to the
Eversion endarterectomy proxi m a l CCA (FIG SC).
• If red u n d a nt res i d u a l ICA is p resent fo l l owi n g p l a q u e
• An o b l i q u e or c i rcu mferenti a l i ncision is m a d e at the j u nc­
rem ova l, the I CA spatu lation is exte nded, as is the CCA
tion of the b u l bous portion of the I CA and CCA (FIG SA) .
a rterioto my, a n d the two ends a re f u rther adva nced over
• T h e I CA adventitia is g rasped w i t h f i n e forceps a n d
each oth e r pri or to closure. Alternatively, a port i o n of
everted away, as gentle tract i o n is p l aced o n t h e p l a q u e
the red u n d a nt ICA may a lso be excised .
with i n t h e a rte ry. T h i s m a neuver i s exte nded d i sta l l y u n t i l
the feath e red e n d p o i nt i d e ntifies itself. Ta ck in g sutu res
Closure
a re not poss i b l e u s i n g this a p p roach, which can be a de-
terrent to a d o pt i o n by s u rgeons tra i n e d with conve n - • See section u nder Ca rotid E n d a rterectomy-Patch
t i o n a l e n d a rterecto my. C o m m o n and exte r n a l carot i d A n g i o p l asty.

External carotid artery

I nternal carotid artery


Artery everted

---- Common carotid artery

A B c
FIG 5 • Carotid evers i o n e n d a rte recto my. The I CA is d ivided from the CCA i n an o b l i q u e l i n e (A) . The d ivided I CA is everted on itse lf
until the plaque e n d point is encou ntered a n d the p l a q u e is removed from the I CA (B). Fol l ow i n g e n d a rterecto my, the I CA is reverted
a n d reattached to the CCA (C) .
1824 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

CAROTI D ARTERY I NTERPOS ITION BYPASS


Incision

• See sect i o n u nder Ca rotid E n d a rterectomy-Patch


A n g i o p l asty.

Dissection and Control of the Carotid Artery

• See sect i o n u n d e r Ca rotid E n d a rte rectomy-Patch


A n g i o p l asty.
• Alth o u g h reve rsed a utog en o u s ve i n is the p referred con­
d u it, when ava i l a b l e, ePTFE p rovid es a s u ita b l e a lterna­
carot i d
tive when n ecessa ry.8 artery

Anastomosis

• The d i seased seg ment of the ca rotid a rtery is resected .


C o m m o n ly, t h e ECA i s oversewn as wel l .
• E n d -to-e n d a n a stom oses a re performed i n sta n d a rd fash­
ion. Prior to comp letion, flush i n g m a n e uvers a re done to External carotid
evacuate p a rticu l a r m atte r o r resi d u a l a i r (FIG 6) . artery (ligated)

Closure

• See sect i o n u nder Ca rotid E n d a rterectomy-Patch


PTFE or vein interposition graft
A n g i o p l asty.

Common carotid artery ----

FIG 6 • Ca rotid i nterposition g raft. F o l l o w i n g resection of


the d iseased seg m e nt, a p rosthetic g raft o r a seg m e nt of
reversed g reater saphenous ve i n is used to bridge the CCA
a n d I CA in an end-to-e n d fash i o n .

CAROT I D ARTE RY LI GATION Endarterectomy

(CAROTI D STU M P SYN D RO M E) • The tech n i q u e is s i m i l a r to that for sta n d a rd I CA e n d a r­


terecto my, the d i fference b e i n g the a rte riotomy b e i n g
Incision
c a r r i e d out o n the d i stal C C A i nto the E C A (FIG 7A).
• See sect i o n u nder Ca rotid E n d a rte rectomy-Patch • The throm bosed I CA is resected, idea l l y in l i n e with the
A n g i o p l asty. common a n d exte r n a l carot i d a rterioto m i es. Closu re is
acco m p l ished via patch a n g i o p lasty (FIG 7B,C) .
Dissection and Control o f the Carotid Artery
Closure
• See sect i o n u nder Ca rotid E n d a rterectomy-Patch
A n g i o p l asty. • See sect i o n u nder Ca rotid E n d a rte rectomy-Patch
A n g i o p l asty.
C h a p t e r 3 CAROT I D S U R G E RY: I nterpos i t i o n/Endarterectomy ( I n c l u d i n g Evers i on)/L i g a t i o n 1825

Resected i nternal

Occluded i nternal
carotid artery
Ligated i nternal
carotid artery

Endarterectomized Oversewn stu m p


external caroti d
�--- Patch
artery
closure

A B c

FIG 7 • Carotid l i gation. The occ l u d e d I CA is a m p utated a n d rem oved {A), a n d the I CA stu m p is oversewn {B) . The p l a q u e i n the
CCA a n d ECA is removed, a n d the a rteriotomy is c l osed with a patch {C) .

PEARLS AND PITFALLS


I ncision • On t ab l e d u p l ex sca n n i n g opti m i zes i n cision p l acement, p a rti c u l a rly for transverse expos u re .
Identify i n g the va g u s • Va g u s n e rve is l ocated posterolatera l to the carot i d a rtery, with i n the ca rotid s h e a t h a n d betwee n
n e rve a n d hypog l ossa l ca rot i d a rtery a n d i nte r n a l j u g u l a r ve i n . Hypog l ossa l n e rve typica l l y crosses I CA a ntero i nferiorly t o
n e rve posterosuperio rly. F o l l o w i n g the a nsa cervica l i s w i l l lead to hypog l ossa l n e rve.
Clamping • A " ro b i n b l u e " hue is often seen i n the d ista i iCA, which sign ifies a soft a rea for safe c l a m p p l acement.
S h u nt i n g • B e p re p a red in a l l cases for potential s h u nt p l acement. This s h o u l d be flushed and prepared o n the
back t ab l e prior to perform i n g the a rteri otomy.
Conventi o n a l • Lava g e the a rte r i a l l u m e n with h e p a r i n ized sa l i n e to ide ntify a n d rem ove l u m i n a l debris.
e n d a rte recto my
Evers i o n e n d a rte recto my • Use caution i n patients with high bifu rcati o n (difficu lty visu a l i z i n g a n d secu r i n g d i stal e n d p o i nt),
those who req u i re a s h u nt, o r those with a sma i i i CA. These p roced u res a re best su ited for patie nts
with red u n d a nt I CAs.
I nterposition bypass • Use the a n asto m otic suture l i n e to tack down d i sta l resi d u a l p l a q u e as n ecessa ry to p revent
a ntegrade d i ssect i o n .
E n s u r i n g tech n i c a l • A co m p l etion i m a g i n g study, e i t h e r a n o n -ta b l e a n g iogram o r a carot i d d u p l ex study, ca n h e l p t o
pe rfection e n s u re tec h n i c a l perfect i o n pri or to s k i n closure.
C l o s u re • If a closed suct i o n drain is p l aced, it should be rem oved o n postope rative day 1 .

POSTOPERATIVE CARE should be obtained t o identify a n d manage restenosis,


which most commonly occurs in the first 2 years following
• Patients should be placed on continuous monitoring to assess endarterectomy.
for blood pressure lability. Patients generally are discharged
on postoperative day 1 or 2 .
OUTCOMES
• A postoperative duplex should be obtained within
30 days of intervention to assess the reconstruction, pro­ • The North American Symptomatic Carotid Endarterectomy
vide a new baseline for long-term surveillance, and monitor Trial (NASCET) demonstrated the 3 0-day CEA stroke and
wound healing and plaque incorporation. Serial ultrasounds death rate of 5 . 5 % for symptomatic patients. 1
1826 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

• The Asymptomatic Carotid Atherosclerosis Study (ACAS) 3. 2011 ASNACCF/AHNAANNIAANS/ACRIASNR/CNS/SAIP/SCAJ/SIR


demonstrated a combined 3 0-day CEA stroke and death rate /SNIS/SVM/SVS guideline on the management of patients with extracra­
nial carotid and vertebral artery disease: executive summary. A Report
of 2.3 % .2
of the American College of Cardiology Foundation/American Heart
• More recently, the Carotid Revascularization Endarter­ Association Task Force on Practice Guidelines, and the American Stroke
ectomy versus Stenting Trial ( CREST) demonstrated the Association, American Association of Neuroscience Nurses, American
3 0-day stroke, death, or rate of myocardial infarction (MI) Association of Neurological Surgeons, American College of Radiology,
to be 5.4% in symptomatic patients and 3 . 6 % in asymp­ American Society of Neuroradiology, Congress of Neurological Surgeons,
tomatic patients, and the 3 0-day death and stroke rates were Society of Atherosclerosis Imaging and Prevention, Society for Cardiovas­
cular Angiography and Interventions, Society of lnterventional Radiology,
found to be 3 . 2 % in symptomatic patients and 1 .4 % in
Society of Neurolnterventional Surgery, Society for Vascular Medicine,
asymptomatic patients undergoing CEA. In the periproce­
and Society for Vascular Surgery. Circulation. 2011;124(4):489-532.
dural period, there is a lower rate of stroke with CEA versus 4. American College of Cardiology Foundation/American Heart Asso­
stenting (2.3 % vs. 4 . 1 %) but a higher rate of MI (2. 3 % vs. ciation Task Force on Practice Guidelines, American Society of Echo­
1 . 1 % ) . Mortality rates are similar.9 cardiography, American Society of Nuclear Cardiology, et al. 2009
ACCF/AHA focused update on perioperative beta blockade incorpo­
COMPLICATIONS rated into the ACC/AHA 2007 guidelines on perioperative cardiovas­
cular evaluation and care for noncardiac surgery. I Am Call Cardia/.
• Cervical hematoma 2009;54:e13-e118.
• Hemodynamic instability 5. Ricotta JJ, Aburahma A, Ascher E, et a!. Updated Society for Vascular
Surgery guidelines for management of extracranial carotid disease.
• Cerebral hyperperfusion syndrome manifested by severe
I Vase Surg. 2011;54:e1-e31.
headache
6. Samson RH, Showalter DP, Yunis JP. Routine carotid endarterectomy
• Cranial nerve palsy without a shunt, even in the presence of a contralateral occlusion.
• Stroke/MI Cardiovasc Surg. 1998;6:475-484.
• Thrombosis ( early) 7. Mcgirt MJ, Perler BA, Brooke BS, et al. 3-Hydroxy-3-methylglu­
• Recurrent stenosis (late) taryl coenzyme A reductase inhibitors reduce the risk of periopera­
tive stroke and mortality after carotid endarterectomy. I Vase Surg.
2005;42:829-835.
REFERENCES
8. Dorafshar AH, Rei! TD, Ahn SS, et a!. Interposition grafts for difficult
1. North American Symptomatic Carotid Endarterectomy Trial Collabora­ carotid artery reconstruction: a 17-year experience. Ann Vase Surg.
tors. Beneficial effect of carotid endarterectomy in symptomatic patients 2008;22(1):63-69.
with high-grade carotid stenosis. N Eng/ I Med. 1991;325:445-453. 9. Mantese VA, Timaran CH, Chiu D, et al. The Carotid Revasculariza­
2. Walker MD, Marler JR, Goldstein M. Endarterectomy for asymptom­ tion Endarterectomy versus Scenting Trial (CREST): scenting versus
atic carotid artery stenosis. Executive Committee for the Asymptom­ carotid endarterectomy for carotid disease. Stroke. 2010;41(suppl 10):
atic Carotid Atherosclerosis Study. IAMA. 1995;273:1421-1428. S31-S34.
I

Chapter 4 Carotid Surgery: Bifurcation


Stenting with Distal Protection
1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - �

Zhen 5. Huang Darren B. Schneider

DEFINITION Vascular exam should note the presence of palpable femoral


and distal lower extremity pulses and carotid bruits.
• Carotid artery stenosis was first successfully treated via per­
cutaneous balloon angioplasty in 1 9 77 by Mathias and col­ IMAGING AND OTHER DIAGNOSTIC
leagues.1·2 This technique has evolved over time to include
STUDIES
use of self-expanding nitinol stents and distal embolic protec­
tion devices (EPD ) . Carotid angioplasty and stenting ( CAS) • Initial carotid duplex ultrasound is obtained to evaluate
is indicated as an alternative to open carotid endarterectomy the degree of stenosis and plaque morphology. Studies have
( CEA) in certain clinical scenarios where the patient's anat­ highlighted a higher potential for embolism during CAS
omy and/or physiology pose a greater risk for complications with hypoechoic lipid-containing plaque.4
with CEA. However, these specific clinical conditions are not • Angiographic imaging of the aortic arch and carotid and
absolute and must be weighed against risks for endovascular cerebral arterial vasculature must be obtained to aid in
intervention. proper patient selection and procedural planning. This is ac­
• Distal EPD complished through computed tomographic arteriography
According to the 20 1 1 ASA/ACCF/AHA/AANN/AANS/ ( CTA) ( FIG 2 ) , magnetic resonance arteriography (MRA), or
A CRJASNR/CNS/SAIP/SCAIISIR/SNIS/SVM/SVS guide­ catheter-based contrast arteriography.
line on the management of patients with extracranial Arch anatomy
carotid and vertebral artery disease, " EPD deployment Aortic arch morphology is variable and can change
during CAS can be beneficial to reduce the risk of stroke with advancing age. The arch anatomy can be divided
when the risk of vascular inj ury is low. " 3 into three types, dictated by the position of the innomi­
A distal filter is placed in the internal carotid artery (ICA) nate artery origin relative to two horizontal lines drawn
distal to the lesion but below the skull base, with the pur­ across the apices of the outer and inner aortic arch cur­
pose of capturing debris to prevent distal embolization vatures ( FIG 3 ) .
during CAS ( FIG 1 ) . The target lesion must be crossed by Type I-the innominate origin arises a t o r above the
the filter before deployment but this system allows for ce­ horizontal plane of the outer arch curvature ( FIG 3A)
rebral protection with maintenance of blood flow to the Type li-the innominate origin arises in between the
brain during subsequent steps of the procedure. The filter two horizontal planes of the outer and inner arch cur­
is mounted on the same wire used to perform CAS and vatures ( FIG 38)
after successful CAS, the filter is retrieved along with any Type III-the innominate origin lies below the horizon­
captured debris. tal plane of the inner arch curvature ( FIG 3C)
The difficulty in gaining access to the carotid arteries in­
PATIENT HISTORY AND PHYSICAL creases from types I to III. There is an increase in angle
acuity of the great vessel origins off the arch with in­
FINDINGS
creasing arch types that make wire/catheter guidance/
• A thorough history should be obtained prior to interven­ exchange more difficult.
tion and should include a detailed description of, if present, Bovine arch-congenital arch variations where the left
symptoms ( quality, duration, etc . ) that may be indicative of common carotid artery ( CCA) shares a common origin
transient ischemic attacks (TIA) or prior stroke, past medical/ with the innominate artery (more frequent) or the left
surgical history (e.g., prior cerebrovascular disease/interven­ CCA branches off the innominate artery. In a pure bo­
tions), current medications (e.g., antiplatelet or anticoagula­ vine arch (extremely rare ), the right subclavian, com­
tion medications) , and social history (e.g., tobacco use ) . mon carotid-both right and left-and left subclavian
• A comprehensive physical exam is mandatory a n d should in­ all derive from one common arterial trunk off the aortic
clude a complete vascular and neurologic/stroke evaluation. arch.

A B c
FIG 1 • D i stal E P D . A. F i lterWire EZ, B osto n Scientific. B. A n g i o g u a rd, Cord i s
E n d ovasc u l a r. C. RX Acc u n et, Ab bot Vasc u l a r.

182 7
1828 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

A B c
FIG 2 • CTA i m a g i n g of a o rtic a rch a n d g reat vessels d e m o nstrat i n g a l eft ICA ste nosis. A. Sag itta l i m a g e . 3-D
image reco nstructions from the CTA i m ages of the a o rtic a rch (B) a n d cervical l eft ca rotid a rte ry, d e m o n strat i n g
the l eft I C A ste nosis (C) .

Shaggy aorta-when extensive aortic wall irregularities device sizes. In addition, severe carotid circumferential
exist, there is a high risk for significant atheroembolism calcification and vessel tortuosity may negatively impact
and thus, this may be a contraindication to CAS. procedural success (e.g., difficulty with inserting stent,
Eggshell aorta-with severe aortic wall calcification, placement of EPD in distal ICA) and may represent a con­
there is increased risk of intimal disruption and diffi­ traindication to CAS.
culty of wire/catheter manipulation/advancement. • Preoperative brain imaging with computed tomography
Cerebral flow to both hemispheres is assessed to deter­ ( CT) or magnetic resonance imaging (MRI) is needed for
mine cerebral reserve. symptomatic patients to document prior infarcts and to rule
Carotid vessel size, tortuosity, and calcification--carotid out preexisting hemorrhagic stroke prior to the initiation of
artery diameter should be assessed to aid in determining the procedure.

A B

FIG 3 • A. Type I a rc h . B. Type II a rc h . C. Type I l l a rc h . (White arrows


in B a n d C i n d icate wi re/catheter t i p traj ectory req u i red for sel ective
catheterization of the i n n o m i n ate/carotid a rteries with i n specific
c a rch type.
C h a p t e r 4 CAROT I D S U R G E RY: Bifurcation Stenting with D istal Protection 1829

SURGICAL MANAGEMENT Preoperative Planning

• The indications for any surgical intervention for carotid dis­ • Patients are initiated on antiplatelet therapy with aspirin
ease depend on the patient's clinical status (i.e., symptom­ 325 mg per day and clopidogrel 75 mg per day for 5 days
atic or asymptomatic) and the characteristics of the carotid prior to intervention. Alternatively, a clopidogrel loading
lesion. dose of 300 mg can be administered 4 to 6 hours prior to the
• It has been widely accepted that appropriate candidates for intervention.
CEA are symptomatic patients with carotid stenosis of 70% • Antihypertensive medications can be held off the day of in­
to 9 9 % on noninvasive imaging and an anticipated periop­ tervention to prevent contribution to the possible periproce­
erative risk of stroke or mortality of less than 6 % . Benefit dural hypotension.
of intervention for symptomatic patients with lesser degrees
of stenosis ( 5 0 % to 69 % ) has also been shown but not for Positioning
symptomatic patients with less than 5 0 % carotid stenosis.
• The patient is placed in the supine position with adequate
CAS is an alternative to CEA for symptomatic patients meet­
monitoring throughout the peri- and postprocedural period.
ing similar criteria along with anatomic and/or physiologic
Minimal monitoring includes continuous electrocardiogram
factors unfavorable for CEA (Table 1 ) . 3 •5
( EKG), intraarterial blood pressure, and pulse oximetry.
• The recommendations/indications for CAS in asymptomatic
The patient's neurologic status must be frequently evaluated
patients are still issues for debate and no consensus exists.
during the procedure via answering of simple questions and
CAS may be considered for patients with asymptomatic ICA
squeezing a plastic sound toy (e.g., rubber duck squeaky toy)
stenosis between 70% and 9 9 % , but there are insufficient
in the contralateral hand.
data to recommend CAS for primary therapy in asymptom­
• Intraarterial blood pressure monitoring is established usu­
atic patients. Therefore, these patients need to be addressed
ally via a radial arterial line.
on a case-by-case basis with consideration of patient comor­
• In order to maintain patient cooperation/comfort and frequent
bidities and risks of CAS.
neurologic monitoring, minimal or no sedation is administered
• The contraindications for CAS are predominantly related to
and only local anesthesia is infiltrated for the access site.
aortic arch and carotid artery anatomic factors (Table 2 ) .

Tab l e 2: Anatomic and Physiologic Factors


Tab l e 1 : Anatom ic a n d Physiologic Factors
Unfavora b l e for Carotid Angioplasty and
Favoring Carotid Ang ioplasty and Stenting
Stenting
Anatomic Factor Physiologic Factor
Anatomic Factor Physiologic Factor
Reoperative neck (e.g., prior C EA, prior radical U nstable angina
neck dissection) Severely angulated aortic arch (type I l l ) Ages 80 years and older
H i story of cervical rad iation Recent M l (<30 days) Shaggy/eggshell aorta Contraindication to anti platelet
High carotid lesion (above C2) C H F with E F less than 30% therapy
H i story of contra lateral CEA with associated Severe C O P D (FEV 1 <30%) Severe aortoiliac occl usive disease Severe renal dysfu nction
cranial nerve injury Severe ICA calcification/tortuosity
Tracheostomy Severe carotid stenosis/string sign
Contralateral carotid occlusion Unstable carotid plaque
Fresh carotid thrombus
Decreased cerebra l reserve
CEA, carotid endarterectomy; CHF, congestive heart failure; EF, ejection frac­
tion; COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory
volume in 1 second ICA, internal carotid artery

PERCUTANEOUS RETROGRADE FEMORAL bifurcati o n i n an a rea with m i n i m a l d isease. The r i g ht


C FA is the m ost conve n i ent s ite for r i g ht-h a n d e d opera­
ARTERY ACCESS tors. The left CFA and b rach i a l a n d ra d i a l a rteries a re a l ­
• O bta i n retro g ra d e access via the c o m m o n fe m o ra l a rtery ternative access sites. U ltim ately, the safest a n d s i m p l est
(CFA) u s i n g a percuta neous m i cro p u ncture (2 1 -g a u g e access site to the target lesion s h o u l d be e m p l oyed .
need l e) system u n d e r u ltraso u n d g u i d a nce. The CFA • The m i c r o p u n ct u re sheath is then excha n ged for a 5-Fr
s h o u l d be accessed i m m e d i ately proxi m a l to the fe moral i ntroducer sheath over the 0.035-in access wire.

ARCH AORTOG RAPHY


• A g u idewire is adva nced i nto the aortic a rch fol l owed by
a pigta i l catheter. The pigta i l catheter is positioned in the
m id-ascending aorta and a rch aortog ra phy is performed i n a
45- to 60-deg ree left a nterior oblique p rojection in order to
adeq uately visual ize the origin of the g reat vessels (FIG 4).
1830 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

FIG 4 • Arch a o rtog raphy with pigta i l catheter i n


m i d asce n d i n g a o rta.

SELECTIVE COM M O N CAROT I D


CATHETERIZATI O N
• B efore f u rt h e r m a n i p u l a t i o n of w i res/catheters i n the
a rc h a n d g reat vessel o r i g i ns, t h e patient i s a d m i n ­
istered syste m i c h e p a r i n a t 7 0 t o 1 00 U/kg i ntrave­
n o u s l y (IV) with a g o a l activated c l ott i n g t i m e of 2 5 0 to
300 seco n d s .
• W h i l e m a i nta i n i n g the l eft a nt e r i o r o b l i q u e (LAO)
p roj ect i o n that a l l ows for opti m a l v i s u a l i z a t i o n of t h e
g reat vessels o r i g i ns, a road m a p i m a g e i s used to as­
s i st in sel ective cathete r i z a t i o n of t h e CCA. The p i gta i l
catheter i s exc h a n g e d for t h e ope rator's catheter of
c h o i ce .
• M u lt i p l e cu rved catheters a re ava i l a b l e (FIG 5), each with
u n i q u e featu res that may be benefi c i a l i n d i fferent a n at­
o m i es. H owever, freq uent ly, sel ective com m o n ca rot i d
catheterization can be acco m p l ished w i t h a com b i nation FIG 6 • Type I a rch with bovi n e confi g u rati o n .
of a n a n g l ed o r simple c u rved catheter and a f l o p py an­
g l ed G l i dewi rerM
• H owever, a retroflexed or co m p l ex cu rved catheter (e . g . ,
S I M o r Vitek) may be n ecessa ry w i t h a d iffi c u l t a rch
a n atomy such as type I l l a rch o r bovi n e confi g u rat i o n
(FIG 6) .
• After the G l i dewi rerM has accessed the co m m o n carotid
Angled
Will JIU (but ta k i n g extreme care not to advance past the bi­
Gl ldl
fu rcation), the sel ective catheter is adva n ced over the
G l i dewi rerM i nto the common ca rot i d . Common ca rotid­
sel ective a n g i ogra ms a re then pe rfo rmed typica l l y i n the
a ntero poste rior, l atera l, a n d o b l i q u e p rojections (more
vi ews a re perfo rmed as needed) (FIG 7) . Contra l atera l
ca rotid a rteriogram can be performed as we l l if neces­
sa ry, but t h i s usua l ly is n ot performed d u ri n g CAS of a
u n i l atera l lesion.
• Cerebra l vessel a n g iography is then perfo rmed, typica l ly
FIG S • Va rious catheters can be used for sel ect ive in a nteroposte rior a n d l atera l views (FIG 8). Addit i o n a l
cathete rization of the co m m o n ca roti d . vi ews c a n be d o n e if n ecessa ry.
C h a p t e r 4 CAROT I D S U R G E RY: Bifurcation Stenting with D istal Protection 183 1

A B c
FIG 7 • A. Sel ective l eft c o m m o n ca rotid a n g iog raphy, cra n ioca u d a l a ntero poste rior p roj ect i o n . B. Sel ective l eft
c o m m o n ca rotid a n g iography, o b l i q u e p roject i o n . C. Sel ective l eft co m m o n ca rotid a n g iog raphy, l atera l p roj ect i o n .

A B
FIG 8 • A. Cerebra l vessel a n g iography via l eft CCA, cra n i oca u d a l a nteroposte rior (AP) p roj ect i o n .
B. Cerebra l vessel a n g i og raphy via l eft CCA. latera l p roject i o n .

PLACEMENT OF G U I D I N G SH EATH to ensure the stiff wire tip does not inadvertently advance
and potentia l ly perforate the ECA branch. The catheter
• After co m m o n ca rotid a n g i o g raphy is com p l ete, it is rec­ is then rem oved leavi ng the stiff wire in pl ace in the ECA
o m m e n d e d that the a ppropriate n ecessary e q u i p m e nt (FIG 9). If there is significant atherosclerotic sten osis i nvolv­
to co m p l ete the p roced u re is sel ected prior to f u rther ing the carotid bifu rcation, or if the ECA is severely stenotic/
sel ective ca n n u l at i o n of the ca rotid vesse ls (e . g . , access occluded that p revents safe ECA access, an AmplatzrM wire
sheaths, wi res, cath ete rs, fi lter and fi lter retrieva l system, with a 1 -cm floppy tip may be left in the d ista l CCA.
pre- and postd i l atation b a l loo ns, ste nt) . • O n ce the s u p p o rtive w i re i s in p l ace, the g r o i n i ntroducer
• In order to advance a sheath i nto the p roximal common sheath is exchanged for a 6-Fr 90-cm sheath. The sheath is
carotid, adequate exchange suppo rt is needed with a stiff tracked over the stiff w i re and p l aced i nto the d i sta l CCA
g u idewire. To achieve this, the selective catheter is caref u l ly prox i m a l to the bifu rcat i o n . It is i m perative that sheath
adva nced over the floppy G l idewi rerM i nto a branch of the adva ncement is performed o n l ive f l u o rosco py, especi a l ly
external carotid a rtery (ECA) . The floppy G l idewi rerM is then when negotiat i n g the t u r n at the co m m o n ca rotid o r i g i n,
exchanged for a stiff g u idewire (e .g., long AmplatzrM Su­ to e n s u re the sh eath is adva n c i n g a p p ropriately.
perstiff wire with floppy tip). Caution needs to be exercised
1832 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

FIG 9 • Stiff w i re with i n ECA to a l l ow g u i d i n g


sheath advancement i nto c o m m o n ca rot i d .

CROS S I N G T H E LESION WITH D I STAL


E M BOLIC PROTECTI O N DEVICES
• With the sheath i n p l a ce a n d u s i n g a road m a p i m a ge,
the I CA lesion is crossed with the 0. 0 1 4- i n w i re compo­
nent of the d ista l EPD. The d ista l E P D should be d e p l oyed
in a stra ight portion of the d i sta i i CA p roxi m a l to the pe­
trous portion at sku l l base (FIG 1 0) . It is i m porta nt not to
a l low i n a dvertent m i g ration of the EPD f u rther d i sta l ly
for risk of i n j u ry to the i ntracra n i a i i CA.

FIG 1 0 • D i sta l E P D d e p l oyed i n the d ista l I CA


p roxi m a l to the petrous port i o n at sku l l base.

PRE D I LATATION WITH AN G I OPLASTY


BALLOON
• After the d ista l E P D is i n position, the ca rotid lesion is
pred i l ated with a 3 - o r 4-m m coro n a ry a n g i o p lasty bal­
loon u p to n o m i n a l p ressu re (FIG 1 1 ) . A h i g h e r i nflation
press u re may be req u i red for heavily cal cified lesions.
Using a b a l loon l e ngth of 4 em should help to m i n i m ize
the risk of the b a l loon s l i p p i n g ("wate r m e l o n seed i n g " )
d u r i n g i nflation. I n a d d ition, it is i m po rtant t o be extra
vi g i l a nt in m o n itoring the patient's heart rate for possi b l e
bradycardia (or even asystole) d u ri n g l e s i o n predi l atation
a n d atro p i n e m ust be rea d i ly ava i l a b l e for a d m i n istrat i o n
before pred i l atat i o n .

FIG 1 1 • Left I CA l e s i o n p red i l atation w i t h 3 - m m coro n a ry


ba l l oo n .
C h a p t e r 4 CAROT I D S U R G E RY: Bifurcation Stenting with D istal Protection 1833

STENTI N G AND POSTD I LATATI O N


• F o l l o w i n g p red i l atat i o n , a c h a n n e l is created that w i l l
acco m m o d ate t h e a d v a n c e m e n t o f t h e ste nt syste m .
A s e l f-expa n d i n g ste nt com pati b l e with t h e d i sta l E P D
syste m i s adva n ced over t h e w i re a n d d e p l oyed u n d e r a
road m a p . The d i sta l a n d p rox i m a l ste nt l a n d i n g z ones
m u st be at a reas of n o rm al ves s el wa l l an d t h i s w i l l f re­
q u e n t l y n ecessitate ste n t i n g a c ross t h e ECA o r i g i n with
t h e prox i m a l l a n d i n g z o n e i n t h e d i sta l CCA (FIG 1 3) .
After ste nt d e p l oy m e nt, it i s postd i l ated (us u a l ly u s i n g
a 5 to 6 m m x 2 em b a l l oo n ) , treat i n g o n ly t h e stented
p o rt i o n s of t h e I CA to m i n i m i ze i nj u ry to the n ative
vesse l wa l l (FIG 1 2) and over postd i l atat i o n i s strictly
avo i d e d to reduce r i s ks of e m b o l i z at i o n . D u r i n g post­
d i latat i o n , the p a t i e nt's h e a rt rate m u st be c l o s e l y
m o n itored for a n y c h a n g es a n d atro p i n e s h o u l d sti l l be
rea d i ly ava i l a b l e . FIG 12 • Ste nt postd i l atation with a 5 m m x 2 em b a l l o o n .

E M BOLIC PROTECTI O N DEVICE


RETRI EVAL A N D COMPLETI O N
ANG I O G RAM
• Co m p l et i o n a n g i o g ra p hy is p e rfo r m e d to assess ste nt
p l acement and postste nt carotid a ntegrade flow be­
fore t h e d i sta l EPD i s rem oved (FIG 1 3) . With n o r m a l
f l o w t h r o u g h t h e stent a n d n o fi l l i n g d efects p resent,
the f i l t e r i s ret r i eved . S l ow flow a n d/o r fi l l i n g d efects
at the fi lter can be seco n d a ry to s i g n ificant d e b r i s a n d
t h i s m u st be a s p i rated p r i o r t o retri eva l . T h e E P D re­
t r i eva l system i s adva nced ca refu l l y past t h e ste nt with­
out e n g a g i n g/catc h i n g o n t h e ste nt. With exte nsive
d e b ris p resent i n the f i l t e r, it i s i m p o rta nt not to f u l ly
reca ptu re t h e fi lter i n t h e retri eva l catheter as t h i s ca n
ext r u d e d e b r i s from the f i l t e r a n d c a u se d i st a l e m b o l i ­
zati o n . D i sta i ! CA vasos pasm c a n be p resent a s we l l a n d
FIG 1 3 • Comp letion a n g i og raphy is performed t o assess
it i s u s u a l l y seco n d a ry t o m i g ra t i o n of E P D d u ri n g t h e ste nt p l acement a n d poststent ca rotid a ntegrade fl ow. N ote
p roced u re . Typ i ca l l y, t h i s i s m a n a g e d conservatively b u t that t h i s ste nt i s p l aced across the ECA orig i n .
with s i g n ificant J CA spasm, n itrog lyce r i n ( 5 0 to 2 0 0 f.Lg)
ca n be a d m i n istered i n s m a l l d oses d i rectly i ntra a rteri­
a l l y i n t h e ! CA .

ACCESS H E MOSTAS I S
• The fe m o r a l a ccess a rte r i a l p u ncture can be cl osed u s i n g
sta n d a rd tech n i q ues e i t h e r w i t h a closure device o r by
d i rect m a n u a l co m p ress i o n . We p refer to use a closure
device a n d do not rout i n e l y reverse h e p a r i n a nticoa g u ­
l a t i o n w i t h p rota m i n e . For b rach i a l a rtery a ccess, d i rect
m a n u a l co m p ression is the p refe rred m ethod for a c h i ev­
i n g hemostasis.
1834 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

PEARLS AND PITFALLS


Sel ective c o m m o n ca rot i d • To rtuous a o rtic a rch/g reat vessel a n atomy may req u i re a d d i t i o n a l m a n i p u lation with va rious
cath erization retroflexed catheters i n order to sel ect the c o m m o n ca rot i d . H owever, with i n creasi n g m a n i p u ­
l a t i o n , there is a g reater r i s k of e m b o l i zation/a o rtic i nj u ry. The refore, a o rtic a rch/g reat vessel
a n atomy should be a n a lyzed preoperatively and, when i n d i cated, suita b l e a lternative p l a n s
s h o u l d be p repa red if the i n it i a l m ethod p roves u nsuccessfu l .
• A n extremely d iseased a o rtic a rch m a y be a rel ative contra i n d ication t o CAS.
Place m e nt of g u i d i n g sheath • When the ECA is occl uded, a s u p p o rtive g u idewire ca n n ot be p l aced to a l l ow track i n g of the
sheath and an a lternative method is needed. Alternatively, an A m p l atz g u idewire with a 1 -cm
floppy t i p in the d i sta l CCA may p rovide suffi cient s u p po rt for sheath p l acement. Sh uttle systems
that perm it tel esco p i n g the sheath i nto the CCA over a g u i dewire and catheter asse m b l y a re
a n other a ltern ative.
Cross i n g the lesion with EPD • D iffi cu lty cross i n g the lesion can be a d d ressed by c h a n g i n g the shape of the cross i n g w i re tip or
using a d i rect i o n a l catheter. Additi o n a l ly, c h a n g i n g the patie nt's head/neck posit i o n may m a ke a
vessel less a n g u l ated .
• Ce rta i n E P D such as the N av-6 (Abbott Vasc u l a r, Ab bott Pa rk, I L) a n d S p i d e r (Covi d i e n , Plymouth,
MN) a re i ntro d u ced over a w i re that is i ntrod uced i n d e pe n d e ntly before the fi lter. I ntrod u ction
of the i n dependent w i re may fa c i l itate su bseq uent i ntrod uct i o n of the fi lter across a t i g htly ste­
n otic lesion o r a lesion with an acute entry a n g l e .
• A " b uddy w i r e " (a d d i t i o n a l 0.0 1 4- i n w i re) can a lso be used t o p rovide extra s u p p o rt a n d faci l i ­
tate cross i n g a d iffi c u l t lesion.
• If the cross i n g p rofi l e of the E P D is too l a rg e to cross the ste n otic lesion, the ste notic lesion can
a lso be pred i l ated with a 2.5-mm b a l loon i n order to create a channel l a rge e n o u g h for EPD.
H oweve r, d i lating the lesion without a n E P D i n p l a ce i n c reases the risk of d i stal e m b o l izat i o n .
D i stal ICA spasm • Usua l ly caused b y d i stal E P D a n d reso lves after E P D a n d w i re a re remove d .
• S m a l l d oses of n itroglyce r i n a d m i n istered d i rectly to ca rotid may a i d i n reso l ut i o n .
Occ l u s i o n of flow p roxi m a l • D i sta i i CA fi lter may be f u l l of debris ca u s i n g slow flow o r ICA occl u s i o n . The debris s h o u l d b e
t o E P D afte r ste nt p l acement aspi rated f r o m the fi lter u s i n g a n a s p i ration catheter a n d repeat a n g iogram i s performed after
to confirm return of flow p r i or to EPD retri eva l .
• If it is d ete r m i ned that occ l u s i o n i s d u e t o acute ste nt t h ro m bosis t h e n i m med iate convers i o n
to open exploration, ste nt rem ova l , a n d fo r m a l CEA may be n ecessa ry. Preparations for ca rot i d
stenti n g s h o u l d a l ways i n c l u d e t h i s poss i b i l ity.
D i stal e m b o l i zation with • N e u ro rescue tech n i q ues a re used to treat d ista l e m b o l i zation or throm bosis, i n c l u d i n g the
n e u ro l o g i c sym ptoms a n d/ fo l l owi n g :
or i ntracra n i a l a rte r i a l • Catheter- d i rected throm bolysis w i t h tissue p l a s m i nogen activato r (tPA)
occl usion • Mech a n ical t h ro m bolysis with a s p i ration
• G lycop rote i n (G P) l l a/l l l b i n h i bitor a d m i n i strati o n
• D i rect remova l w i t h s n a re (intra a rte r i a l )
• D i rect b a l loon a n g i o p lasty to restore a l u m e n
N o t e : I ntracra n i a l n e u rorescue tech n i q ues shou l d be perfo rmed by physicians w i t h a p p ropriate
expe rience a n d tra i n i n g .

POSTOPERATIVE CARE • The patient needs to remain on bed rest in the supine posi­
tion for 4 to 6 hours after access site hemostasis is achieved.
• Neurologic status i s immediately evaluated after completion The head of the bed can be inclined to a maximum 30 de­
of the procedure and continuous invasive blood pressure grees to promote patient comfort and respiratory function.
monitoring and pulse oximetry are maintained. Typically, Afterward, the patient can ambulate as tolerated.
CAS patients are observed in a monitored step-down unit • Immediate head and neck imaging along with neurology
overnight. consultation are mandatory if the patient experiences a post­
• Goal systolic blood pressures should be based on preop­ operative neurologic event.
erative measurements . Vasopressor and/or inotropic sup­ • Antiplatelet therapy with clopidogrel should be continued
port may be required to compensate for hypotension and/ for at least 1 month post-CAS, whereas aspirin is continued
or bradycardia likely due to carotid sinus distension re­ indefinitely.
lated to the procedure until the carotid sinus adapts to the
presence of the stent. Other causes of hypotension need to
OUTCOMES
be excluded prior to attributing the cause to angioplasty/
stenting alone. Conversely, antihypertensives should be • Studies prior to year 2000 failed to define the role of CAS
used as needed to prevent hypertension and potential ce­ in treating carotid artery disease due to numerous factors.
rebral hyperperfusion. More recent randomized controlled trials (RCTs ) were
C h a p t e r 4 CAROT I D S U R G E RY: Bifurcation Stenting with D istal Protection 1835

performed in order to elucidate CAS' role in carotid disease, CEA was safer than CAS as treatment for patients with
namely as a noninferior alternative to CEA. symptomatic carotid stenosis of 5 0 % or greater ( enrolled
• The Stenting and Angioplasty with Protection in Patients 1 , 7 1 3 patients; CAS, n = 8 5 5 ; CEA, n = 8 5 8 ) .U The pri­
at High Risk for Endarterectomy (SAPPHIRE) trial6 ran­ mary composite endpoint, 120-day incidence of stroke,
domized symptomatic patients with 5 0 % or greater carotid death, or MI was higher in CAS compared to CEA ( 8 . 5 %
stenosis or asymptomatic patients with 8 0 % or greater ste­ v s . 5 . 2 % ; HR, 1 . 69; 9 5 % CI, 0 . 1 6 t o 2.45; P = . 0 0 6 ) . The
nosis with comorbidities that increased their risk of surgery adverse events occurring with the 3 0-day postprocedure pe­
to receive either CEA or CAS. For the CAS patients, they riod accounted for the maj ority observed at 120 days where
all had self-expandable nitinol stents (S.M.A.R.T. or PRE­ the cumulative incidence of stroke, death, and MI was 7.4%
CISE; Cordis, Miami Lakes, FL) placed with EPD (Angio­ in CAS compared to 4 . 0 % in CEA (P = .003 ) . The authors
guard or Angioguard XP; Cordis, Miami Lakes, FL). The concluded that CEA should remain the treatment of choice
primary endpoint was composite incidence of death, stroke, for symptomatic carotid stenosis patients that are suitable
or myocardial infarction (MI) within 30 days postprocedure for surgery while awaiting the long-term follow-up data of
or death or ipsilateral stroke between 31 days and 1 year. ICSS.
Only 334 patients were randomized- 1 6 7 to CEA and 1 6 7 • The Carotid Revascularization Endarterectomy versus Stent­
t o CAS (trial stopped early due t o poor enrollment) . N o sig­ ing Trial ( CREST) is a U.S. trial that is the most recent and
nificant difference in the primary composite endpoint rate largest RCT to compare the efficacy between CAS and CEA
was detected in the periprocedural period ( 3 0 days) for CAS in standard-risk patients. 12 Two thousand and five hundred
compared to CEA. However, 1 -year primary composite end­ two patients with asymptomatic carotid stenosis of 70 %
point rate was lower in CAS compared to CEA ( 1 2.2% vs. or greater (based on ultrasound criteria ) or symptomatic
2 0 . 1 %; P = .004) with a more pronounced difference in carotid stenosis of 5 0 % or greater ( based on angiographic
asymptomatic ( 9 . 9 % in CAS vs. 2 1 . 5 % in CEA; P = .02) North American Symptomatic Carotid Endarterectomy
than in symptomatic patients ( 1 6 . 8 % in CAS versus 1 6 . 5 % Trial criteria) were randomized to either CAS (n = 1 ,262;
i n CEA; P = . 9 5 ) . This difference vanished i n long-term RX Acculink stent; Carotid Stent System, Abbott Vascular,
follow-up and at 3 years, the major secondary endpoint (pri­ Abbott Park, IL) and a distal EPD (RX Accunet Embolic
mary endpoint plus death or ipsilateral stroke 1 to 3 years) Protection System, Abbott Vascular, Abbott Park, IL) or
cumulative incidences were 24. 6 % for CAS vs. 2 6 . 9 % for CEA (n = 1 ,240 ) . The primary composite endpoint was
CEA; P . 7 t . l Thus, the SAPPHIRE authors concluded that
= stroke, death, or MI during the periprocedural period or any
CAS with EPD was not inferior to CEA in patients with se­ ipsilateral stroke within 4 years. During the periprocedural
vere carotid artery stenosis and increased surgical risk. period, the primary endpoint incidence was similar with
• However, these results were not mirrored in two large CAS and CEA ( 5 . 2 % and 4 . 5 % , respectively; HR for stent­
European multicenter RCTs-Stent-Supported Percutaneous ing 1 . 1 8 ; 9 5 % CI, 0 . 8 2 to 1 .6 8 ; P . 3 8 ) . However, the rates
=

Angioplasty of the Carotid Artery versus Endarterectomy of individual endpoints differed between CAS and CEA:
( SPACE)8 and Endarterectomy Versus Angioplasty in Pa­ greater risk of stroke in CAS (4. 1 % vs. 2 . 3 % , respectively;
tients with Symptomatic Severe Carotid Stenosis (EVA-3 S ) 9 P = . 0 1 ) , greater risk of MI in CEA ( 1 . 1 % vs. 2.3 % , re­
trials. Both of these studies failed t o show noninferiority o f spectively; P = . 0 3 ) , no difference in death ( 0 . 7 % vs. 0 . 3 % ,
CAS compared t o CEA i n their respective study populations. respectively; P = . 1 8 ) . The periprocedural risk o f stroke or
In SPACE, the primary endpoint (rate of death or ipsilateral death was higher after CAS for symptomatic patients ( 6 . 0 %
ischemic stroke 3 0 days postprocedure) was 6 . 8 4 % in CAS vs. 3.2%; P = . 0 2 ) . There was n o significant difference in
and 6 . 3 4 % in CEA ( absolute difference 0 . 5 1 %, 9 0 % CI the estimated 4-year rate of the primary endpoint between
- 1 . 8 9 % to 2 . 9 1 %; noninferiority P = . 0 9 ) . In EVA-3S, the CAS and CEA (7.2% vs. 6 . 8 % , respectively; HR, 1 . 1 1 ;
results demonstrated greater rates of stroke and death in the P . 5 1 ; 9 5 % CI, 0 . 8 1 to 1 . 5 1 ) . CREST also demonstrated
=

CAS group as compared to the CEA group: 3 0-day incidence an interaction between age and treatment efficacy (P = .02)
of stroke or death was 9 . 6 % in CAS ( 9 5 % CI, 6.4 to 1 4 . 0 ) where CAS tended to show greater efficacy at younger than
a n d 3 . 9 % i n CEA ( 9 5 % C I , 2.0 t o 7.2 ) ; the relative risk o f 70 years of age and CEA at older than 70 years of age.
any stroke o r death after CAS as compared with CEA was • Overall, CAS as a noninferior or equivalent alternative treat­
2.5 ( 9 5 % CI, 1 .2 to 5 . 1 ) . At 6 months, the incidence of any ment compared to CEA has not been definitively established
stroke or death was 1 1 . 7% after CAS and 6. 1 % after CEA and further studies are needed.
(P .02). However, long-term data at 4 years from EVA-3S
=

did not demonstrate significant differences in the risk of any


COMPLICATIONS
stroke or death in between both CAS and CEA; the hazard
ratio (HR) was 1 . 3 9 ( 0 . 9 6 to 2.00; P = . 0 8 ) . 1 0 The authors • Postoperative complications
interpreted these results to " suggest that carotid stenting is Stroke-the incidence of stroke is higher with CAS than
as effective as carotid endarterectomy for middle-term pre­ CEA.1 1 Risk factors include advanced age, symptomatic
vention of ipsilateral stroke, but the safety of carotid stenting carotid stenosis, and complex anatomy. Postoperative
needs to be improved before it can be used as an alternative stroke needs to be addressed immediately with full neuro­
to carotid endarterectomy in patients with symptomatic ca­ logic evaluation and potential intervention.
rotid stenosis . " Hypotension-frequently observed post-CAS; however, it
• A more recent international multicenter RCT, the Interna­ usually will resolve spontaneously. Patients may require
tional Carotid Stenting Study (ICSS ), demonstrated that transient blood pressure support with vasopressors/volume.
1836 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

Cerebral hyperperfusion syndrome-may occur within of Cardiology Foundation/American Hearr Association Task Force on
the first week post-CAS and is usually associated with Practice Guidelines, and the American Stroke Association, American
Association of Neuroscience Nurses, American Association of Neuro­
poorly managed underlying hypertension. It presents as a
logical Surgeons, American College of Radiology, American Society
unilateral headache and can progress to seizures, intracra­ of Neuroradiology, Congress of Neurological Surgeons, Society of
nial hemorrhage, and/or coma. Head CT is obtained and Atherosclerosis Imaging and Prevention, Society for Cardiovascular
focal cerebral edema may be observed. The treatment is Angiography and Interventions, Society of Interventional Radiology,
aggressive blood pressure management. Society of Neurolnterventional Surgery, Society for Vascular Medicine,
MI---c a rdiac complications, namely MI, may occur during and Society for Vascular Surgery. Circulation. 2011;124(4):489-532.
4. Biasi GM, Froio A, Diethrich EB, et al. Carotid plaque echolucency
the periprocedural period for CAS. This is likely due to
increases the risk of stroke in carotid stenting: the Imaging in Ca­
the typically high-risk patient population selected for CAS
rotid Angioplasty and Risk of Stroke (ICAROS) study. Circulation.
given that most are poor candidates for CEA. 2004;110(6):756-762.
Access site complications-the most common access site 5. Ricotta JJ, Aburahma A, Ascher E, et al. Updated Society for Vascu­
complications that are inherent to endovascular proce­ lar Surgery guidelines for management of extracranial carotid disease.
dures are hematoma, pseudoaneurysm, retroperitoneal J Vase Surg. 2011;54(3):e1-e31.

hematoma, and arteriovenous fistula. To minimize the 6. Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery
stenting versus endarterectomy in high-risk patients. N Eng/ J Med.
risk for these complications, we recommend direct visu­
2004;351(15):1493-1501.
alization of the access vessel under ultrasound and using 7. Gurm HS, Yadav JS, Fayad P, et al. Long-term results of carotid
a micropuncture access system. In addition, proper use stenting versus endarterectomy in high-risk patients. N Eng/ J Med.
of vessel arteriotomy closure devices and/or manual ves­ 2008;358(15):1572-1579.
sel compression is mandatory to reduce the risk for these 8. Ringleb PA, Allen berg ], Briickmann H, et al. 30 day results from the
complications. SPACE trial of stent-protected angioplasty versus carotid endarrer­
ectomy in symptomatic patients: a randomised non-inferiority trial.
Stent restenosis-restenosis will occur in any current stent
Lancet. 2006;368(9543 ):1239-1247.
placed in the body and can be managed with reinterven­ 9. Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus stenting
tion as needed. in patients with symptomatic severe carotid stenosis. N Eng/ J Med.
2006;355(16):1660-1671.
REFERENCES 10. Mas JL, Trinquarr L, Leys D, et al. Endarrerectomy Versus Angio­
plasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S)
1. Mathias K. A new catheter system for percutaneous translumi­ trial: results up to 4 years from a randomised, multicentre trial. Lancet
nal angioplasty (PTA) of carotid arrery stenoses. Fortschr Med. Neural. 2008;7(10):885-892.
1977;95(15):1007-1011. 11. Ederle ], Dobson ], Featherstone RL, et al. Carotid artery stenting
2. Mathias K, Mittermayer C, Ensinger H, et al. Percutaneous catheter compared with endarterectomy in patients with symptomatic carotid
dilatation of carotid stenoses. Rofo. 1980;133(3):258-261. stenosis (International Carotid Stenting Study): an interim analysis of
3. Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/ a randomised controlled trial. Lancet. 2010;375(9719):985-997.
AANS/ ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on 12. Brott TG, Hobson RW II, Howard G, et al. Stenting versus endar­
the management of patients with extracranial carotid and vertebral terectomy for treatment of carotid-artery stenosis. N Eng/ J Med.
arrery disease: executive summary. A report of rhe American College 2010;363(1):11-23.
- I

Chapter 5 Carotid Surgery:


Distal Exposure and Control
Techniques and Complication
I
Management
:
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ·
I

Cheong J. Lee

DEFINITION • Although duplex scanning provides accurate and reproduc­


ible assessment of the presence and severity of carotid ste­
• The carotid artery typically bifurcates at the level of the
nosis, precise anatomic detail required for surgical planning
C3-C4 cervical spine. High carotid bifurcations and lesions
is optimally obtained from computed tomographic angiog­
that extend to the C l -C2 level pose technical challenges that
raphy ( CTA) or magnetic resonance arteriography (MRA).
may increase perioperative risk of stroke and cranial nerve
Localization of the carotid bifurcation in regard to cervical
injury. Ideally, the need for high access in carotid surgery
landmarks, as well as the distal extent of internal carotid ar­
should be anticipated preoperatively, with familiarity of the
tery (ICA) disease, is best assessed by CTA or MRA ( FIG 1 ) .
anatomy and exposure necessary for distal carotid control.
IMAGING AND OTHER DIAGNOSTIC
PATIENT HISTORY AND PHYSICAL
STUDIES
FINDINGS
• Current indications for carotid endarterectomy were re­
• As with any medical therapy, the clinician must first clearly
viewed in Part 6, Chapter 3 . 1-3
define the goals of treatment and thoroughly review the op­ • In recent years, CTA and MRA have assumed preeminent
erative risk with the patient.
roles in carotid intervention planning. Improved resolu­
• Optimal medical therapy must be instituted prior to inter­
tion has enabled highly accurate characterization of plaque
vention (e.g., antiplatelet agent, statin, beta-blocker) .
morphology, which may provide useful guidance regarding
• Patients with hostile neck anatomy, such as those with his­
plaque vulnerability during operative manipulation.
tory of high-dose neck radiation or severe systemic comor­ • MRA and CTA also provide essential information regarding
bidities contraindicating general or cervical block anesthesia,
potential collateral arterial flow through the circle of Willis
should be offered carotid angioplasty and stenting ( CAS) as
and the need for adjuvant maneuvers such as shunt place­
an alternative procedure.
ment during carotid revascularization ( FIG 2 ) .
• Patients with prior contralateral carotid revascularization
procedures should have laryngeal, hypoglossal, and glosso­
SURGICAL MANAGEMENT
pharyngeal nerve function documented prior to ipsilateral
dissection and exposure. When evidence of prior inj ury to Preoperative Planning for Distal Cervical Carotid
CN IX, X, or XII is evident, CAS should be considered as Exposure
an alternative. If CAS is not feasible under these circum­
• Knowledge of patient-specific cervical anatomy is essential
stances, the potential need for tracheostomy to manage
to successful management of distal carotid disease. When
postoperative airway obstruction should be reviewed with
recognized as necessary, specifying nasotracheal, rather
the patient.
than orotracheal, intubation for general endotracheal

FIG 1 • Refo rm atted CTA of a ca rotid body t u m o r exte n d i n g to FIG 2 • Rendered CTA d e m o nstrating i ncom pete n cy of the c i rcle
the d ista l I CA at the C1 cervical s p i n e leve l . of Wi l l is.

1837
1838 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

via intraoral wiring, facilitates exposure from infratemporal


ICA to the skull base. Subluxation is distinguished from dis­
location, which is more injurious and can potentiate long­
term temporomandibular j oint pain syndromes.

Positioning

• The patient is positioned supine, with the head extended


and rotated away from the operative site. Shoulder rolls
and shays are placed to stabilize the neck and optimize
extension. The nasotracheal tube is secured over the head
( FIG 3 ) .
• Arms are tucked t o the p atient's side t o allow the opera­
tor and the assistant to maneuver and stand comfortably.
This position also facilitates C-arm positioning when
needed.
• The patient is placed in the " beach chair" position to limit
FIG 3 • N a sotrachea l i ntu bation fac i l itates exposu res of the venous hypertension ( FIG 4) .
d i sta i i CA by open i n g the angle between the masto i d p rocess and
the m a n d i b l e (black lines).

anesthesia is a simple and highly effective maneuver to im­


prove exposure. Nasotracheal intubation allows the mouth
to stay closed during surgery, providing more room between
the ramus of the mandible and mastoid process for distal
dissection.
• Temporomandibular subluxation may further advantage
carotid exposure cephalad to the C2 cervical spine. Sub­
luxation of the ipsilateral mandibular condyle, performed FIG 4 • Patient i n t h e " beach c h a i r " posit i o n .

ANTERIOR APPROACH TO T H E D I STAL Exposure o f the Internal Carotid Artery Distal t o the
Bifurcation
I NTERNAL CAROT I D ARTE RY
• Key structu res that lie superior to the carotid bifurcation a re
Incision
the posterior bel ly of the digastric muscle, the hypoglossa l
• A vertical, rath e r t h a n tra nsverse, cervical i n c i s i o n is rec­ nerve, crossing veins from the sternocleidomastoid m uscle to
o m m e n d e d for o pti m a l d ista i iCA access (FIG S) . the i nternal j u g u l a r vein, and m uscu lar arterioles of the pos-
• Sta n d a rd expos u re of the ca rotid a rtery i n the sh eath terior branches of the external carotid a rtery (ECA) (FIG 6) .
was previously described in Part 6, Cha pter 3 . • The hypog lossa l nerve is identified safely using a posterolat­
eral to a nteromed ial dissection of the ICA. Movi ng cepha-
lad, the hypog lossa l nerve is d issected free from the medial
surface of the d i gastric m uscle. Crossing artery and veins of
the SCM often tether this nerve closer to the bifu rcation.
M eticulous identification and control led d ivision of these
tetheri ng vessels w i l l enable mobilization of the nerve.
Tracing the cou rse of the descending branch of the ansa
cervica lis back to the hypog lossa l itself provides positive con­
fi rmation of the location and cou rse of the nerve (FIG 7).
• The poste r i o r d i g a stric m uscle b e l l y may be retracted o r
d ivided as req u i red for exposu re, fo l l ow i n g r e l e a s e of
the a d h e rent hypog l ossa l n e rve.
• Additional cepha lad exposu re at this j u nctu re req u i res d ivi­
sion of the occipita l branch of the ECA. This further rel eases
the hypogl ossa l nerve. This m a neuver a lso req u i res d ivision
of the styloid m uscu lature (styloglossus, stylopharyngeus).
FIG 5 • Anato m i c l a n d m a rks for ca rot i d exposu res i n c l u d e
• Conti n u e d c e p h a l a d d i ssection exposes the g l ossopha­
the m asto i d p rocess, the a n g l e of the m a n d i b l e, a n d t h e
ste r n a l n otch . S k i n i n c i s i o n f o r ca rotid exposu res a re p l aced ryn g e a l n e rve, seen as a single o r double tru n k cross i n g
a nterior to the sternocleidom asto i d m uscle (SM) (solid line). the I CA anteriorly a n d cours i n g poste rior to the ex­
If d ista l exposu re is a ntici pated, the i n c i s i o n can be ca rried i n te r n a l carot i d . Ca re m u st be taken in separat i n g the
front o f t h e e a r (dotted line). hypog l ossa l and g l osso p h a ryngeal n e rves, as sma l l motor
C h a p t e r 5 CAROT I D S U R G E RY: Distal Exposure and Control Techniques and Complication Management 1839

PBD
Arterial
branch to

XII

I CA

sternocleidomastoid

FIG 8 • M o b i l ization of the hypo g l ossa l n e rve (XI I) a l l ows


FIG 6 • Once the ca rotid sheath is e ntered, expos u re of the expos u re of the d i sta l I CA.
d ista i iCA from an a nterior a p p roach beg i n s with identification
and d i ssection of the hypo g l ossa l n e rve (XI I), the poste rior
b e l l y of the d i g astric m uscle (PB D), a n d the cross i n g ve i n s and fi bers exit i n g the vagus n e rve a lso cou rse in this p l a n e .
a rteries to the sternocleidomasto i d m uscle. D a m a g e to these n e rves o r the g l osso p h a ryngeal ca n
cause swa l l owi n g dysfu ncti o n . Classical ly, i n j u ry to the
g l osso p h a ryngea l n e rve i n t h i s reg i o n may i m p a i r the
a b i l ity of the soh p a l ate to rise suffi ciently with swa l l ow­
i n g to p reve nt naso p h a ryngeal l i q u i d reflux.
• When these ste ps a re safe ly co m p l eted, the ICA may be
adeq uately exposed for reco nstruct i o n u p to the l evel of
C2 (FIG 8). F u rther exposure to the level of C1 fo l l owi n g
t h i s cou rse req u i res sty l o i d ectomy a n d/or preoperative
m a n d i b u l a r s u b l uxat i o n .
• D ista l d i ssect i o n may a l so be fa c i l itated by m o b i l ization
of the pa rotid g l a n d a n d fac i a l n e rve. This is most safe ly
acco m p l ished with assista nce from oto l a ryn g o l o g i sts o r
cra n i o m axi l l ofa c i a l surgeon. T o provide t h i s m e t h o d o f
exposu re, the s k i n i n c i s i o n is c a r r i e d ce p h a l a d a nterior to
the e a r (FIG 9) . This e n a b les m o b i l ization of the pa rot i d
g l a n d superiorly a n d m ed i a l ly.
• The p a rotid fasci a is entered a n d the b ra nches of the fa­
cial n e rve a re d i ssected, i d e ntified, and p rotected before
d i vi d i n g the poste rior belly of the d i g astric m uscle.
• Ca re is a g a i n taken to ide ntify the g l osso p h a ryngeal
n e rve a n d the motor fi bers of the va g u s n e rve (FIG 1 0) .
FIG 7 • Fol lowing d ivision of the d i g astric m u scle a n d the
cross i n g m uscu l a r vein a n d a rteries to the sternocleidom asto id,
• D ista l contro l o f t h e I CA a t h i g h C 1 -C2 level m a y req u i re
the d esce n d i n g a nsa cervica l i s n e rve (DAC) can be l i g ated speci a l ized i n strum entati o n . S m a l l detach a b l e occl u d i n g
to f u rther m o b i l ize the hypog l ossa l n e rve (XI I) . To f u rther c l a m ps (s uch as t h e Heifetz o r Yasa rg i l c l i ps) m a y p rovide
fac i l itate hypog l ossa l m o b i l ization, the occ i pital a rtery co m i n g i m p roved expos u re co m p a red to tra d i t i o n a l " h a n d l e d "
off t h e E C A h a s been l i g ated a n d d iv i d e d . vasc u l a r c l a m ps i n t h i s reg i o n . When u s e d , however,
1840 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

FIG 9 • If f u rther exposure of the I CA is req u i red a n d


m a n d i b u l a r s u b l uxation is n o t fea s i b le, i n c i s i o n can be carried
i n front of the e a r for m o b i l ization of the p a rotid g l a n d .

care m ust be taken to avo i d c l a m p d islodgement i n t h i s F I G 1 0 • O nce t h e pa rotid fascia is entered, t h e branches of
crowded a n d moving field, which when it does h a p p e n the fac i a l nerve (VI I ) a re identified fo l l owed by the division of
u s u a l l y d o e s so at the maxi m a l ly i n conve n ient t i m e . the poste rior belly of the d i g astric m uscle (PBD). Dissection is
• A s a n a ltern ative t o d ista l c l a m p control, short occl u d i n g then carried a nterior to the I CA from the hypog l ossa l nerve (XI I )
i ntra l u m i n a l catheters can be used, s u c h as a # 2 Fogarty d ista l ly t o identify the g l ossopharyngeal nerve (IX) . M otor fi bers
e m bolectomy catheter with stopcock. Extreme ca re m ust from the vagus nerve (X) a re ca refu l l y identified a n d p rese rved.
be taken in positio n i n g a n d deploying embolecto my bal­
loons i n this a rea, however, as i nflation with i n the petrous com p l ications a lso include pseudoa n e u rysm or a rteriove­
portion or overinflation i n any reg ion may p rec i p itate d is­ nous fistula fo rmation. The infl ated catheter should be se­
section, a rterial rupture, or throm bosis. Only the lowest cured to p revent its m i g rati o n . Stay sutu res may be placed
a m o u nt of i nflation req u i red to p revent back-b leed i n g in the d i stal carotid to m a i nta i n access should control be
s h o u l d be used. T h e carotid a rtery is thi n-wa l led a t t h i s lost due to ref l ux of the bal loon from the d i sta l a rtery or
level a n d easily tra u m atized b y bal loon i nflation . Late bal loon p u ncture d u ri n g suture closure of the a nastomosis.

RETROJ U G U LAR APPROACH TO THE • Using this a p p roach, it is essenti a l to identify the s p i n a l
accessory n e rve where it exits 2 t o 3 em below the edge
D I STAL I NTERNAL CAROT I D ARTERY
of the m asto i d p rocess, a nterior to the SCM. The SCM is
Retrojugular Dissection fu l ly m o b i l ized to fa c i l itate t h i s exposure.
• O n ce the s p i n a l accesso ry n e rve is i d e ntified a n d isol ated,
• A t h i rd a p p roach to the d i stal I CA is p rovided by retro­ the I J ve i n i s d issected a l o n g its poste rior border. The
j u g u l a r access. The i ntern a l j u g u l a r (IJ) ve i n a n g les a n ­ va g u s n e rve is i d e ntified and refl ected a nterio rly. With
te riorly as it ascends f r o m the b a s e of the n eck t o t h e the ve i n and vagus n e rve m o b i l ized a nte riorly, the hypo­
base of the sku l l a n d overl ies the d i stai i CA as the a rtery g l ossa l n e rve re m a i n s a nterior to the d i sta i i CA (FIG 1 1 ) .
a p p roaches the transverse p rocess of C l .
• U s i n g the poste rior a p p roach, d i ssect i n g beh i n d the IJ Identification o f the Superior Laryngeal Nerve
ve i n , obvi ates the need for hypog l ossa l exposu re a n d re­
• I n the retroj u g u l a r space, the I CA ca n be d i ssected a l o n g
l ocation, as that n e rve passes a nte riorly over the I CA.
i t s poste rior latera l wa l l superiorly whereupon the s u ­
p e r i o r l a ryngea l n e rve w i l l be encou ntered exit i n g the
Identification of the Spinal Accessory Nerve
va g u s n e rve and l o o p i n g a r o u n d the d i sta l I CA. Often,
• The retroj u g u l a r d i ssect i o n uses t h e s a m e i n c 1 s 1 o n s the superior cervical g a n g l i o n can be i d e ntified j u st l at­
as ot h e r a p p ro a c h e s to t h e d i sta l i nter n a l carotid, e r a l to t h i s l o o p i n g point (FIG 1 2) .
with t h e i n c i s i o n made vertica l ly, a nt e r i o r to t h e S C M • F o r a d d e d exposu re, the n e rve is ca refu l l y l i fted from t h e
m u sc l e . I CA adventit i a .
C h a p t e r 5 CAROT I D S U R G E RY: Distal Exposure and Control Techniques and Complication Management 1841

IJV

FIG 1 1 • Retroj u g u l a r exposu re of the ICA: D i ssection is FIG 12 • At the d ista l aspect of this retroj u g u l a r space, the
carried beh i n d the IJ ve i n a n d the va g u s n e rve (X) m o b i l ized I CA will be looped by the super l a ryngeal n e rve (SLN) as it
a nterior to the I CA. Care i s taken i n i d e ntify i n g the s p i n a l comes off the vag us n e rve (X) . Ofte n, the s u peri or cervical
accessory n e rve (XI) at the s u p e r i o r aspect of the d i ssect i o n . g a n g l i o n (SCG) se rves as a l a n d m a rk for where the SLN
This a p p roach a v o i d s m o b i l ization of the hypog l ossa l n e rve e m a n ates.
(XI I ) as the p l a n e of d i ssection re m a i n s poste rior to the n e rve.

PEARLS AND PITFALLS


Ind ications • M a ke n ote of s i g n ificant radiation o r surgery to the neck, whi c h may i nform the choice of p roced u re
(su rg e ry vs. ste nt) .
• M a ke ce rta i n the patie nt's cra n i a l n e rve status is d o c u m e nted, especi a l ly i n the sett i n g of p r i o r neck
o perations.
I ma g i ng • Alt h o u g h d u p l ex i m a g i n g a l o n e i s suffi c i e n t to plan m ost rout i n e ca rot i d s u r g e ry, cross-sect i o n a l
i m a g i n g (CTA/M RA) p rovides esse n t i a l g u i d a n ce for co m p l ex exposu res a n d reco nstructive
tech n i q ues.
• The status of the c i rcle of W i l l is s h o u l d be defi ned i n the cou rse of preoperative p l a n n i n g .
Technique • F o r lesions exte n d i n g t o t h e C 1 -C2 cervica l spi ne, co nsider a t a m i n i m u m n asotracheal i ntubation.
• I n extreme situatio ns, m a n d i b u l a r s u b l uxati o n may p rovi d e critical additional deg rees of freed o m .
• M a n d i b u l a r d i s location is n ot reco m m e n d e d a n d s h o u l d n ot be pe rfo rmed t o assist carotid surgery.
• Knowledge of cranial nerve anatomy is the most important determinant of success.
• Any n e u r a l tissue cross i n g a nterior to the ca rotid bi furcation a n d the I CA s h o u l d not be d i v i d e d .
• M o b i l ization of d iseased a rte r i a l seg m e nts, i n c l u d i n g the carotid bifu rcation, s h o u l d be avoided o r
m i n i m ized prior to h e p a r i n izat i o n .
• Anterior d ista i i CA expos u re is dependent o n the extent to which the hypog l ossal n e rve ca n be safe ly
m o b i l ized.
• Poste rior, retroj u g u l a r expos u re req u i res early i d e ntification of the spinal a ccesso ry n e rve a n d a nte r i o r
reflection of the vag u s n e rves to vis u a l ize the superior l a ryngea l n e rve e n c i rc l i n g the d ista l i nte r n a l
ca rot i d .
• B a l loon occ l u s i o n may fac i l itate far d i stal ca rotid control, but ove radva ncement a n d overi nflation a re
rea l risks that m ust be considered. P l a ce m e nt of stay sutu res w i l l fac i l itate future control m a n e uvers
s h o u l d the catheter become d i s l o d g e d .
1842 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

POSTOPERATIVE CARE of the Nationwide Inpatient Sample (NIS ) identified 259,0 8 0


carotid revascularization procedures performed during 2003
• Following carotid revascularization, the immediate post­ and 2004. Although the study examined and compared out­
operative care is focused on close neurologic surveillance. comes of both carotid endarterectomy and carotid artery
Patients are recovered typically in an intensive care unit or stenting, endarterectomy outcomes alone demonstrated an
monitored setting to facilitate ready identification of evolv­ impressive overall stroke rate of 0 . 8 8 % and operative mor­
ing neurologic deficits. tality rate of 0 . 3 9 % .4 Similarly, data prospectively obtained
• Careful blood pressure monitoring and management is also from National Surgical Quality Improvement Program
essential. Following carotid revascularization, patients need (NSQIP) participation reviewed 1 3 ,622 carotid endarterec­
to avoid the extremes of blood pressure, which may elicit tomies performed between 2000 and 2003 at 123 Veterans
hemodynamic stroke and intracerebral hemorrhage. Affairs and 14 private sector academic medical centers dem­
• Immediate postoperative ( <24 hours ) neurologic deficits onstrated a combined stroke and death rate of 3 . 4 % . 5
should be assumed to be thromboembolic in nature, most • Data describing outcome of distal ( base of skull) carotid re­
commonly associated with a technical (surgical) error. Fur­ vascularizations is based on more limited, institution-specific
ther imaging studies are unlikely to alter decision making case series. In these circumstances, outcomes are more diffi­
and should not delay immediate reoperation. Neurologic cult to benchmark. One recent series reported that one of five
deficits arising later in the postoperative period (> 24 hours) patients requiring a distal ICA bypass for aneurysm repair
may be due to intracranial hemorrhage; in these cases, com­ suffered a stroke; 6 0 % suffered varying degrees of cranial
puted tomography ( CT) or magnetic resonance (MR) imag­ nerve deficit. 6 The largest experience reported to date is that
ing may assist the decision-making process and should be of Sessa et a!./ who reported a 3% and 6% rate of periop­
considered when etiologic circumstances are less certain. erative stroke and restenosis at 1 year, respectively. When
• Bleeding complications following carotid surgery are rare distal carotid/skull base exposure appears to be necessary
but potentially serious or fatal. These may occur during the to safely manage an occlusive lesion, consideration should
first several hours after surgery or even later, particularly in again be given to CAS as a lower risk alternative technique
patients resuming anticoagulation therapy for existing con­ to open endarterectomy or interposition grafting.
ditions early in the postoperative period. Recognition and
expeditious control of the airway is of utmost importance COMPLICATIONS
as a wound hematoma develops, as cord and airway edema
rapidly worsen in response to reduced venous and lymphatic • Stroke
drainage. Reopening a carotid incision prior to anesthetic • Cranial nerve injury
induction may facilitate emergency endotracheal intuba­ • Horner's syndrome
tion; however, this dramatic maneuver is best performed in a • Seroma
controlled environment with resuscitation equipment avail­ • Infection
able should complications ensue. Ideally, preparations are
made for wound decompression as endotracheal intubation REFERENCES
is being attempted, with the wound being opened as a last 1. North American Symptomatic Carotid Endarterectomy Trial. Meth­
step maneuver prior to emergency cricothyroidotomy. Cord ods, patient characteristics, and progress. Stroke. 1991;22:711-720.
edema in these circumstances may be profound, however, 2. Endarterectomy for asymptomatic carotid artery stenosis. Executive
and visualization may not improve sufficiently after hema­ Committee for the Asymptomatic Carotid Atherosclerosis Study.
JAMA. 1995;273:1421-1428.
toma evacuation to enable orotracheal or nasotracheal intu­
3. Randomised trial of endarterectomy for recently symptomatic carotid
bation. Therefore, cricothyroidotomy may become necessary
stenosis: final results of the MRC European Carotid Surgery Trial
in extreme circumstances, and all carotid surgeons should be (ECST). Lancet. 1998;351:1379-1387.
facile in this maneuver as a matter of course. 4. McPhee JT, Hill JS, Ciocca RG, et al. Carotid endarterectomy was per­
formed with lower stroke and death rates than carotid artery scenting in
OUTCOMES the United States in 2003 and 2004. J Vase Surg. 2007;46:1112-1118.
5. Stoner MC, Abbott WM, Wong DR, et al. Defining the high-risk
• Although carotid endarterectomy is a well-established tech­ patient for carotid endarterectomy: an analysis of the prospective
nique continually refined over several decades, good out­ National Surgical Quality Improvement Program database. J Vase
comes are not limited to regional centers of excellence. Data Surg. 2006;43:285-295; discussion 295-296.
6. Eliason JL, Netterville JL, Guzman RJ, et al. Skull base resection with
provided to the American Board of Surgery regarding surgi­
cervical·to·petrous carotid artery bypass to facilitate repair of distal
cal case experience in the 12 months preceding application
internal carotid artery lesions. Cardiovase Surg. 2002;10:31-37.
for recertification in vascular surgery, carotid endarterec­ 7. Sessa CN, Morasch MD, Berguer R, et al. Carotid resection and re­
tomy is recorded as one of the most common procedures per­ placement with autogenous arterial graft during operation for neck
formed by contemporary vascular surgeons. A recent query malignancy. Ann Vase Surg. 1998;12:229-235.
I

Chapter 6 Vertebral Transposition


Techniques and Stenting
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - · - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - �
I

Mark D. Morasch
t

DEFINITION insufficiency. Benign vertiginous states should also be


considered. Physical examination can alert the physician to
• Treatment for occlusive lesions involving the origin of the the possibility of subclavian steal in patients with differences
vertebral artery (V1 segment) is undertaken to relieve pos­ in brachial blood pressure greater than 25 mmHg or with
terior brain circulation ischemia, otherwise known as ver­ diminished left upper extremity pulses. Reversed flow in the
tebrobasilar insufficiency. Revascularization options include ipsilateral vertebral artery demonstrated on duplex scanning
open surgical and endovascular techniques. The most com­ is pathognomonic for subclavian steal physiology and sub­
mon operation is a proximal vertebral to common carotid clavian steal syndrome in patients with appropriate symp­
transposition. Endoluminal treatment includes balloon toms at rest or following exercise in the ipsilateral upper
angioplasty and (typically) stenting. extremity.
• Patients may relate symptoms of vertebrobasilar insuffi­
DIFFERENTIAL DIAGNOSIS ciency to positional changes, including turning or extending
• Other medical conditions mimicking posterior circulation their head. These dynamic symptoms usually appear when
ischemia include postural hypotension, cardiac arrhythmias, turning the head to one side. In this circumstance, symptoms
anemia, brain tumors, and benign vertiginous states. A thor­ may be elicited by extrinsic compression of the dominant or
ough investigation consists of ruling out ( 1 ) inner ear pa­ sole vertebral artery (in the case of unilateral occlusion) by
thology, (2) cardiac arrhythmias, ( 3 ) internal carotid artery adj acent arthritic bone spurs. 1
stenosis/occlusion, and (4) complications of excessive blood
pressure control (Table 1 ) . PATIENT HISTORY AND
• Evaluation o f patients with posterior circulation isch­ PHYSICAL FINDINGS
emia requires defining the precise circumstances that
elicit symptoms. Vertigo, instability, and occasional loss • In general, ischemic mechanisms in vertebrobasilar insuf­
of consciousness often accompany positional changes and ficiency can be categorized as hemodynamic or embolic.
standing in older individuals due to reduced sympathetic Symptoms of vertebrobasilar insufficiency include dizziness,
venous tone. This is particularly common in p atients vertigo, drop attacks, diplopia, perioral numbness, alternat­
with diabetes. The presence of orthostatic hypotension ing paresthesia, tinnitus, dysphasia, dysarthria, and ataxia.
should be evaluated as a common alternative cause for When two or more of these symptoms are present, verte­
vertebrobasilar symptoms. Any decreases in basilar ar­ brobasilar ischemia is more likely to be the inciting cause.
tery perfusion pressure may precipitate hemodynamic Unlike other regions of the brain, strokes in the posterior
symptomatology, with or without concomitant vertebral circulation territory occur due to large artery occlusive
occlusive disease . diseases.
• The next most common cause of brainstem ischemia is re­ • Patients with "hemodynamic " ischemia experience transient
duced cardiac output. When suspected, evaluation includes vertebrobasilar symptoms due to inadequate vertebral artery
24-hour Holter monitoring and echocardiography. In pa­ inflow or collateral circulation. Symptoms are typically short
tients with vertebrobasilar insufficiency, palpitations may be lived, repetitive, somewhat predictable, and rarely result in
noted with the onset of symptoms. Transesophageal echo­ stroke. Postural hypotension may precipitate serious trau­
cardiography may be necessary to rule out structure heart matic injury, however, when patients lose their balance with
ISSUeS. standing.
• Inner ear pathology, including rare cerebellopontine angle • Embolic events may also precipitate vertebrobasilar ischemia
tumors, produces symptoms suggestive of vertebrobasilar as well as cerebellar and brainstem infarction. Microemboli
from the heart, aortic arch, or any arteries leading directly
to the basilar artery may arise from atherosclerotic lesions,
Table 1 : Nonvascular and Cardiac Conditions intimal defects, repetitive trauma, fibromuscular dysplasia
that M i m i c Vertebrobas i l a r Ischem i a lesions, aneurysms, or dissections. Although much less com­
mon than hemodynamic vertebrobasilar insufficiency, when
Cardiac a rrhyth mia present, microemboli are much more likely to cause fatal
Pacemaker ma lfunction
Cardioemboli events or debilitating infarcts. 2-4
Antihypertensive medications • Timing of the onset of symptoms following positional
Labyrinth i n e dysfunction changes may help differentiate vertebrobasilar insufficiency
Cerebellopontine angle tumors from labyrinthine disorders. In the latter circumstance,
Cerebellar degeneration
rapid head movement invokes immediate symptoms. In
Myxedema
Electrolyte imbalance the case of vertebrobasilar insufficiency, however, a short
Hypog lycemia delay usually precedes the onset of symptoms, including
nystagmus.

1843
1844 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

IMAGING AND OTHER DIAGNOSTIC a number of normal variants may be encountered, including
STUDIES congenital atresia of either vertebral artery.
• The vertebral artery origin may not be visualized adequately
Duplex ultrasound, an otherwise excellent tool for the assess­ with either duplex ultrasonography or MRA. O blique pro­
ment of extracranial cerebrovascular disease, has limitations in j ections are required during arteriography due to superim­
the diagnosis of vertebral artery pathology. Direct visualization position of the subclavian artery over the vertebral origin.
of the second portion is obscured by the transverse processes Additional projections, including craniocaudal tube an­
of C2-C6 . As previously mentioned, however, duplex imaging gulation, may also be required to optimize visualization.
reliably identifies subclavian steal physiology, as well as detect The presence of a poststenotic dilatation in the first centi­
proximal velocity increases consistent with orificial vertebral meter of the vertebral artery is a clue that should prompt
or proximal subclavian stenosis.5 further projections to isolate the origin from the overlying
• Magnetic resonance imaging (MRI) provides safe, nonin­ subclavian artery.
vasive, and detailed evaluation of the aortic arch and great • Dynamic arteriography, incorporating provocative position­
vessels, the extracranial and intracranial arterial vascula­ ing, may be required to assess the possibility of extrinsic
ture, as well as the presence of mass lesions, fluid collections, vertebral artery compression. Finally, delayed imaging may
or parenchymal defects in the posterior fossa. Contrast­ demonstrate reconstitution of patent distal extracranial ver­
enhanced magnetic resonance angiography (MRA), with tebral arteries through cervical collaterals when the origin
three-dimensional reconstruction and maximum image inten­ initially appears occluded.
sity techniques, provides excellent image quality in high reso­
lution ( FIG 1 ) . As in other applications, however, in low-flow SURGICAL MANAGEMENT
circumstances, excessive signal dropout may result in overes­
timation of lesion severity based on signal intensity alone.
• Some degree of vertebral artery orificial stenosis is present
• In contrast to computed tomographic ( CT) imaging, trans­
in 2 0 % to 4 0 % of patients with other manifestations of
axial MRI readily diagnoses both acute and chronic brain cerebrovascular disease.2 A number of operative approaches
infarctions in the posterior fossa. Brainstem infarctions are will satisfactorily address Vl segment disease and orificial
typically small and as such may be overlooked with noncon­ stenosis. 6•7 Vertebral transposition, or repositioning of the
trast CT imaging. Brain MRI is performed in symptomatic origin of the vertebral artery onto the adj acent common
patients prior to vertebral artery intervention to identify in­ carotid artery is the most common. Endoluminal dilata­
farctions when they are present and provide baseline images tion, with or without stenting, is also appropriate in selected
for future comparison. circumstances.
• Evaluation of vertebral anatomy via catheter-based, contrast
Vertebral to Common Carotid Transposition
arteriography requires acquisition of images in multiple pro­
j ections to fully evaluate the entire extent of both vertebral • General endotracheal anesthesia is preferred. Positioning su­
arteries. Evaluation begins with the aortic arch to deter­ pine, with the back of the table slightly elevated toward a
mine the origin of the bilateral vertebral arteries. Anoma­ chair position with the head rotated away from the planned
lous origin of the left vertebral artery, arising directly from incision site facilitates additional deep mediastinal exposure
the aorta proximal to the left subclavian, is present in 6 % when required.
o f patients. Much less frequently, the right vertebral artery • Proximal vertebral artery exposure is similar to that re­
originates from the innominate or right common carotid quired for subclavian-to-carotid transposition. One finger­
artery. This anomaly often accompanies an aberrant right breadth above the clavicle, a transverse incision is created
subclavian artery, which itself may precipitate symptoms of directly over the two heads of the sternocleidomastoid mus­
dysphagia lusoria. cle ( SCM) . Between the SCM heads, the omohyoid muscle
• Usually, right and left posterior oblique proj ections are suf­ is identified and divided. Lateral retraction of the internal
ficient to comprehensively evaluate the Vl (first) vertebral j ugular vein and vagus nerve exposes the carotid sheath
artery segment from the origin to the transverse process of medially. Maximal proximal carotid artery exposure, facili­
C6. In most patients, the left artery is usually dominant, but tated by positioning of the primary operator at head of the
patient, is necessary to ensure an optimal result ( FIG 2 ) .
• The sympathetic ganglia are identified running behind and
parallel to the carotid artery. On the left side, the thoracic
duct is divided between ligatures to minimize lymphatic
leaks. The proximal end should be doubly ligated, avoid­
ing transfixion sutures. Accessory lymph ducts-often seen
on the right side-should also be ligated and divided when
identified. The entire dissection is confined medial to the
prescalene fat pad covering the scalenus anticus muscle and
phrenic nerve. These latter structures are left unexposed lat­
eral to the field. The inferior thyroid artery, running trans­
versely across the field, is also ligated and divided.
• The vertebral vein is next identified emerging from the
FIG 1 • Verte b ra l M RA (with the ca rot i d i m a g e su btracted). angle formed by the longus colli and scalenus anticus and
C h a p t e r 6 VERTEBRAL TRA N S P O S I T I O N TEC H N I Q U E S A N D STE NTI N G 1845

A B

I nferior thyroid artery

Vag us
nerve
Thoracic d uct

Subclavian artery Internal


jugu lar vein

FIG 2 • A. Access to the p roxi m a l vertebra l a rtery betwee n the sternoc l e i d o m asto id m uscle
b e l l ies. B. Tra nspositi o n of the proxi m a l verte bral a rtery to the poster i o r wa l l of the common
carot i d a rte ry.

overlying the vertebral artery and, at the bottom of the field, is performed in open fashion with continuous 6-0 or 7-0 poly­
the subclavian artery. Unlike its sister artery, the vertebral propylene suture while avoiding any tension on the vertebral
vein has branches. It is ligated in continuity and divided. artery, which tears easily. Before completion of the anastomo­
Below the vertebral vein lies the vertebral artery. It is im­ sis, any slack in the suture is tightened appropriately with a
portant to identify and avoid injury to the adj acent sym­ nerve hook, standard flushing maneuvers are performed, and
pathetic chain. The vertebral artery is dissected superiorly the suture is tied to reestablish flow ( FIG 3 ) .
to the tendon of the longus colli and inferiorly to its origin
in the subclavian artery. The vertebral artery is freed from
the sympathetic trunk resting on its anterior surface without
damaging the trunk or the ganglionic rami. Preserving the
sympathetic trunks and the stellate or intermediate ganglia Common
resting on the artery usually requires freeing the vertebral carotid
artery from these structures, and after dividing its origin, the artery
latter is transposed anterior to the sympathetics.
• Once the artery is fully exposed, an appropriate site for re­
implantation in the common carotid artery is selected. The
patient is systemically anticoagulated with intravenous hep­
arin. The distal portion of the Vl segment of the vertebral
artery is clamped below the edge of the longus colli with a
microclip placed vertically to indicate the orientation of the
artery and to avoid axial twisting during its transposition.
The proximal vertebral artery is closed by transfixion with
5-0 polypropylene suture immediately above the stenosis at
its origin. The artery is divided at this level, and its proximal
stump is further secured with a hemoclip. The artery is then
brought to the common carotid artery and its free end is
spatulated for anastomosis.
• The carotid artery is then cross-clamped. An elliptical 5- to
7-mm arteriotomy is created in the posterolateral wall of the
common carotid artery with an aortic punch. The anastomosis FIG 3 • Proxi m a l vertebra l-to-co m m o n ca rotid tra nspositi o n .
1846 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Vertebral Artery Angioplasty and Stent Placement and transradial ( 5 % ) access has also been used as noted in
one recent review. 8 The stenotic lesions are crossed and then
• In the past decade, endovascular treatment of vertebral artery
dilated with 0.014- or 0 . 0 1 8 -in guidewires and small coronary­
disease has gained increasing acceptance. For endovascular
diameter balloons. If a stem is chosen, these are usually
intervention, patients are pretreated with dual antiplatelet
bare metal type, but drug elution has also been used. The
therapy (aspirin and clopidogrel) . The procedure is usually per­
same 0.0 14- or 0 . 0 1 8 -in guidewires are used as platforms
formed with local anesthesia and conscious sedation, enabling
over which the stems are delivered and then deployed. Post­
continuous neurologic monitoring of the patient. The patients
deployment angioplasty may be necessary in selected cases.
are positioned supine and prepped to allow percutaneous
Procedures can be performed with or without the assistance
entry into the chosen access vessel. Most cases are performed
of embolic protection, although most vertebral arteries are too
from a femoral approach (93 % ) , although transbrachial ( 3 % )
small to accommodate most distal protection devices.

PEARLS AND PITFALLS


P l acement of i ncision • It i s i m porta nt to p l ace the i ncision m ed i a l ly e n o u g h to d i ssect between the heads of the
sternocleidom asto i d . An a p p roach l atera l to this struct u re will make the transposition c h a l l e n g i ng, if
n ot i m poss i b le, to co m p l ete.
O r i e ntation • Enough of the V 1 seg ment of the verte bral a rte ry, u p to n e a r where it d isappears i nto the tra nsverse
p rocess of C6, needs to be m o b i l ized. Al so, p l a n a h ead and see where o n the ca rotid is best to
re i m p l a nt the verte bral before creati n g the ca rotid a rteriotomy.
Closure • A d ra i n is usua l ly h e l pf u l , especi a l ly on the l eft side where the thoracic d uct crosses the exposu re, j ust
in case a tie comes off of a l a rg e lymp hatic. The d ra i n a l l ows for early d i ag nosis of t h i s co m p l icat i o n .

POSTOPERATIVE CARE Complications included transient ischemic attack, flow-limit­


ing dissection, hematoma, and catheter-access-site problems.
• Following surgical transposition, absent significant lym­ At 1 year of follow-up, six patients had died and five had ex­
phatic drainage from the wound, the patient may be safely perienced a vertebrobasilar stroke, and at approximately 2.5
discharged on the first or second postoperative day. Simi­ years of follow-up, 70% of patients remained symptom free,
larly, after endoluminal therapy, patients are kept overnight but 1 3 % of patients had restenosis requiring retreatment.11
to ensure neurologic stability. • A recent systematic review of the available literature noted
a weighted mean technical success rate of 97% . The authors
OUTCOMES estimated mean periprocedural stroke and death rate from
combined angioplasty and stenting to be around 1 . 1 % .
• After proximal vertebral-to-common carotid transposition,
Transient ischemic events occurred i n 1 .5 % o f patients.
patency rates at 5 and 10 years equal or exceed 9 5 % and
Recurrent symptoms occurred in 8 % of patients within a
9 1 % , respectively. When selected appropriately, more than
reported range of follow-up of 6 to 54 months and greater
8 0 % of patients will experience symptomatic relief follow­
than 5 0 % restenosis developed in 23 % of the subset of
ing proximal surgical reconstruction.9
patients who underwent follow-up imaging. 8
• Appropriate reconstruction and subsequent reperfusion of the
brainstem in patients experiencing hemodynamic vertebrobas­
COMPLICATIONS
ilar symptoms may also improve hypertension management.
• Overall, retrospective reviews suggest that endoluminal ver­ • Proximal vertebral to common carotid transposition has
tebral artery intervention is reasonably safe, although a se­ been reported to have a combined stroke and death rate
lection bias exists. A 2005 Cochrane review identified 3 1 3 of 0 . 9 % . 9 Among patients undergoing this operation, in
interventions for vertebral artery stenosis, with j ust over half one report, there were no deaths or strokes in those who
using stem placement as part of the treatment. The technical underwent only a vertebral reconstruction. Berguer and
success rate was 9 5 % , and the 3 0-day stroke and death rate coauthors reported four instances of immediate postop­
was 6 .4 % .1 0 erative thrombosis ( 1 .4 % ) . Three of the four patients had
• Despite high technical success rates, vertebral artery an­ vein grafts interposed between the vertebral artery and the
gioplasty alone, especially when used for the treatment of common carotid because of a short V1 segment. The grafts
disease at the origin of the vessel, appears to have an unac­ kinked and thrombosed. Other complications that are par­
ceptably high rate of restenosis. Adjuvant stent placement ticular to proximal reconstruction include vagus and recur­
adds to the clinical durability but adds potential morbidity rent laryngeal nerve palsy ( 2 % ) , Horner's syndrome ( 8 .4 %
such as malposition or potential fracture. In their series of 105 t o 2 8 % ) , lymphocele ( 4 % ) , and chylothorax ( 0 . 5 % ) .
patients who underwent endovascular stenting for symptom­ • Periprocedural risks for angioplasty and stenting include ac­
atic vertebral artery disease, Jenkins et alY achieved 1 0 0 % cess complications, distal embolization and stroke, arterial
radiographic improvement (residual stenosis � 3 0 % ) . The rupture, stent malposition, and vessel thrombosis or dissec­
authors reported immediate ( 30-day) periprocedural risk of tion. Later, restenosis and stent fracture are not uncommon
death of 1 % and periprocedural complication rate of 4. 8 % . ( FIG 4) .
C h a p t e r 6 VERTEBRAL TRA N S P O S I T I O N TEC H N I Q U E S A N D STE NTI N G 1847

REFERENCES
1. Bauer R. Mechanical compression of the vertebral arteries. In: Berguer
R, Bauer R, eds. Vertebrobasilar Arterial Occlusive Disease: Medical
and Surgical Management. New York: Raven; 1 9 84:45-7 1 .
2. Caplan LR, Wityk RJ, Glass TA, e t al. New England Medical Center
Posterior Circulation registry. Ann Neurol. 2004; 5 6 : 3 8 9-3 9 8 .
3. Caplan L , Tettenborn B. Embolism i n the posterior circulation. In:
Berguer R, Caplan L, eds. Vertebrobasilar Arterial Disease. St. Louis,
MO: Quality Medical; 1 992:52-65.
4. Pessin M. Posterior cerebral artery disease and occipital ischemia. In:
Berguer R, Caplan L, eds. Vertebrobasilar Arterial Disease. St. Louis,
MO: Quality Medical; 1 992:66-75 .
5. Berguer R, Higgins R, Nelson R. Noninvasive diagnosis of reversal of
vertebral-artery blood flow. N Eng/ ] Med. 1 9 8 0 ; 3 02 : 1 349-1 3 5 1 .
6. Edwards WH, Mulherin J L Jr. The surgical approach t o significant
stenosis of vertebral and subclavian arteries. Surgery. 1 9 8 0 ; 8 7:20-2 8 .
7. Roon A], Ehrenfeld WK , Cooke PB, e t al. Vertebral artery reconstruc­
tion. Am ] Surg. 1 9 79; 1 3 8 :29-3 6 .
8. Antoniou GA, Murray D, Georgiadis GS, et al. Percutaneous trans­
luminal angioplasty and stenting in patients with proximal vertebral
artery stenosis. ] Vase Surg. 2 0 1 2;55 : 1 1 6 7-1 1 77.
9. Berguer R, Flynn LM, Kline RA, et al. Surgical reconstruction of the
extracranial vertebral artery: management and outcome. ] Vase Surg.
FIG 4 • Verte bral a rte ry ste nt with fractu re a n d i n -ste nt 2000;3 1 :9-1 8 .
reste nosis (Fro m : Cronenwett J L, J o h nsto n KW, eds. Rutherford's 10. Coward LJ, Featherstone RL, Brown MM. Percutaneous transluminal
Vascular Surgery. 7th e d . P h i l a d e l p h ia, PA: S a u n d e rs; 2 0 1 0, with angioplasty and stenting for vertebral artery stenosis. Cochrane Data­
permission.) base Syst Rev. 2005 ; ( 2 ) : CD0005 1 6 .
1 1 . Jenkins J S , Patel SN, White CJ, e t al. Endovascular stenting for verte­
bral artery stenosis. J Am Coli Cardia/. 2 0 1 0;55 ( 6 ) : 5 3 8-542.
-

Chapter 7 Neurogenic T horacic Outlet


Syndrome Exposure and
Decompression: Supraclavicular
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - � - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ·

Robert W Thompson Chandu Vemuri

which promotes scalene/pectoralis muscle spasm, fibrosis,


DEFINITION
and other pathologic changes.4 These muscular alterations,
• Thoracic outlet syndrome (TOS) is a group of conditions in turn, lead to compression and irritation of the adj acent
caused by compression of one of the neurovascular structures brachial plexus nerves. The presence of a cervical rib is often
that serve the upper extremity.1-3 Neurogenic thoracic outlet cited as a risk factor for NTOS; however, few NTOS patients
syndrome (NTOS) is the most frequent of these, occurring in (approximately 1 0 % ) have a definable cervical rib, and de­
8 5 % to 90% of thoracic outlet patients. It is caused by com­ velopment of NTOS symptoms are rare in cervical rib pa­
pression and irritation of the brachial plexus nerves within the tients in the absence of predisposing inj ury.5
supraclavicular scalene triangle and/or underneath the pecto­ • NTOS often occurs in individuals involved in occupational or
ralis minor muscle tendon in the subcoracoid space ( FIG 1 ) . recreational activities requiring repetitive overhead activities
NTOS tends t o occur i n patients between the ages o f 1 5 and with the arms and/or heavy lifting, occasionally aggravated
40 years, typically manifesting as neck and upper extremity by injury (e.g., motor vehicle collisions or falls upon the out­
pain, paresthesias, and functional limitations in the ipsilateral stretched arm ) . Other predisposing conditions include low­
arm. Although relatively uncommon, clinical recognition and grade repetitive strain injury (e.g., prolonged keyboard use) ,
appropriate treatment are crucial to optimizing outcome in poor posture, and dysfunctional shoulder girdle mechanics.
young active individuals with NTOS-related disability.4 • Surgical treatment for NTOS may be effectively accomplished
• The causes of NTOS include anatomic variations ( anoma­ by several different approaches, including transaxillary 1 st rib
lous scalene musculature, aberrant fibrofascial bands, and/ resection and anterior (supraclavicular) decompression. The su­
or cervical ribs) and previous neck or upper extremity injury, praclavicular approach has long been a mainstay in the surgical

Scalene triangle

� Middle scalene
muscle

Anterior scalene

P h renic nerve Long thoracic


nerve
Subclavian
artery -�':31•

Subclavian
plexus nerve
vein
roots (C5-T1 )
Fi rst rib

Subcoracoid space

FIG 1 • Anatomy of the thoracic


outlet, with em phasis o n the su pra­
Axi l lary artery
Pectoralis m i nor clavicu l a r sca lene tri a n g l e and the
m uscle i nfraclavicu l a r su bcoraco i d space.
1848
C h a p t e r 7 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 1849

worsening of symptoms and related disability. Hand muscle


Tab l e 1 : Differential Diagnosis of Neurogenic
weakness and atrophy ( Gilliatt-Sumner hand) are rare, typi­
Thoracic Outlet Syndrome
cally following long-standing brachial plexus compression
Acro m ioclavicu lar a rthropathy Fi bromyalgia and fibromyositis due to an associated cervical rib or similar bony anomaly.
Arterial atheroem bolism Nerve sheath neoplasm • Physical examination typically identifies reproducible ten­
B rach ial plexus (stretch) injury Pancoast tumor (lung apex) derness to palpation over the supraclavicular scalene trian­
Carpal tunnel syndrome (median nerve) Parsonage-Turner syndrome gle and/or the infraclavicular subcoracoid space ( FIG 2 ) .
Cervical dystonia Psychogenic syndrome
Cervical spine degenerative a rthritis Radial nerve compression
• Most NTOS patients experience recurrent upper extremity
(extensor forearm) symptoms in response to provocative positional maneuvers,
Complex regional pain syndrome Raynaud syndrome such as the upper limb tension test (ULTT) or the 3-minute
Cervical spine degenerative disc disease Rotator cuff tendinitis elevated arm stress test (EAST) ( FIG 2 ) . Positional dampen­
Cervical spine (m uscular) stra in Scleroderma
ing of the radial artery pulse at the wrist during arm ab­
C u bital canal syndrome (ulnar nerve) Vascul itis
duction and external rotation (Adson's test) is nonspecific
and inaccurate and is generally not useful in establishing or
excluding a diagnosis of NTOS.
treatment of NTOS, providing excellent exposure for safe and • Directed physical examination is performed to determine the
definitive decompression of the relevant neurovascular struc­ presence of cervical spine degenerative disease or peripheral
tures as well as the flexibility to manage the entire spectrum of nerve compression (carpal tunnel and cubital canal syn­
circumstances that may be encountered intraoperatively.6-1 0 dromes) as potential alternative sources of NT OS-like symp­
toms as well as evidence of arterial or venous compromise
DIFFERENTIAL DIAGNOSIS to the affected extremity. Signs of increased upper extremity
sympathetic tone are also sought, including digital swelling,
• NTOS-related symptoms may mimic or overlap those ob­
discoloration, and skin hypersensitivity ( allodynia) .
served in other upper extremity neurologic and muscu­
• Documentation o f patient-reported symptoms and quantifi­
loskeletal disorders, expanding the differential diagnosis
cation of disability prior to treatment are accomplished by
(Table l ) Y·12 Successful intervention requires differentiation
completion of standardized outcomes measurement tools
of NTOS from other cervical-brachial syndromes as well as
such as the Disabilities of the Arm, Shoulder, and Hand
optimal patient and procedural selectionY
(DASH) questionnaire and quality-of-life instruments.14
• NTOS should be readily differentiated from venous TOS,
Repeated use of these instruments at various intervals before
which produces marked arm swelling, cyanotic discoloration,
and after treatment has provided increasing insight into the
and distention of subcutaneous veins around the shoulder and
relative value of alternative management strategiesY
chest walL Venous TOS often presents clinically as axillary­
subclavian vein " effort-related thrombosis " (Paget-Schroetter
syndrome) . NTOS should also be distinguished from arterial IMAGING AND OTHER DIAGNOSTIC
TOS, which causes either fixed subclavian artery obstruction STUDIES
or poststenotic aneurysm formation. The former may precipi­
• Although imaging and other diagnostic studies may provide
tate arm or hand pain with exercise ( " arm claudication" ) , the
helpful ancillary information, there is no definitive test to
latter aneurysm thrombosis and distal embolization, hand
confirm or exclude the diagnosis of NTOS. Diagnosis re­
ischemia, rest pain, and/or digital ulceration and necrosis.
mains quintessentially clinical and dependent on experi­
• Some NTOS patients exhibit severe upper extremity pain
enced pattern recognition.
and hypersensitivity, with digital swelling and discoloration,
• Plain anteroposterior chest radiographs will identify a cervical
suggesting the presence of sympathetic nerve overactivity. In
rib when present. No other currently available imaging study
such cases, the coexistence of reflex sympathetic dystrophy
adds significant value to the clinical diagnosis of NTOS ( FIG 3 ) .
(complex regional pain syndrome [CRPS] ) should be deter­
• Conventional electrophysiologic tests (electromyography and
mined by assessing the symptomatic response to a temporary
nerve conduction studies) are often performed to exclude pe­
cervical sympathetic (stellate ganglion) anesthetic block.
ripheral nerve compression disorders or cervical radiculopa­
thy. These tests are usually negative or nonspecific in NTOS
PATIENT HISTORY AND PHYSICAL FINDINGS
and cannot be used to establish or exclude the diagnosis.
• Symptoms attributable to brachial plexus nerve compres­ • Vascular laboratory studies (Duplex ultrasound) may detect
sion include pain, numbness, and tingling (paresthesia) alterations in upper extremity blood flow attributable to
in the neck, shoulder, arm, and hand. The distribution of subclavian artery compression during arm elevation. How­
symptoms in the hand often extends beyond that expected ever, positional subclavian artery compression may represent
for either the median or ulnar nerves, involving all fingers. an incidental and unrelated vascular finding and does not
Patients with NTOS attributable to compression at the pec­ establish a diagnosis of neurogenic or arterial TOS. As they
toralis minor tendon often describe upper anterior chest and do not assess the presence or severity of brachial plexopathy,
axillary pain. The intensity of symptoms of NTOS can vary vascular laboratory studies add little specificity beyond the
with the extent of upper extremity activity and are usually clinical diagnostic criteria.
reliably exacerbated with arm elevation and abduction. • Performance of image-guided anterior scalene and/or pec­
• Many NTOS patients experience relatively mild symptoms, toralis minor muscle anesthetic blocks may assist the
with gradual progression in severity punctuated by peri­ clinical diagnosis of NTOS.16 A positive block, character­
odic exacerbations. Others experience steady, progressive ized as temporary relief or improvement in the presenting
1850 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

E Office Chert Dlegrem


3m -EAST ULTT DASH
(minutes) (+ or -) (0-1 00)
+
D D D 1m 30s 76.8

D D D D 0 0 +++
*

Scalene Scalene
Subcoracoid Subcoracoid
D D D D 0 0 ++
*

R L

Exemple: Left-Sided NTOS with Brechtel


Plexus Compression et Both Scelene
Trlengle end Subcorecold Spec•

FIG 2 • Physica l exa m i nation reveals local ized te n d e rness to p a l pat i o n over the s u p raclavicu l a r sca l e n e tria n g l e (A) a n d/o r the
i nfraclavicu l a r su bcoraco i d space (B) . The U LTT (C) a n d the 3-m i n ute EAST (D) use p rovocative posit i o n a l m a n e uvers that ra p i d ly e l icit
reprod u ction of upper extrem ity sym ptoms i n patie nts with NTOS. E. An office c h a rt d i a g ra m is used to easily s u m m a rize physica l
exa m i nation f i n d i ngs for patie nts b e i n g eva l u ated for NTOS.

symptoms, strongly supports the clinical diagnosis of NTOS. blockade does exclude the diagnosis of NTOS and should
A positive block may predict symptomatic relief from surgi­ not preclude consideration of surgical management in other­
cal decompression and is therefore highly useful in select­ wise compelling clinical candidates.
ing candidates for 1 st rib resection. Unfortunately, however, • Initial treatment for NTOS is based on physical therapy
failure of temporary symptom resolution following muscle to relieve scalene/pectoralis minor muscle spasm, improve
C h a p t e r 7 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 185 1

following prior surgery, particularly when continued conser­


vative measures prove ineffective.
• For patients with symptoms referable to the subcoracoid
space, release of the pectoralis minor tendon should be
included in the supraclavicular thoracic outlet decompres­
sion procedure. Pectoralis minor tenotomy may also be per­
formed as a stand-alone procedure when nerve compression
symptoms are limited to this areaY·18
• Decompression should be performed as a staged, sequen­
tial procedure in patients with bilateral NTOS symptoms.
The initial supraclavicular decompression, with or without
FIG 3 • A left-s ided cervical r i b i d e ntified by p l a i n ch est pectoralis minor tenotomy, is performed on most symptom­
rad i o g ra phy (arrow). atic or dominant extremity. If symptoms remain present or
progress, contralateral supraclavicular decompression may
be performed within 6 to 12 weeks of the initial procedure.
posture, enhance functional limb mobility, strengthen asso­ Normal phrenic nerve function should be verified on the side
ciated shoulder girdle musculature, and diminish repetitive of the previous procedure, by chest fluoroscopic examina­
strain exposure in the workplace. Incorrect approaches to tion, before contralateral intervention.
physical therapy can result in worsening of symptoms and
failure of conservative management. In many NTOS patients, Preoperative Planning
significant symptomatic improvement may be experienced
in response to physical therapy, particularly in the first 4 to • The supraclavicular surgical site is marked in the preoperative
6 weeks. Because NTOS is commonly chronic, however, and holding area, including the subcoracoid space when concomi­
subject to acute symptomatic "flare ups " (often related to tant pectoralis minor tenotomy is planned. Prophylactic antibi­
overuse activities or new injury), such patients should con­ otics are administered within an hour of the planned procedure.
tinue prescribed physical therapy exercises during long-term
follow-up. Patients that fail a conscientious and effective Positioning
physical therapy, as well as alternative conservative mea­
• After the induction of general endotracheal anesthesia, the pa­
sures, are referred for consideration of surgical intervention.
tient is positioned supine with the head of the operating table
elevated 30 degrees. The neck is extended and turned to the
SURGICAL MANAGEMENT
opposite side; a small inflatable pillow is placed behind the
• Supraclavicular decompression (scalenectomy, 1 st rib resec­ shoulders; and the neck, chest, and affected upper extremity
tion, and brachial plexus neurolysis) is recommended on are prepped into the field. The arm is wrapped in stockinette
the basis of ( 1 ) sound clinical diagnosis of NTOS, (2) sub­ to permit free range of movement during the operation and
stantial resulting disability (interference with daily activities then held comfortably across the abdomen ( FIG 4} . Lower
and/or work), and ( 3 ) an inadequate response to standard extremity sequential compression devices are used for throm­
physical therapy. Supraclavicular decompression may also boprophylaxis. Neuromuscular blocking agents are not used
provide relief from persistent or recurrent NTOS symptoms following the initial induction of anesthesia.

Pectoralis Minor ---.


Incision

FIG 4 • Patient position and p l a n ned i ncisions for l eft-sided su praclavicu l a r thoracic outlet deco m p ression with pectora l i s m i n o r ten otomy.
1852 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

SUPRACLAVICULAR DECOMPRESSION the sca l e n e fat pad. The sternocleidomasto i d m uscle is


retracted med i a l ly but is not d ivided (FIG S) .
Incision and Mobilization o f the Scalene Fat Pad
• O n e of the keys to s i m p l ify i n g the s u p raclavicu l a r expo­
• A tra nsverse neck i n cision is m a d e p a ra l le l to a n d j u st s u re is proper m o b i l ization and latera l reflection of the
a bove the clavicle, beg i n n i n g at the l atera l edge of the sca l e n e fat p a d . This beg i n s with d eta c h m e nt of the fat
sternocleidom asto i d m u scle and exte n d i n g to the a nte­ pad a l o n g the latera l edge of the i nte r n a l j u g u l a r vei n
rior edge of the tra pezius m uscle. The i n c i s i o n is carried a n d t h e superior edge o f t h e clavicle, with l i gation of
through the su bcuta neous layer, the p l atys m a m uscle is sma l l blood vessels and l y m p h atic tissues. The thoracic
d ivided, a n d s u b p l atysm a l f l a ps a re d eve loped to expose d u ct, u s u a l l y observed n e a r the j u nct i o n of the i nternal

FIG S • A. The s k i n i n c i s i o n is m a d e j u st a bove a n d p a ra l l e l to the clavicle, exte n d i n g from the


latera l border of the sternocl e i d o m asto i d m uscle to the a nterior border of the tra pezius m u scle.
B. S u b p l atysm a l f l a ps a re created to expose the u n d e r l y i n g sca l e n e fat p a d . The sca lene fat pad
is m o b i l ized, beg i n n i n g with its m ed i a l attac h m e nts to the i ntern a l j u g u l a r ve i n (IJV) (C), a n d the
o m o hyo id m u scle is d ivided (D) .
C h a p t e r 7 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 1853

Tab l e 2 : Critica l Views Obta i ned d u r i n g S upraclavicular Thoraci c Outlet Decompression

1 . View of the operative field after lateral reflection of the sca lene fat pad, with visual ization of the interna l jugular vein, anterior scalene m uscle, phrenic
nerve, brach ial plexus, subclavian artery, middle scalene m uscle, and long thoracic nerve
2. View of the lower part of the anterior scalene m uscle where it attaches to the 1 st rib, with space sufficient to al low a fi nger to pass behind the anterior
sca lene m uscle and in front of the brachial plexus and subclavian artery, prior to division of the anterior scalene m uscle insertion from the top of the 1 st rib
3 . View of the upper part of the anterior scalene m u scle at the level of the C6 transverse process, in relation to the C S and C6 nerve roots, prior to d ivision of
the a nterior scalene muscle origin
4. View of the i nsertion of the middle sca lene m u scle on the 1 st rib, with each of the five nerve roots of the brach ial plexus and the subclavian a rtery re­
tracted medially and the long thoracic nerve retracted lateral ly, prior to division of the middle sca lene m uscle insertion from the top of the lateral 1 st rib
5 . View of the posterior neck of the 1 st rib, with the T 1 nerve root passing from underneath the rib to join the C8 nerve root to form the i nferior trun k of the
brachial plexus, prior to division of the posterior 1 st rib
6 . View of the anterior portion of the 1 st rib, with placement of the rib shears medial to the sca lene tubercle, prior to division of the anterior 1 st rib

j u g u l a r and subclavian vei ns o n the l eft side (a p ro m i nent the posteri or aspect of the m uscle often pass a r o u n d the
accessory thoracic d u ct may a l so exist o n the r i g ht side), subclavian a rtery to form a teth e r i n g " sl i n g " a n d s h o u l d
may be l i g ated and d ivided. The o m o hyo i d m u sc l e is rou­ a lso be resected to fu l ly release the a rtery. Any sca l e n e
tinely d ivided (FIG S) . m i n i m u s m u scle fi bers fo u n d to be present (pass i n g be­
• The sca l e n e fat pad is prog ressively e l evated i n a med i a l twee n the roots of the b rach i a l p l exus) a re d ivided as
t o latera l d i rection, b y gentle f i n g e rt i p d i ssection over the a nte rior sca lene m uscle is m o b i l ized. As the a nterior
the su rface of the a nte rior sca l e n e m uscle. The p h r e n i c sca l e n e m uscle is l i fted f u rther, it is passed u n d e rn eath
n e rve i s o bse rved pass i n g i n a latera l to m ed i a l d i rection and m ed i a l to the p h r e n i c n e rve and its posteri or attach­
as it descends along the m u scle su rface. Gentle m a n i p u­ m e nts a re d ivided with d i rect visua l i zation and p rotec­
lation of the p h re n i c n e rve prod uces a " d a rt l e " (d i a ­ tion of the u p per brach i a l p l exus n e rve roots. D i ssection
p h ra g matic sta rt le) response. of the m u scle is carried su periorly to its orig i n o n the C6
• U p o n f u rther l atera l rotati o n of the sca l e n e fat pad, the transverse p rocess, whi c h is easily p a l pated i n the u p pe r
brach i a l p l exus n e rve roots (poste rior a n d latera l to the aspect of the operative f i e l d (the a pex of the " sca l e n e t r i ­
a nterior sca l e n e m u scle) a n d the m i d d le sca l e n e m uscle a n g l e " ) . The a nte rior sca l e n e m u scle is then d ivided with
(be h i n d the b rach i a l p l exus) are brought i nto vi ew. The scissors from its orig i n o n the transverse p rocess u n d e r
latera l aspect of the 1 st r i b is p a l pated and visua l i zed, d i rect vision a n d the entire m uscle is removed, w i t h a
and the long thoracic n e rve is i d e ntified as it e m e rges
from the body of the m i d d l e sca l e n e m uscle to cou rse
past the l atera l p a rt of the 1 st r i b . The sca l e n e fat pad is
then h e l d in posit i o n with sever a l s i l k retraction sutu res
a n d the exposure is m a i ntained with a H e n ley self-reta i n ­
i n g retractor (usi n g the t h i rd a r m t o h o l d the e d g e of t h e
sternocleidom asto i d m uscle). The res u l t i n g expos u re rep­
resents the fi rst and most i m portant of six "critical views"
to be o bta i n e d d u r i n g s u p raclavicu l a r deco m p ress i o n
(Ta b l e 2) (FIG 6) .

Anterior Scalenectomy

• Attention is turned to the i n se rtion of the a nte rior sca­


lene m uscle o n the 1 st r i b . At the l ower latera l edge of
the a nterior sca l e n e m uscle, the subclavian a rtery a n d
brach i a l p l exus a re ca refu l ly m o b i l ized u n t i l a f i n g e rt i p
ca n be e a s i l y passed beh i n d the m uscle j u st a bove the 1 st
r i b, thereby d i s p l a c i n g the n e u rovasc u l a r structures pos­
tero latera l ly. B l u nt f i n g e rt i p d i ssect i o n is conti n u ed be­
h i n d the m u scle to its m ed i a l edge, ta k i n g ca re to avo i d
the p h r e n i c n e rve. O n ce the i nsertion of the a nterior
sca l e n e m uscle onto the 1 st r i b has been isol ated u n d e r
d i rect vision to p rotect the p h r e n i c n e rve, the s u b c l a v i a n
a rte ry, a n d the b rach i a l p l exus, it is sharply d ivided from
the top of the bone with scissors (FIG 7) .
FIG 6 • F o l l ow i n g latera l reflection of the sca l e n e fat pad,
• The e n d of the d ivided a nte rior sca l e n e m uscle is e l evated d i rect visua l i zation is o bta ined of the i nter n a l j u g u l a r ve i n
a n d its attac h m e nts to the u n d e rlying extra p l e u r a l fascia (IJV), a nterior sca l e n e m uscle (ASM), p h r e n i c n e rve (PhN),
a re sharply d ivided (el ectroca ute ry is not used to avo i d b rach i a l p l exus (BP), subclavian a rtery (SCA), m i d d l e sca l e n e
i n advertent n e rve i n j u ry) . M u sc l e fi bers exte n d i n g from m u scle (MSM), a n d l o n g t h o r a c i c n e rve (LTN).
1854 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

A B

FIG 7 • A. The a nterior sca l e n e m uscle (AS M) i n se rtion is isol ated by d i s p l a c i n g the u n d e r l y i n g subclavian a rtery (SCA) a n d
b rach i a l p l exus ( B P), u s i n g b l u nt f i n g e rt i p d i ssect i o n beh i n d the m u sc l e, a n d the m uscle is s h a r p l y d ivided f r o m the t o p of the 1 st
r i b . B. The e n d of the d ivided a nterior sca l e n e m u scle is l i fted a n d sharply d i ssected free of structu res lyi n g beh i n d the m uscle,
i n c l u d i n g the subclavian a rte ry. C. As it is m o b i l ized, the a nte rior sca l e n e m uscle is passed u n d e rneath and to the m e d i a l side
of the p h r e n i c n e rve (Ph N ) . D. The d i ssection is carried u p to the l evel of the C6 transverse p rocess where the a nte rior sca l e n e
m uscle can be safely d ivided f r o m i t s orig i n a n d removed .

typ ical speci m e n we i g h i n g 5 to 1 0 g . Any m i n o r bleed i n g Mobilization of the Brachial Plexus and Middle
from t h e e d g e o f t h e d ivided m uscle o r i g i n is contro l l ed Scalenectomy
with sma l l polypropyl en e sutu res rather t h a n e l ectroca u ­
tery, g iven the p rox i m ity of the n e rve roots (FIG 7) .
• The b rach i a l p l exus n e rve roots a re n ext sepa rated from
• A n o m a l o u s f i b rofasc i a l b a n d s may be o bse rved after a n ­ the front edge of the m i d d l e sca l e n e m uscle. B l u nt f i n ­
terior sca l e n e m uscle resection, typ i ca l ly pass i n g i n front g e rt i p d i ssection a l o n g the l atera l aspect of the n e rves is
of the lower b rach i a l p l exus n e rve roots. These structu res used to exte n d the exposure deeper to the i n n e r cu rve of
a re a lso resected as they a re encou ntered to e n s u re thor­ the 1 st rib a n d the extra p l e u ra l space, and a sma l l m a l ­
o u g h deco m p ress i o n a n d fu l l n e rve root m o b i l ity. l e a b l e retractor is p l a ced between the brach i a l p l exus
C h a p t e r 7 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 1855

brach i a l p l exus. A rig ht-a n g l e c l a m p is passed u nd e r­


n eath the poste rior neck of the 1 st r i b a n d gently spread
to detach a d d it i o n a l i nte rcosta l tissues. A mod ified Sti l l e­
G i e rtz rib cutter is i nserted a r o u n d the neck of the 1 st r i b .
After verify i n g p rotection of the C8 a n d T 1 n e rve roots,
the bone is sharply d ivided. A Kerrison bone rongeur is
used to sm ooth the poster i o r e n d of the bone, to a level
m ed i a l to the u n derlying T 1 n e rve root, and the e n d of
the bone i s sea led with bone wax (FIG 9) .
• The free e n d of the d ivided poste rior 1 st r i b is e l evated,
and b l u nt fi n g e rt i p d i ssection is used to sepa rate the
re m a i n i n g extra p l e u r a l fasci a a n d i nte rcosta l m uscle
atta c h i n g to the u n de rs u rface of the r i b, prog ress i n g
a nteriorly t o t h e level of the sca l e n e tu bercle (the p revi­
ous site of atta c h m e nt of the anterior sca l e n e m uscle).
N o effort is m a d e to avo i d o pe n i n g the p l e u ra d u r i n g
1 st r i b resection, as the opened p l e u ra l space w i l l a l l ow
better d r a i n a g e of posto perative f l u i d s away from the
brach i a l p l exus (which m i g ht otherwise promote peri­
neural a d h esions).
• The soft tissues u n d e rneath the c l a v i c l e, i n c l u d i n g the
s u bc l a v i a n ve i n , are e l evated with a sma l l R i c h a rdson
FIG 8 • The brach i a l p l exus is sepa rated f r o m the a ntero­ ret racto r. The poste r i o r 1 st r i b i s d i s p l aced i nferiorly
m e d i a l border of the m i d d l e sca l e n e m uscle down to the level with f i n g e rt i p p ressure to o p e n t h e a nterior costoc la ­
of the 1 st rib and extra p l e u r a l fascia and gently retracted vicu l a r spa ce, a nd t h e s u b c l a v i a n a rtery a n d brach i a l
m ed i a l ly to visu a l ize a l l five n e rve roots (C5 to T 1 ) . p l exus a re d i s p l aced latera l ly with a s m a l l m a l l e a b l e
ret racto r. The Sti l l e-G i e rtz r i b cutter is p l aced a r o u n d
the a nterior 1 st rib, i m m e d i ately m e d i a l to the sca l e n e
tu bercle (FIG 1 0) . The 1 st r i b i s t h e n d ivi ded u n d e r d i ­
n e rves a n d the m i d d l e sca l e n e m uscle. With gentle me­
rect v i s i o n , a n d the i ntact spec i m e n is extracted from
d i a l retract i o n of the brach i a l p l exus, each n e rve root
t h e o p e rative field (FIG 1 1 ) . The re m a i n i n g a nterior end
from C5 to T1 is seq uenti a l l y i d e ntified (FIG 8).
of the 1 st rib i s remodeled to a sm ooth su rface with a
• The tra nsve rse cervica l a rtery and ve i n s h o u l d be l i g ated
b o n e ro n g e u r, to a l evel we l l u n d e rneath the c l a v i c l e .
and d ivided where they pass t h ro u g h the brach i a l p l exus
Oxid ized ce l l u lose fa b r i c (Ethicon, I n c., S o m e rvi l l e, NJ) is
a n d m i d d l e sca l e n e m uscle to avo i d bleed i n g shou l d
p l aced with i n the bed of the resected 1 st r i b as a to p i c a l
these vessels be avu lsed d u ri n g retract i o n .
h e m ostatic a g e n t .
• A seco n d m a l l e a b l e retractor i s p l aced l atera l to t h e
• Cervical r i bs a rise with i n the p l a n e of the m i d d l e sca­
m i d d l e sca l e n e m uscle a n d 1 st r i b, to d isplace the l o n g
lene m u sc l e, poster i o r to the brach i a l p l exus and sub­
thoracic n e rve poste riorly. The o b l i q u e atta c h m ent of t h e
clavian a rtery a n d anterior to the l o n g thoracic n e rve.
m i d d l e sca l e n e m uscle a l o n g the top of the poste rol at­
I n c o m p l ete cervica l r i bs typica l ly have a l i g a m e ntous
e ra l 1 st rib i s expose d . This m uscle i n se rtion is ca ref u l ly
exte n s i o n to the 1 st r i b, whereas com p l ete cervica l r i bs
d ivided from the su rface of the bone with the e l ectro­
attach to the latera l 1 st r i b i n the form of a true j o i nt.
ca ute ry, u s i n g a perioste a l e l evato r as the d i ssect i o n
The poste r i o r portion of a cervica l rib is thereby rea d ­
proceeds poste riorly, exte n d i n g to a p o i nt o n the 1 st r i b
i l y encou ntered d u r i n g d i ssection of the m i d d l e sca l e n e
t h a t is p a ra l l e l w i t h the u n derlyi n g T 1 n e rve root. T h e
m uscle a n d i s d ivided i n a m a n n e r s i m i l a r t o the poste­
b u l k of the m i d d l e sca l e n e m uscle a nterior to the l o n g
rior 1 st r i b . The a nterior atta c h m e nt of the cervical r i b
thoracic n e rve is then s h a r p ly excised, w i t h a typical
is then d ivided a n d the bone is removed pri or to 1 st r i b
spec i m e n we ight of 3 to 8 g (FIG 9) . Minor bleed i n g
resect i o n . When there i s a t r u e j o i n t between a co m p l ete
from t h e c u t e d g e o f t h e m i d d l e sca l e n e m uscle shou l d
cervical r i b a n d the 1 st r i b, the a nte rior portion of the
be contro l l ed w i t h sutu res rath e r t h a n the e l ectrocautery
cervical r i b is l eft atta ched while the 1 st r i b resection is
to avo i d therm a l i nj u ry to the C8 n e rve root or l o n g tho­
co m p l eted, a n d the two a re rem oved togeth e r as a s i n g l e
racic n e rve.
speci m e n (FIG 1 1 ) .

First Rib Resection


Brachial Plexus Neurolysis
• O n ce the sca l e n ecto my has been co m p l eted, the i nter­
costa l m u sc l e atta c h i n g to the latera l edge of the 1 st • T h e l a st ste p of s u p ra c l av i c u l a r deco m p ress i o n is to
r i b is sepa rated from the bone with the e l ectroca ute ry. fu l ly m o b i l i ze each of t h e i n d i v i d u a l n e rve roots con­
The 1 st r i b is f u l l y exposed poste riorly, where the T1 t r i b u t i n g to t h e b r a c h i a l p l ex u s . E a c h n e rve root from
n e rve root e m e rges from u n d e rn eath the bone to j o i n C 5 to T 1 i s meti c u l o u s l y d i ssected free of a n y a d h e r­
t h e C8 n e rve root i n form i n g the l ower tru n k o f t h e ent p e r i n e u r a l f i b r o u s sca r tissue that m i g h t i m p a i r
1856 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

Anterior scalene m uscle (7 grams)

A
Middle scalene muscle (7 grams)
B

c D

FIG 9 • A. After d eta c h i n g the m i d d l e sca l e n e m u scle ( M S M ) from the top of the posterolatera l 1 st r i b u s i n g the e l ectrocautery,
the m uscle tissue lyi n g anterior to the l o n g thoracic n e rve (LTN) is excised. B. Typ i c a l ope rative spec i m e n s of the a nte r i o r
a n d m i d d l e sca l e n e m uscles. C. The poste rior 1 st r i b is exposed w i t h visu a l i zation of the C8 a n d T 1 n e rve roots, a n d the r i b
is d ivided w i t h a mod ified G i e rtz-St i l l e r i b cutter. D. T h e poste rior e d g e of the 1 st r i b is f u rther re modeled w i t h a Kerrison
ro n g e u r to o bta i n a sm ooth edge i m med iately m ed i a l to the T 1 n e rve root.

m o b i l ity (exte r n a l n e u ro l ysis) . I n spect i o n of the m ost Drain Placement and Closure
p roxi m a l aspect of the C8 a n d Tl n e rve roots w i l l
often revea l a s m a l l fi b rofasc i a l b a n d ove r l y i n g th ese
• U po n the com p l etion of su praclavicu l a r deco m p ression,
n e rves, w h i c h s h o u l d be specifica l ly s o u g ht out a n d re­ the a pex of the p l e u r a l m e m brane is opened to promote
sected . This a s pect of t h e o p e r a t i o n i s n ot c o n s i d e red postope rative d r a i n a g e of f l u i d i nto the chest cavity,
co m p l ete u n t i l each n e rve root h a s b e e n co m p l etely away from the brach i a l p l exus. 1 9-Fr cl osed suction d r a i n
c l e a re d t h r o u g h o u t its cou rse i n t h e o p e rative field i s p l aced t h r o u g h a sepa rate sta b wound i nto the opera­
(FIG 1 2) . tive field, p l aced poste rior to the brach i a l p l exus with its
C h a p t e r 7 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 1857

A B

FIG 1 0 • A. With t h e poste r i o r e n d of t h e 1 st r i b p u s h e d downward to o p e n t h e a nt e r i o r costo c l a v i c u l a r s p a ce, t h e


a nt e r i o r p o rt i o n of t h e 1 st r i b i s e x p o s e d u n d e r neath t h e c l a v i c l e a n d t h e s u b c l a v i a n ve i n . B. The s u b c l a v i a n a rtery (S CA)
a n d b r a c h i a l p l ex u s (B P) a re p rotected, a n d the a nt e r i o r 1 st r i b i s d i v i d e d with a r i b cutte r i m m e d i ately m ed i a l to t h e
sca l e n e t u b e r c l e .

t i p exte n d i n g i nto the poste rior p l e u r a l space. Two m u l ­


t i h o l e perfusion catheters a re p l aced with i n t h e wound,
positioned adjacent to the brach i a l p l exus a n d with i n the
bed of the resected 1 st r i b, a n d conn ected to a n osmotic
pump for conti n u ous postope rative i nfusion of loca l an­
esthetic (0 . 5 % b u pivaca i n e for 3 days) . A b i o resorba b l e
polylactide fi l m (Eth icon, I n c., Somervi l l e, NJ) is p l aced
a r o u n d the b rach i a l plexus to s u p p ress deve l o p m ent of
postope rative peri n e u r a l f i b rosis and h e l d in p l ace with
seve ral 5-0 polydioxa n o n e sutu res. The sca l e n e fat pad is
restored to its a n ato m i c position overlyi n g the brach i a l
p l exus a n d h e l d i n p l ace with seve ral ta c k i n g sutu res to
the back of the sternocleidomasto i d m uscle a n d to the
pericl avic u l a r su bcuta neous fasc i a . The p l atysm a m uscle
layer is rea p p roxim ated with i nterru pted sutu res and the
skin is closed with a n a bsorba b l e su bcuticu l a r stitc h .

FIG 1 1 • Operative speci mens fol lowing 1 st rib resection (A) and
fol lowi ng combi ned resection of a cervica l rib a n d 1 st rib (B) .
1858 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

F I G 1 2 • A-C. F i brous sca r tissue i s rem oved


from each of the brach i a l p l exus (BP) n e rve
roots by exte r n a l n e u rolysis. SCA, s u bclavian
a rte ry.

PECTORALIS M I N OR TENOTOMY Division of the Pectoralis Minor Muscle Tendon

Incision and Exposure • The pecto ra l i s m i n o r m u s c l e t e n d o n is i d e ntified w h e re


it ext e n d s from t h e a nt e r i o r c h est wa l l to t h e coracoid
• A short vertical i n c i s i o n is m a d e i n the d e ltopecto ral
p rocess. T h e fasci a a l o n g its m e d i a l b o r d e r i s opened
g roove, beg i n n i n g at the level of the coracoid p rocess.
and t h e m u scle is e n c i rc l e d using b l u nt fi n g e rt i p d i s­
The d e ltoid and pecto ra l i s major m uscles a re gently
sect i o n . The fasc i a a l o n g t h e l a t e r a l b o r d e r of t h e pec­
sepa rated and the plane of deeper d issection is ca rried
tora l i s m i n o r m u s c l e i s o p e n e d to e n s u re its s e p a r a t i o n
med i a l to the cepha l i c ve i n . The latera l edge of the pec­
from t h e s h o rt h e a d of t h e b i ceps m u s c l e, w h i c h a l so
tora l i s major m uscle is gently l ifted with a sma l l Deaver
i n se rts on the coraco i d p rocess. Ta k i n g ca re to p rotect
retractor, and the p l a n e u n d e rn eath the m u scle is sepa­
the u n d e r l y i n g n e u rovasc u l a r b u n d le, the pecto ra l i s
rated from the u nd e r lyi n g fascia by b l u nt f i n g e rt i p d is­
m i n o r te n d o n i s t h e n e l evated w i t h u m b i l i ca l ta pe o r
sect i o n . The fasci a over the pecto ra l i s m i n o r m uscle is
r u b b e r t u b i n g a n d i t s i n se rt i o n o n t h e coraco i d p ro­
exposed, where the m u scle can be easily i d e ntified by
cess i s exposed with a s m a l l R i c h a rdson ret racto r. A
p a l pation (FIG 1 3) .
fi n g e r is p l aced beh i n d t h e m u s c l e to p revent t h e r m a l
C h a p t e r 7 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 1859

Pectoralis
major
m uscle
Pectoralis
minor
muscle

Coracoid process

A
Cephalic vein
B
FIG 13 • A. Pecto ra l i s m i n o r tenotomy is performed t h ro u g h a short vertica l i n cision in the d e ltopecto ral
g roove j u st below the coraco i d p rocess. B. The plane of d i ssect i o n is carried m e d i a l to the ce p h a l i c ve i n , a n d the
pectora l i s major m uscle is l i fted to expose the fasci a over the pectora l i s minor m uscle.

i nj u ry to t h e n e u rovasc u l a r st r u ct u res and t h e i n se r­ the pectora l i s major m u scle. The rema i n i n g clavi pecto ral
t i o n of t h e pectora l i s m i n o r t e n d o n is d iv i d e d with t h e fasc i a is a lso i ncised to the level of the clavicle, a l o n g
e l ectroca utery. After t h e pecto ra l i s m i n o r m u s c l e h a s w i t h a n y oth e r a n o m a l o u s fasci a l b a n d s t h a t m i g ht b e
b e e n d i v i d e d , t h e l ower e d g e w i l l retract i nfe r i o r l y to present over the brach i a l p l exus, s u c h as La n g e r's axil­
release any co m p ress i o n of t h e n e u rovasc u l a r b u n d l e l a ry a rch, but n o f u rther d i ssection of the brach i a l p l exus
(FIG 1 4) . n e rves o r the axi l l a ry vesse ls i s performed. The edge of
• T h e i n ferior edge o f t h e d ivided pecto ra l i s m i n o r m uscle the pectora l i s major m u scle is i nfi ltrated with a long­
is oversewn with a r u n n i n g sutu re to e n s u re hemostasis acti n g loca l a n esthetic a n d the wo u n d is irri gated, then
a n d to faci l itate contraction of the m uscle u n d e rneath c l osed i n layers without a d ra i n .

Pectoralis
minor muscle Pectoralis
(encircled) minor muscle
(divided) A:'T--- Coracoid
process
Neurovascular
bundle --------::

A
Pectoralis B
major
muscle
FIG 14 • A. The pecto ra l i s m i n o r m uscle is e n c i rcled n e a r its i nsert i o n on the coracoid p rocess a n d then
d ivided with the e l ectrocautery. B. The retracted edge of the d ivided pectora l i s m i n o r m uscle is oversewn
with a cont i n uous suture.
1860 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

PEARLS AND PITFALLS


I n d i cations • Operative treatment of NTOS shou l d be based o n a so u n d c l i n ical d i a g nosis, a su bsta nt i a l l evel of d i s­
a b i l ity, a n d fa i l u re of sym ptoms to i m p rove with an a d e q u ate tri a l of conservative m a n a g e ment.
• I m a g i n g stu d i es, e l ectro phys i o l o g i c tests, and vasc u l a r l a b o ratory exa m i nations a d d l itt l e i n the eva l­
uation of NTOS but may be usefu l i n exc l u d i n g oth e r cond itions.
• A positive a nte rior sca l e n e m uscle block s u p p o rts the d i a g nosis of NTOS a n d i n d i cates a stro n g l i ke l i ­
h o o d of responsiveness t o s u r g i c a l treatment.
• Assess the potential co ntri bution of brach i a l p l exus c ompress i o n at the level of the su bcoraco i d space
a n d i n c l u d e pectora l i s m i n o r te n otomy if p resent.
M o b i l ization of the • Avo i d d ivision of the sternoc l e i d o m asto i d m u sc l e .
sca l e n e fat pad • P r o p e r m o b i l ization a n d l atera l reflection of the sca l e n e f a t pad is a k e y s t e p i n s i m p l ify i n g su p ra­
clavicu l a r expos u re for thoracic outlet deco m p ress i o n . This perm its the critica l view to be o bta i ned
i n which all of the relevant structu res can be v i s u a l ized i n the same operative fi eld (inte r n a l j u g u l a r
ve i n , p h r e n i c n e rve, a nterior sca l e n e m uscle, b rach i a l p l exus, m i d d l e sca l e n e m uscle, 1 st r i b, a n d l o n g
thoracic n e rve) .
• Ligate a n d d ivide the thoracic d u ct, if necessa ry, to p reve nt postoperative lym p h leak.
• Visu a l ize a n d p rotect the p h r e n i c n e rve.
Anterior sca l e necto my • D ivide a l l fi bers pass i n g from the poste r i o r aspect of the a nterior sca l e n e m uscle to the subclavian
a rtery a n d extra pleural fasc i a .
• D ivide a n y sca l e n e m i n i m u s m uscle encou nte red .
• Pass the a nterior sca l e n e m uscle u nd e rneath the p h r e n i c n e rve to fac i l itate d i ssection of the m uscle
u p to its superior orig i n o n the C6 tra nsve rse p rocess.
M o b i l ization of the • Visu a l ize a l l five n e rve roots of the brach i a l p l exus.
b rach i a l p l exus • Ligate a n d d ivide the tra nsverse cervical vessels where they pass t h ro u g h the b rach i a l p l exus and
m i d d l e sca l e n e m uscle.
M i d d l e sca l e n ecto my • Visu a l ize and p rotect the l o n g thoracic n e rve.
• Control m i n o r bleed i n g from the cut edge of the m uscle with s i l k sutu res rath e r than e l ectrocautery.
1 st rib resection • Visu a l ize the T1 a n d C8 n e rve roots at the level of the poste rior 1 st rib, p r i o r to d ivision of the bone,
to avo i d n e rve i n j u ry.
• Rem ove a sma l l seg m e nt of the d ivided poste rior 1 st r i b to fac i l itate f i n g e rt i p d i ssect i o n u n d e rneath
the re m a i n i n g l atera l and a nterior portions of the bone.
• Do n ot try to avo i d o pe n i n g the p l e u ra .
• D ivide the a nte rior 1 st r i b at a level m e d i a l to the sca l e n e tu bercle, u n d e rneath the clavicle a n d s u b ­
c l a v i a n ve i n , w h i l e p rotect i n g the subclavian a rtery a n d b rach i a l p l exus.
• Resect a n y cervical r i b present along with the 1 st rib.
B rach i a l p l exus neu rolysis • Thoro u g h l y rem ove f i b rous scar tissues from around each n e rve root (CS to T1 ) of the brach i a l p l exus
to avo i d o n e of the ca uses of persistent sym ptoms.
• Resect a ny sma l l fi b rofasc i a l bands overlyi n g the p roxi m a l aspect of the C8 and T 1 n e rve roots.
D ra i n p l acement a n d • Wra p the brach i a l p l exus with a b i o resorba b l e fi l m to m i n i m ize peri n e u r a l f i b rosis.
closure • Place a cl osed suct i o n drain beh i n d the brach i a l p l exus with its t i p exte n d i n g i nto the p l e u r a l space.
• Use conti n u o u s postoperative i nfusion of a local a n esthetic to d i m i n ish the need for o p i ate p a i n
med ications.
Pecto ra l is m i n o r • I nc l u d e pectora l i s m i n o r te n otomy as p a rt of the s u p raclavicu l a r deco m p ress i o n if there a re conco m i -
tenotomy t a n t sym ptoms of NTOS refera b l e to the su bcoraco i d space.
• D ivide the pectora l i s m i n o r tendon cl ose to its i nsertion o n the coracoid p rocess.
• Oversew the d ivided edge of the pectora l i s m i n o r m uscle for hem ostasis.
• It is n ot n ecessa ry to p l ace a sepa rate d ra i n i n the su bcoraco i d space.

prescribed at hospital discharge and for at least several


POSTOPERATIVE CARE
weeks following surgery. Postoperative hospital stay is typi­
• An upright chest radiograph is performed in the recovery cally 3 to 4 days. The closed suction drain is removed in the
room and each morning for 3 days, and any small air or outpatient office when its output is less than 50 mL per day,
pleural fluid collections are observed with the expectation of usually 5 to 7 days after surgery.
spontaneous resolution. Postoperative analgesia is provided • Physical therapy is resumed the day after surgery to maintain
by continuous-infusion perineural local anesthesia ( discon­ range of motion and limit muscle spasm. The patient is al­
tinued on postoperative day 3) and patient-controlled intra­ lowed to use the extremity as tolerated, with no use of a sling
venous opiates until adequate pain control is achieved by or other restraint. Physical therapy is continued after hospital
oral medications alone. Oral narcotics, a muscle relaxant, discharge, with advice to avoid excessive reaching overhead
and a nonsteroidal antiinflammatory agent are routinely or heavy lifting with the affected upper extremity and other
C h a p t e r 7 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 186 1

activities that might result in muscle strain, spasm, and sig­ COMPLICATIONS
nificant pain in the sternocleidomastoid, trapezius, and other
neck muscles. Further rehabilitation is overseen by a physi­ • Persistent pain, numbness, and/or paresthesias
cal therapist with expertise in the management of NTOS,
• Postoperative bleeding, localized hematoma, or hemothorax
usually in conj unction with a physical therapist located near
• Wound infection (cellulitis or abscess)
the patient, emphasizing a gradual steady return to normal • Pleural effusion ( serosanguineous)
use of the upper extremity. • Persistent lymph leak, chylothorax
• The maj ority of patients are permitted cautious light duty
• Brachial plexus nerve dysfunction (temporary or sustained)
work activities by 4 to 6 weeks. Restrictions on upper ex­ • Phrenic nerve dysfunction (temporary or sustained)
tremity activity are progressively lifted between 6 and
• Long thoracic nerve dysfunction (temporary or sustained)
1 2 weeks, when recovery from surgery is typically consid­ • Recurrent NTOS
ered complete. Patients are seen in follow-up every 3 months
in the first year to assess long-term results. Physical therapy REFERENCES
and other aspects of care are continued as long as necessary 1. Sanders RJ, Haug CE. Thoracic Outlet Syndrome: A Common Sequelae
to achieve an optimal level of function. of Neck Injuries. Philadelphia, PA: JB Lippincott; 1991.
2. Molina JE. New Techniques for Thoracic Outlet Syndromes. New York,
NY: Springer; 2012.
OUTCOMES 3. Illig KA, Thompson RW, FreischlagJA, et al. Thoracic Outlet Syndrome.
1st ed. London, United Kingdom: Springer-Verlag; 2013.
• In properly selected patients with disabling NTOS, approxi­
4. Thompson RW, Driskill M. Thoracic outlet syndrome: neurogenic.
mately 8 0 % to 8 5 % can expect a substantial improvement
In: Cronenwett JL, Johnston KW, Rutherfod R, eds. Rutherford's
in symptoms and increased functional use of the upper ex­ Vascular Surgery. 7th ed. Philadelphia, PA: Elsevier; 2010:1878-1898.
tremity within several months of supraclavicular decompres­ 5. Sanders RJ, Hammond SL. Management of cervical ribs and anom­
sion.1-3 ·19 This estimate is elevated to approximately 90% to alous first ribs causing neurogenic thoracic outlet syndrome. 1 Vase
9 5 % in those who exhibited a positive anterior scalene/pecto­ Surg. 2002;36(1):51-56.

ralis minor muscle block prior to treatment. Factors that tend 6. Hempel GK, Rusher AH Jr, Wheeler CG, et al. Supraclavicular resec­
tion of the first rib for thoracic outlet syndrome. Am 1 Surg. 1981;
to diminish responsiveness to treatment include extremely
141(2):213-215.
long-standing ( > 5 years) and debilitating symptoms, wide­ 7. Sanders RJ, Raymer S. The supraclavicular approach to scalenectomy
spread pain syndromes, multiple previous operations (cervical and first rib resection: description of technique. 1 Vase Surg. 1985;2:
spine, shoulder, or peripheral nerves), depression, older age 751-756.
( > 5 0 years), and preexisting use of opiate pain medications. 8. Reilly LM, Stoney RJ. Supraclavicular approach for thoracic outlet
• Patients with long-standing NTOS can often display residual decompression. 1 Vase Surg. 1988;8:329-334.
9. Thompson RW, Petrinec D, Toursarkissian B. Surgical treatment of tho­
symptoms that may not be completely eliminated by tho­
racic outlet compression syndromes. II. Supraclavicular exploration and
racic outlet decompression. Although these symptoms may vascular reconstruction. Ann Vase Surg. 1997;11(4):442-451.
be tolerable and are expected to gradually improve, the sur­ 10. Sanders RJ, Hammond SL. Supraclavicular first rib resection and total
geon must provide continuing support and reassurance dur­ scalenectomy: technique and results. Hand Clin. 2004;20:61-70.
ing the prolonged period of recovery and rehabilitation. 11. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syn­
• Patients in the adolescent age-group ( < 2 1 years) tend to drome. 1 Vase Surg. 2007;46(3):601-604.
12. Emery VB, Rastogi R, Driskill MR, et al. Diagnosis of neurogenic
have even better outcomes than adults, based on assessment
thoracic outlet syndrome. In: Eskandari MK, Morasch MD, Pearce
of patient-reported survey instruments and postoperative
WH, et al, eds. Vascular Surgery: Therapeutic Strategies. Shelton, CT:
use of opiate pain medications. 14 Patients that have been People's Medical Publishing House; 2010:129-148.
selected for isolated pectoralis minor tenotomy can exhibit 13. Jordan SE, Ahn SS, Gelabert HA. Differentiation of thoracic outlet
early outcomes similar to those of patients that have un­ syndrome from treatment-resistant cervical brachial pain syndromes:
dergone combined supraclavicular decompression and pec­ development and utilization of a questionnaire, clinical examination
toralis minor tenotomy but require ongoing follow-up for and ultrasound evaluation. Pain Physician. 2007;10(3):441-452.
14. Caputo FJ, Wittenberg AM, Vemuri C, et al. Supraclavicular decom­
recurrent symptoms to determine if supraclavicular decom­
pression for neurogenic thoracic outlet syndrome in adolescent and
pression may be warranted at a later time. 17•18 adult populations. J Vase Surg. 2013;57(1):149-157.
• Recurrent symptoms of NTOS that might warrant reoperation 15. Povlsen B, Belzberg A, Hansson T, et al. Treatment for thoracic outlet
occur in 1 % to 2% of patients, usually within the first 2 years syndrome. Cochrane Database Syst Rev. 2010;(1):CD007218.
of treatment. Reoperations for NTOS are generally performed 16. Jordan SE, Machleder HI. Diagnosis of thoracic outlet syndrome using
using the supraclavicular approach, because this provides the electrophysiologically guided anterior scalene blocks. Ann Vase Surg.
1998;12(3 ):260-264.
most complete exposure of the anatomy with the greatest mar­
17. Sanders RJ, Rao NM. The forgotten pectoralis minor syndrome:
gin of safety.2° Following lateral reflection of the scalene fat 100 operations for pectoralis minor syndrome alone or accompanied
pad, the brachial plexus nerve roots are carefully exposed and by neurogenic thoracic outlet syndrome. Ann Vase Surg. 2010;24:
mobilized. Great care must be taken during this dissection to 701-708.
avoid nerve and blood vessel injury, given the dense fibrous 18. Vemuri C, Wittenberg AM, Caputo FJ, et al. Early effectiveness of iso­
scar tissue that is usually present witltin the operative field. Any lated pectoralis minor tenotomy in selected patients with neurogenic
thoracic outlet syndrome. J Vase Surg. 2013;57(5):1345-1352.
structures that were retained at the initial operation are then
19. Hempel GK, Shutze WP, Anderson JF, et al. 770 consecutive supra­
resected, including the scalene muscles, anomalous fibrofascial
clavicular first rib resections for thoracic outlet syndrome. Ann Vase
bands, and/or the 1 st rib. A complete brachial plexus neuroly­ Surg. 1996;10(5):456-463.
sis is performed and the nerves are protected with a bioabsorb­ 20. Ambrad-Chalela E, Thomas GI, Johansen KH. Recurrent neurogenic
able film and soft tissue coverage with the scalene fat pad. thoracic outlet syndrome. Am 1 Surg. 2004;187(4):505-510.
-

Chapter 8 Neurogenic T horacic Outlet


Syndrome Exposure and
I
Decompression: Transaxillary
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - � - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - �

George J. Arnaoutakis Thomas Reifsnyder Julie Ann Freischlag

DEFINITION is commonly an antecedent history of hyperextension neck


injury or repetitive neck trauma. Patients frequently manifest
• In 1 82 1 , Sir Astley Cooper recognized the constellation tenderness on palpation in the supraclavicular fossa over the
of neurovascular symptoms involving the thoracic outlet. anterior scalene muscle. A careful vascular physical examina­
Ochsner called this the scalenus anticus syndrome in 1 9 3 6 tion should confirm the presence of normal circulation.
and described the presence o f muscle abnormalities second­ Three physical examination maneuvers support the diag­
ary to repetitive trauma. Peet assigned this condition its nosis of neurogenic TOS.
contemporaneous moniker thoracic outlet syndrome (TOS) Rotation of the neck and tilting of the head to the op­
in 1 96 6 . 1 posite side elicit pain in the affected arm.
• T O S is a condition defined as compression o f one o r more of The upper limb tension test in which the patient first
the neurovascular structures contained within the thoracic abducts both arms to 90 degrees with the elbows in
outlet. a locked position, then dorsiflexes the wrists, and fi­
• The thoracic outlet is a narrowly defined anatomic region nally, tilts the head to the side. Each subsequent step
encompassing the space between the neck and the shoulder, imparts greater traction on the brachial plexus, with
cephalad to the thoracic cavity, and beneath the clavicle. the first two positions causing discomfort on the ipsilat­
From the surgeon's point of view the thoracic outlet can be eral side and the head-tilt position causing pain on the
visualized as an anatomic triangle: the two sides being the contralateral side.
anterior and middle scalene muscles with the 1 st rib serving During the elevated arm stress test (EAST), the patient
as the base of the triangle. The scalene muscles, which origi­ raises both arms directly above the head and repeatedly
nate from the lower cervical spine, may hypertrophy with opens and closes the fists. Characteristic upper extrem­
repetitive neck motion or minor trauma. This hypertrophy ity symptoms arise within 60 seconds in patients with
is believed to contribute to compression of thoracic outlet neurogenic TOS.
structures. • Approximately 4 % of patients with TOS present with ve­
• TOS is subdivided into three discrete entities . nous involvement. Venous TOS patients typically present
Neurogenic with acute onset of dull aching pain of the upper extrem­
Venous ity associated with arm edema and cyanosis. Paresthesias
Arterial may be present but are due to hand swelling instead of tho­
• Appropriate classification of the type of TOS is important racic outlet nerve involvement. A history of strenuous and
in guiding perioperative management, as well as surgical repetitive work or athletics involving the affected extrem­
approach. This chapter focuses on transaxillary decompres­ ity is common, and most patients are young. This specific
sion and 1 st rib resection for neurogenic TOS. condition is also known as Paget-Schroetter syndrome or
effort vein thrombosis, as the entrapped subclavian vein
DIFFERENTIAL DIAGNOSIS has progressed to thrombosis. Some patients will present
• Carpal tunnel syndrome less acutely with nonthrombotic subclavian vein occlusion
• Ulnar nerve compression or stenosis manifested by intermittent swelling with activity.
• Rotator cuff tendinitis Regardless, the etiology of venous TOS is mechanical, and
• Pectoralis minor syndrome treatment is ultimately aimed at eliminating not only the ve­
• Cervical spine strain nous obstruction but also the muscular bands and ligaments
• Cervical disc disease that have entrapped and damaged the vein.
• Cervical arthritis
• Arterial TOS typically presents in one of three ways:
• Brachial plexus injury ( 1 ) asymptomatic, (2) arm claudication, and ( 3 ) critical isch­
• Fibromyositis emia of the hand. The majority of these patients have a cervical
rib, which may or may not be fused to the 1 st rib and is most
commonly posterior to the subclavian artery. The etiology is
PATIENT HISTORY AND PHYSICAL FINDINGS
chronic repetitive injury to the subclavian artery as it exits the
• A careful history and physical examination enables proper thoracic outlet. This injury may cause subclavian artery steno­
classification of TOS. sis but more commonly leads to ectasia or a true aneurysm.
• The neurogenic form accounts for the maj ority of cases in In asymptomatic patients, a pulsatile mass or supracla­
modern series ( > 9 5 % ).2 Symptoms of neurogenic TOS, vicular bruit can be detected on physical examination.
which is more prevalent in women, include paresthesia; pain; Arm claudication is caused by areas of stenosis which may
and impaired strength in the affected shoulder, arm, or hand be static due to long-standing repetitive injury or dynamic,
along with occipital headaches and neck discomfort. There occurring only with arm abduction or extension.

1862
C h a p t e r 8 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 1863

Critical ischemia is due to emboli of fibrinoplatelet aggre­ • The transaxillary approach is preferred by many surgeons
gates that originate from an ulcerated mural thrombus in because of its relative ease, low-risk profile, and documented
the aneurysmal segment. improvement in patients' quality of life.4•5 This approach ef­
fectively decompresses the thoracic outlet and is generally
PREOPERATIVE EVALUATION AND OTHER reserved for patients with neurogenic or venous TOS.
• If vessel reconstruction is anticipated, a different approach
DIAGNOSTIC STUDIES
should be considered as the transaxillary approach limits
• In young patients ( <40 years of age) with a classic presenta­ vessel exposure.
tion of neurogenic TOS, there is no need for extensive pre­
operative testing. Surgical Anatomy
• Older patients and those with a history of neck trauma
should undergo magnetic resonance imaging (MRI) to rule
• The subclavian artery and the five nerve roots ( C5-T 1 ) to the
out cervical disc pathology. brachial plexus are located within the thoracic outlet. The
• Preoperative physical therapy should be attempted for at artery courses anterior to the brachial plexus nerve roots
least 8 weeks in patients with a diagnosis of neurogenic TOS. and exits the mediastinum in its course over the 1 st rib be­
The aims of therapy are to improve posture and achieve hind the posterior border of the anterior scalene muscle. The
greater range of motion. Patients with persistent symptoms cervical spine nerve roots j oin to form the initial trunks of
of neurogenic TOS despite 8 weeks of physical therapy merit the brachial plexus within the thoracic outlet and are located
surgical intervention. At least 60% of patients will improve posterior to the subclavian artery. Subsequent merging and
with physical therapy and lifestyle alterations. branching of these trunks into divisions, cords, and terminal
• A radiographically guided anterior scalene block with local nerves occurs outside the thoracic outlet.
anesthetic ( lidocaine) inj ection may provide a few hours of
• Other significant nerves within the thoracic outlet are the
symptomatic relief. Patients with suspected neurogenic TOS phrenic and long thoracic nerves.
often present with a wide constellation of physical com­ The phrenic nerve receives fibers from C3-C5 and courses
plaints, not all of which are directly attributable to the disor­ in a descending oblique direction from the lateral to the
der. A scalene block not only helps confirm the diagnosis but medial edge of the middle portion of the anterior scalene
also simulates the expected postoperative result, especially muscle. The phrenic nerve approaches the mediastinum
in older patients. 3 This provides the patient and the surgeon posterior to the subclavian vein.
reassurance that surgical intervention will be of benefit and The long thoracic nerve, composed of nerve fibers from
demonstrates which symptoms can be reliably expected to CS-C7, passes through the center of the middle scalene
improve. muscle and heads toward the chest wall to innervate the
• As an alternative to surgical therapy, patients can then opt serratus anterior muscle.
for a Botox (Allergan, Irvine, CA) injection. The Botox takes
• The subclavian vein technically does not course through
an average of 2 weeks to work and may be repeated. This the thoracic outlet. It passes over the 1 st rib anterior to the
may provide symptomatic relief for 2 to 3 months, allow­ anterior scalene muscle. However, the middle segment of
ing participation in physical therapy. However, not all TOS the vein remains susceptible to compression between the
patients respond to Botox. This practice is especially helpful anteromedial 1 st rib, clavicle, and the subclavius muscle
in patients who have had cervical spine fusions or shoulder ( FIG 1 ) . Hypertrophy of the subclavius muscle and ten­
operations as they can strengthen the muscles of their neck don may occur in athletes and is often implicated in ve­
and back, which may alleviate the TOS symptoms. nous TOS.
• Plain film chest x-ray is recommended for all patients under­
• Several anatomic anomalies are relevant to the surgeon, as
going surgical intervention for TOS to rule out a cervical rib. they predispose patients to the development of TOS.
• Nerve conduction studies are typically normal in neurogenic The most common is a cervical rib, and a preoperative
TOS but may be useful in ruling out nerve compression such chest radiograph is adequate for its detection. When pres­
as carpal tunnel or cubital compression syndrome. ent, cervical ribs appear as extensions of the transverse
• Duplex ultrasonography is the initial diagnostic modality to process of C7. Cervical ribs may be complete or partial,
confirm pathology in patients with arterial TOS. Although with the anterior end attaching to the 1 st rib or floating
useful to confirm axillosubclavian vein thrombosis in pa­ freely. Additionally, the anterior end may be fibrous and
tients with suspected venous TOS, venography often sup­ not calcified and thus not completely visualized on chest
plants it for both diagnostic and therapeutic reasons. Lastly, radiograph. By rigidly confining the thoracic outlet, cervi­
venous TOS is frequently bilateral. cal ribs render the neurovascular structures more prone to
compression. Although present in the general population
with an incidence of 0 . 5 % to 1 % , they are found in 5 %
SURGICAL MANAGEMENT t o 1 0 % o f all TOS patients.
Surgical Approach A prominent C7 transverse process or bifid 1 st rib is also
associated with TOS.
• Patients with a diagnosis of TOS who are appropriate surgi­
cal candidates should undergo surgical decompression of the
Positioning
thoracic outlet.
• The optimal approach should be individualized depending on • General endotracheal anesthesia is induced and sequential
the patient's symptoms, anatomy, and surgeon's experience. compression devices are applied.
1864 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Anterior scalene
muscle
Subclavian artery

C8-T1 nerve root

Middle scalene

Subclavian vein
FIG 1 • R i g ht-sided thoracic outlet a n atomy from
Subclavius muscle the su rgeo n 's perspective as viewed t h ro u g h the
operative f i e l d i n a transaxi l l a ry a pproach. Inset,
First rib
n o r m a l a n ato m i c relati onshi ps of i m portant thoracic
outlet structu res.

• The patient is then moved to the lateral decubitus position • An adj ustable Machleder arm support is affixed to the
using a beanbag to facilitate positioning. operating table with the vertical support bar attached to the
Care should be taken to pad the dependent axilla and sup­ operating table at the level of the patient's chin.
port the head. The sterile field incorporates the arm, axilla, Generous padding around the patient's arm prior to place­
and shoulder. ment in the arm holder protects the median and ulnar nerves
from compression as they cross the elbow joint ( FIG 2) .

F I G 2 • A p h otog raph d e p i cti n g p r o p e r patient positi o n i n g


f o r r i g ht tra nsaxi l l a ry 1 st r i b resection a n d u s e of the
Machleder a r m support with g e n e rous pad d i n g to p reve nt
co m p ression n e rve i n j u ry. A padded axi l l a ry ro l l is p l a ced u n d e r
the dependent (l eft) axi l l a, a n d the patient is sta b i l ized i n t h e
l eft l atera l decubitus w i t h the a i d of a bea n b a g . The dashed
line i n d i cates the p referred locat i o n of the skin i n c i s i o n .
(Repri nted f r o m Arnaoutakis G, Freisc h l a g J A , Reifsnyd e r T.
Tra nsaxi l l a ry r i b resection for thoracic outlet syn d ro m e . I n :
Ca m b r i a R , C h a i kof E, eds. Atlas o f Vascular a n d Endovascular
Surgery: Anatomy and Technique. P h i l a d e l p h i a, PA: E l sevier;
2 0 1 4 : 1 93-203, with permission from E l sevier.)

I NCISION m uscle and the poste r i o r s u rface of the pectora l i s major


m uscle.
• Prophylactic a ntibiotics are a d m i n istered. A fi rst-generation • A tra nsverse s k i n l i n e i n cision should be m a d e i n the
cephalosporin is preferred. In patients with penici l l i n a l lergy, i nferior axi l l a ry h a i r l i n e exte n d i n g between these two
clindamycin or vancomycin is used . m uscle borders.
• After secu r i n g the a rm i n the retractor, the s u rgeon
i d e ntifies the a nterior border of the l atissi m u s d o rs i

EXPOSURE chest wa l l-a n d if i n the correct a nato m i c plane-gentle


b l u nt d issection with the surgeon's fingers or a pair of
• E l ectroca utery is used to d ivide the su bcuta neous tissue until Kittner or pea n ut d i ssectors easily sepa rates the soft tissues
t h i n a reo l a r tissue superficial to the chest wa l l is encoun­ from the chest wa l l . This d i ssection is i n a cepha lad d i rec­
tered . A self-reta i n i n g Cerebe l l a r o r Weitl aner retractor tion a n d the 2nd rib w i l l ra p i d ly come i nto view.
is then inserted i nto the wou n d . Upon enco u nteri ng the
C h a p t e r 8 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 1865

Anterior scalene

Subclavian artery
Subclavian
vein
C8- T1 nerve root

Middle scalene

I ntercostal muscle Fi rst rib


detachment
FIG 3 • A perioste a l e l evato r is used to
d i ssect a l o n g the superior su rface of the
1 st r i b i n order to d ivide i ntercostal m u scle
atta c h m e nts.

• The i nte rcostobrach i a l n e rve is l ocated in the 2 n d i nter­ detach the sca l e n e m e d i u s fi bers from the r i b . The l o n g
costa l space. Alth o u g h freq uently d iffic u l t to avoid, ca re thoracic n e rve cou rses a l o n g the latera l edge of t h e
s h o u l d be taken not to i m pa rt excess traction as i n j u ry sca l e n e m e d i u s m u scle but i s g e n e ra l ly n o t visu a l ized.
resu lts i n n u m b n ess or dysesthesia of the m e d i a l aspect Avo i d i n g sharp d i ssect i o n and c l osely adhering to the
of the proxi m a l a r m . su rface of the r i b d u r i n g b l u nt d issection p revents i n j u ry
• R a i s i n g t h e M a c h l ed e r a rm s u p p o rt at t h i s p o i n t a l - to the l o n g thoracic n e rve.
l ows f o r o pt i m a l access to t h e 1 st rib and t h o r a c i c • The a nte rior sca l e n e m uscle sho u l d n ow be clearly identi­
o u t l et. T h e aid of fi beroptic- l i g hted Deaver retrac­ fied as it a rises from the m ed i a l superior aspect of the
tors fa c i l itates v i s u a l i za t i o n d u r i n g this p o rt i o n of the 1 st rib (FIG 4) . A rig ht-a n g led c l a m p is passed b e h i n d the
d i ssect i o n . A l t e r n ative l y, t h e s u rg e o n s h o u l d wear a a nte rior sca l e n e m uscl e near its i n se rtion o n the sca lene
h e a d l i g ht. tu bercle. Gently l ifti n g the a nterior sca lene with the
• The 1 st r i b is identified n e a r its i nsertion at the sterno­
c l avicu l a r j o i nt a n d g e n e ra l ly encou ntered h i g h e r than
a ntici pated . A Kittner o r peanut d i ssecto r is then used to
gently sweep away the loose fibrous tissue overlyi n g the
1 st r i b p a rti a l ly expos i n g the b rach i a l p l exus, subclavian
a rtery a n d vein, a n d sca l e n e m uscles. There i s occasion­
a l ly a sma l l branch of the subclavian a rtery that m ust be
l i g ated and d ivided i n order to f u l l y expose the operative
field.
• The n ext ste p is to fu l ly expose the r i b . Depe n d i n g o n
the patie nt's a n atomy, it g e n e ra l ly is easi est to fi rst clea r
off the i ntercosta l m uscles l atera l ly. A Cobb perioste a l
e l evator works best, but a ny type of l o n g e l evato r may
be used (FIG 3) . The d i ssect i o n p roceeds i n the a nte rior
a n d poste rior d i rections u n t i l all the i nte rcosta l m uscle
attac h m e nts a re d ivided from the r i b . The e l evator can
FIG 4 • An image of the g ross anatomy from a close-up
then be used to e l evate the 1 st ri b, thus separat i n g the
perspective of the rig ht-sided thoracic outlet. The i m portant
r i b from the u nd e r lyi n g parietal pleura. This m o b i l ization
re lationsh i ps between the 1 st rib, a nterior sca lene m uscle, and
should cont i n u e from beh i n d the brach i a l p l exus i n the subclavian vessels ca n be seen. (Repri nted from Arnaoutakis G,
poste rior d i rection to beyo n d the subclavian ve i n i n the Freischlag JA, Reifsnyder T. Tra nsaxi l l a ry rib resection for thoracic
a nte rior d i rect i o n . outlet syndrome. In: Cambria R, Chaikof E, eds. Atlas of Vascular
• Atte ntion is then d i rected to the superior b o r d e r of t h e and Endovascular Surgery: Anatomy and Technique. Philadelph ia,
1 st r i b, w h e r e the perioste a l e l evator is u s e d to b l u ntly PA: Elsevier; 20 1 4 : 1 93-203, with permission from Elsevier.)
1866 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

Anterior scalene

Subclavian
vein
C8-T 1 nerve root

Middle scalene
muscle

FIG S • A rig ht-a ng led clamp is insinuated


behind the a nterior sca lene muscle. Gentle
elevation p u l l s the m uscle away from the
u nderlying subclavian artery thereby protecting
the artery prior to d ivid ing the m uscle with
scissors. The subclavius m uscle is a crescent­
shaped liga mentous attachment to the 1 st rib
First rib adjacent to the subclavian vei n . The subclavius
m uscle is sharply d ivided with scissors with ca re
not to injure the subclavian vei n .

rig ht-a n g led c l a m p p rotects the subclavian a rtery as it when c o m p a red w i t h d ivision at i t s i n se rtion p o i nt o n
cou rses poste rior to the m uscle (FIG S) . It is i m portant the r i b .
to free seve ral ce ntimete rs of the m u scle prior to d ivid- • Lastly, the su bclavius m uscle w i l l a p pea r as a crescent­
i n g it with M etze n b a u m scissors (FIG 6) . This m a n euver sha ped l i g a m e ntous attac h m e nt to the 1 st rib adjacent to
faci l itates resection of a portion of the a nte rior sca lene the subclavian ve i n . With care n ot to i nj u re the su bclavian
m uscle, which has been shown to reduce recu rrence rates ve i n , the s u bclavius m uscle is sharply d ivided with scissors.

FIG 6 • The 1 st rib is seen in the foreg ro u n d of the operative


photo taken d u r i n g a l eft 1 st rib resect i o n . M etze n b a u m
scissors a re u s e d t o s h a r p l y d ivide the anterior sca l e n e m uscle,
with the rig ht-a n g l e d c l a m p e l evat i n g the m u scl e to p rotect
the subclavian a rtery as it cou rses beh i n d the m u scle. The
d ivided ends of the te n d i n o u s anterior sca l e n e fi bers can be
see n . (Repri nted from Arnaoutakis G, Freisc h l a g JA, Reifsnyd e r
T. Tra nsaxi l l a ry r i b resection for t h o r a c i c outlet syn d ro m e . I n :
Ca m b r i a R , C h a i kof E , eds. Atlas of Vascular a n d Endovascular
Surgery: Anatomy and Technique. P h i l a d e l p h ia, PA: E l sevier;
20 1 4: 1 93-203, with permission from E l sevier.)

RIB RESECTI O N • A bone rongeur is used to rem ove res i d u a l r i b a n d to


sm ooth the cut ends u nt i l there is no resi d u a l n e rve i m ­
• With the r i b co m p l etely m o b i l ized, a bone cutter is used p i n g e m e nt. A Roos retractor o r s i m i l a r i nstr u m ent m a y
to d ivide the 1 st rib. G e n e ra l ly, it is d ivided a nteriorly be used t o p rotect the n e rves d u r i n g u s e of the r o n g e u r
a n d then poste riorly; h owever, the patie nt's body h a bitus (FIG 8).
may make the reverse order easier (FIG 7) . • It is i m portant to e n s u re that no resi d u a l fi bers from the
• I n i t s a nterior extent, t h e r i b i s d ivided adjacent to t h e a nterior sca l e n e m uscle crosses beneath the subclavian
s u b c l a v i a n ve i n , a n d i n the poste r i o r d i rect i o n , it is d i ­ a rte ry a n d i n se rts onto the t h i ckened su rfa ce at the a pex
vided j u st a nterior t o t h e brach i a l p l exus; t h i s e n s u res of the p l e u ra, k n own as S i bso n 's fasc i a . Any such fi bers
that the n e rve roots a re n ot i n a dve rte ntly i n j u re d . The s h o u l d be i d e ntified and d i v i d e d .
rib i s then removed .
C h a p t e r 8 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 1867

Anterior scalene
muscle

Subclavian artery Subclavian


vein

C8-T1 nerve root Subclavius


muscle

FIG 7 • A bone cutter is used to d ivide the 1 st


r i b i n its a nterior a n d poste rior d i rect i o n . Once
First rib
removed, the ro n g e u r is used to ach ieve smooth
rib edges.

�r.�{rr:·��
I
...
�-:__,. .
. '
·;·

. \',
4 .._
FIG 8 • From the top of the image in the cl ockwise d i rection,
the instru ments depicted a re (1) Roos retractor, (2) Alexander
peri osteotome, (3) Kerrison p u nch upbiting i nstrument,
(4) double-action bone cutter, (5) Cobb periosteal elevator,
a n d (6) Rongeur. (Repri nted from Arnaoutakis G, Freischlag
- /
,
JA, Reifsnyder T. Tra nsaxi l l a ry rib resection for thoracic outlet
' I synd rome. I n : Cambria R, Chaikof E, eds. Atlas of Vascular and
I '
Endovascular Surgery: Anatomy and Technique. Philadelphia,
PA: Elsevier; 2 0 1 4 : 1 93-203, with perm ission from E lsevier.)

CLOSURE tube may not be n ecessa ry. I n this situation, a 1 2- o r


1 4-Fr r e d r u b b e r catheter is p l aced i nto the b e d of t h e
• The s u r g i ca l fie l d is n ext i n spected for b l eed i n g . Te m po­ 1 st r i b a n d atta ched t o g e n t l e suct i o n . T h e M a c h l e d e r
rarily packing the wo u n d re l i a bly controls m i n o r b l eed­ a r m h o l d e r i s lowered to fa c i l itate a tensio n-free closure .
ing. The wound is then reins pected, and hemostasis is The su bcuta neous fascia is then cl osed a r o u n d the tube.
co m p l eted with j u d icious use of e l ectrocautery. While suction is a p p l ied to the red rubber catheter, the
• The wound is then fi l led with sa l i n e . Several positive p res­ a n esthesia tea m p rovides a susta i n ed Va lsa lva a n d the
s u re venti lations a re a d m i n istered with sa l i n e l eft in the fasc i a l sutu re i s tied as the suct i o n tube is ra p i d ly re­
wound to assess for a n air leak i n d i cative of a posto pera­ m oved . This m a n euver g e n e ra l ly avo i d s a c l i n ica l ly sig­
tive p n e u m othorax. If a n a i r leak is p resent, a sma l l ca l i be r n ificant postope rative p n e u m othorax.
( 1 2 F r e n c h [Fr]) ch est tube is warra nted prior to c l o s u r e . • Closure is perfo rmed with a bsorba b l e 2-0 suture i n the
• If the i rrigation d ra i ns i nto the p l e u r a l space but there fasc i a a n d a 4-0 su bcuticu l a r skin closure.
is no a i r l e a k, the p l e u ra has been breached, but a ch est

PEARLS AND PITFALLS


Operative m a ntra • Look twice and cut once. Always d o u b l e-check p l acement of the bone cutters before d i v i d i n g the 1 st
rib.
I ncorrect d i a g nosis • A su ccessf u l operation h i nges o n a n accu rate p reoperative d i a g nosis. A thoro u g h h i story a n d physica l
a n d the a nterior sca l e n e b l ock h e l p to i d e ntify patients l i kely to benefit from 1 st r i b resect i o n .
B rach i a l p l exus i n j u ry • Proper positio n i n g a n d caref u l retraction h e l p p revent excessive traction a n d i nj u ry to the brach i a l plexus.
M isidentification of • D u r i n g i n it i a l exposu re, the 2nd rib is often m ista ken for the 1 st rib. The ce p h a l a d su rface of the 1 st r i b
the 1 st r i b is f l a t u n l i ke the 2 n d , w h i c h i s m o r e co n cave.
1868 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

I n c o m p l ete 1 st r i b • I nco m p l ete 1 st r i b resect i o n has been associ ated with recu rrent TOS. After cutt i n g a n d remov i n g the
resection ri b, take your t i m e to trim back the ends with the ro n g e u r.
H e m ostasis • To keep a cl ean ope rative field, pack a 4 x 4 g a uze i nto the wound, lower the a r m retractor, a n d wait a
co u p l e of m i n utes. T h i s often a i d s i n hem ostasis.

POSTOPERATIVE CARE • Pneumothorax


This complication occurs in 2% to 1 0 % of patients.8 Ac­
• A chest x-ray is performed in the recovery room. cordingly, an upright chest x-ray is routinely performed in
Small, clinically asymptomatic pneumothoraces may be the recovery room.
observed with a follow-up chest x-ray the next morning. Radiographically detected pneumothoraces only require a
• Patients are typically discharged from the hospital when ad- chest tube if symptomatic or enlarging.
equate oral analgesia has been achieved. Adhering closely to the inferior surface of the 1 st rib dur­
Activity is restricted by the amount of postoperative pain. ing blunt dissection will help protect against postoperative
Occasionally, a sling is required for patient comfort, but it pneumothorax.
is preferable to have the arm as mobile as tolerated. • Recurrence
• Physical therapy should be prescribed after 2 weeks in Symptoms of TOS recur in 1 0 % to 2 0 % of patients. 1 0-12
all patients undergoing transaxillary 1 st rib resection, Two intraoperative factors are known to reduce recur­
regardless of the cause, to restore range of motion and rence rates.
strength. Resecting a significant portion (2 to 3 em) of the ante­
rior scalene muscle as opposed to simply dividing it at
OUTCOMES its insertion point
Ensuring that the posterior edge of the 1 st rib is resected
• Improvement after surgery for neurogenic TOS is somewhat
sufficiently so as to leave as short a rib stump as techni­
subjective and based on the patient's perception of disability
cally feasible
before and after decompression. Improvement in symptoms
Patients with spontaneous recurrence compared to those
exceeds 9 0 % . 6
that are reinjured have worse outcomes when reoperation
• Over time, the durability of these results may decrease, rein­
is performed.
forcing the need for close follow-up of these patients beyond
2 years?•8
REFERENCES
• Factors that predict surgical failure include major depression,
chronic symptoms, work-related inj ury, lack of response to 1. Roos DB. Transaxillary approach for first rib resection to relieve tho­
anterior scalene muscle blocks, and a short segment of di­ racic outlet syndrome. Ann Surg. 1 9 6 6 ; 1 6 3 : 3 54-3 5 8 .
2. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syn­
vided anterior scalene muscle.9
drome. ] Vase Surg. 2007;4 6 : 6 0 1-604.
3. Lum YW, Brooke BS, Likes K, et al. Impact of anterior scalene lido­
COMPLICATIONS caine blocks on predicting surgical success in older patients with neu­
rogenic thoracic outlet syndrome. ] Vase Surg. 2 0 1 2;55 : 1 3 70-1 375.
• Vascular injury 4. Chang DC, Lidor AO, Matsen SL, et al. Reported in-hospital com­
A national query identified injury to the subclavian vessels plications following rib resections for neurogenic thoracic outlet syn­
as the most common complication following transaxillary drome. Ann Vase Surg. 2007;21 : 5 64-5 70.
5. Chang DC, Rotellini-Coltvet LA, Mukherjee D, et al. Surgical inter­
rib resection for neurogenic TOS, occurring in 1 % to 2 %
vention for thoracic outlet syndrome improves patient's quality of life.
o f cases.4
J Vase Surg. 2009;4 9 : 6 3 0-63 5 ; discussion 635-637.
Patients experiencing a vascular inj ury have greater 6. Roos DB. The place for scalenectomy and first-rib resection in thoracic
lengths of stay as well as increased hospital charges. outlet syndrome. Surgery. 1 9 82;92 : 1 077- 1 0 8 5 .
It is difficult to obtain proximal control of these vessels 7. Rochlin D H , Gilson MM, Likes K C , e t al. Quality-of-life scores in
from the transaxillary approach, and therefore, the sur­ neurogenic thoracic outlet syndrome patients undergoing first rib re­
geon should exercise extreme caution when dissecting section and scalenectomy. J Vase Surg. 2 0 1 3 ;57:436-44 3 .
8. Altobelli G G , Kudo T, Haas BT, et al. Thoracic outlet syndrome: pat­
near these vessels.
tern of clinical success after operative decompression. J Vase Surg.
• Nerve injury 2005;42 : 1 22-1 2 8 .
Major nerve inj ury has been traditionally regarded as the 9.
Axelrod DA, Proctor MC, Geisser ME, e t al. Outcomes after surgery
most common complication following surgery for TOS. for thoracic outlet syndrome. j Vase Surg. 200 1 ; 3 3 : 1 220-1 225.
However, large contemporary series disprove this belief, 10. Mingoli A, Feldhaus RJ, Farina C, et al. Long-term outcome after trans­
with rates of brachial plexus injury for patients undergo­ axillary approach for thoracic outlet syndrome. Surgery. 1 9 9 5; 1 1 8 :
840-844.
ing transaxillary 1 st rib resection approaching 0 % .4•8
11. Mingoli A, Sapienza P, di Marzo L, et al. Role of first rib stump length
Temporary or permanent numbness of the upper medial
in recurrent neurogenic thoracic outlet syndrome. Am J Surg. 2005;
arm due to excessive traction or division of the intercos­ 190:156.
tobrachial nerve occurs in up to 1 0 % . Frequently, these 12. Sanders RJ, Haug CE, Pearce WH. Recurrent thoracic outlet syn­
symptoms will improve over time. drome. J Vase Surg. 1 9 9 0 ; 1 2 : 3 9 0-3 9 8 ; discussion 3 9 8-400.
I

Chapter 9 Venous and Arterial T horacic


Outlet Syndrome
. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - �

Jason T. Lee

DEFINITION Brachial plexus

Overlying Subclavian artery


• Venous thoracic outlet syndrome (vTOS), also known as effort
thrombosis or Paget-von Schrotter syndrome, involves repeti­ clavicle Subclavian vein
tive subclavian venous compression that leads to endothelial
Subclavius tendon
injury and intermittent stasis that ultimately contributes to and muscle
acute thrombosis of the axillosubclavian venous system. The Costoclavicular ligament
external compression of the vein occurs between the clavicle
and subclavius muscle from above and by the 1 st rib and the
anterior scalene muscle insertion from below ( FIG 1 ) .
• Arterial thoracic outlet syndrome (aTOS) i s the least com­
Fi rst
mon presentation of thoracic outlet syndrome and most
rib
often involves subclavian artery compression leading to ex­
trinsic compression, poststenotic dilatation, aneurysmal de­
generation, and subsequent distal embolization. 1 Bony and
muscular abnormalities are typically present in patients with
aTOS and can include a cervical rib, anomalous 1 st rib, an­
terior or middle scalene muscle bands, or hypertrophic cal­
lus from a healed clavicular inj ury or fracture ( FIG 2 ) .

DIFFERENTIAL DIAGNOSIS Middle Anterior


scalene scalene
• Compared to neurogenic thoracic outlet syndrome (TOS), muscle muscle
vTOS and aTOS are much more straightforward in their di­
FIG 1 • N o r m a l stru ctu res in the thoracic outlet that can
agnostic workup. vTOS patients with swelling must be distin­ contrib ute to ve n o u s c ompress i o n .
guished from secondary causes of axillosubclavian thrombosis,
namely iatrogenic catheterization or instrumentation of the
venous system leading to thrombosis, which is obvious upon • Because aTOS usually involves distal embolization t o the
eliciting a careful history. Also, a hypercoagulable state or hand from thrombus in a subclavian aneurysm, a thorough
malignancy can present as isolated upper extremity venous workup for a cardiogenic source should be sought before
thrombosis and there is some debate about the need for addi­ assigning the etiology to aTOS. Transesophageal echocar­
tional medical workup in patients suspected of having vTOS.2 diography, with bubble enhancement to identify paradoxical

Anterior
scalene
muscle

FIG 2 • A b n o rm a l a nt e r i o r a n d m i d d l e
sca l e n e b a n d s a n d a b n o r m a l cervica l
r i bs l e a d to co m p ress i o n a n d s u bseq u e nt
postste n ot i c d i l at a t i o n of t h e s u b c l a v i a n
a rte ry, ca u s i n g a rter i a l T O S .
1869
1870 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

mass or bruit may be present in the supraclavicular fossa or


a bony prominence in that region may hint toward a cervical
rib or muscular abnormality. Symptoms often are gradual
and unnoticed by patients until occurring more frequently or
when complete thrombosis occurs and the patient presents
with critical upper extremity ischemia.

IMAGING AND OTHER DIAGNOSTIC


STUDIES
• Patients suspected of having vTOS should undergo duplex
ultrasound of the affected area. Axillosubclavian venous im­
aging can be challenging due to the clavicle's location as well
as many of these patients being quite muscular. Color flow
duplex, phasicity of flow with respiration, and augmenta­
tion with compressive maneuvers can all aid in confirming
the diagnosis of deep venous thrombosis (DVT). An expe­
rienced vascular sonographer and interpreter can make the
diagnosis with high accuracy based on duplex alone. Cross­
FIG 3 • 1 8-yea r-o l d baseba l l catcher present i n g with a r m sectional imaging with magnetic resonance imaging (MRI)
swe l l i ng, p a i n , cya n osis, a n d promi nent superfi c i a l vasc u l at u re or computed tomography ( CT) venography is rarely needed
after a stre n u o u s workout after a g a m e .
or indicated in the workup of vTOS. Catheter-based venog­
raphy is the key confirmatory imaging study to document
the extent of vTOS and leads to the initial recommended
emboli, m a y be necessary t o exclude cardiogenic emboli.
therapeutic strategy of thrombolysis and reduction of clot
Computed tomography angiography ( CT-A) of the arch and
burden.
upper extremity vessels would also be reasonable to exclude
• Patients presenting with digital ischemia suspicious for aTOS
other arterial causes including axillary branch artery aneu­
should undergo plain radiographic imaging to assess for a
rysms, congenital abnormalities, or traumatic injuries and
cervical rib ( FIG 4) . Digital plethysmography of bilateral
dissections of the axillosubclavian arterial system, which
upper extremities can be performed to visualize blood flow
can be seen in high-performance athletes and individuals
to each finger and can rule out Raynaud's type etiologies in
performing repetitive upper extremity motions.
the differential diagnosis. Wrist-brachial indices should be
documented prior to any further intervention to establish
PATIENT HISTORY AND PHYSICAL
baseline flow characteristics. CT-A of the neck and upper
FINDINGS extremity in provocative positioning ( arms at 1 8 0 degrees
• Most patients with vTOS are young, healthy, and often overhead) provides the most definitive visualization of the
athletically inclined who present with the abrupt onset of affected region, confirming the presence of the cervical rib,
unilateral arm swelling in their dominant arm after repeti­ delineating the amount of thrombus in the subclavian aneu­
tive, strenuous use for sport, work, or recreation. Athletes rysm, and documenting the proximal and distal vasculature
affected can include baseball pitchers, rowers, swimmers, for operative planning ( FIG 5) .
water polo players, weightlifters, volleyball players, surfers,
football quarterbacks, or any others relying on repetitive
upper extremity effort. The swelling is noted in the shoulder,
arm, and hand and can be accompanied by aching, throb­
bing, or tightness that worsens with more activity. Because
most patients are otherwise young and healthy, an orthope­
dic cause such as strain, muscle pull, or j oint inj ury is often
considered initially. Cyanosis of the affected extremity, vis­
ible chest wall venous collaterals, or progressively worsening
symptoms suggest a vascular etiology, prompting referral to
an interventionalist. On exam, the arm is swollen, tender to
palpation, warm, and often has visible superficial collaterals
that track onto the anterior chest wall ( FIG 3 ) . Range of mo­
tion of the affected extremity can be impeded due to patient
discomfort.
• aTOS patients will present with mild hand ischemia due to
distal embolization, which manifests as digital ischemia or
splinter hemorrhage. The diagnosis is often delayed due to
the fact that these patients have no typical atherosclerotic
risk factors and are mostly young and athletic. A pulsatile FIG 4 • Ch est x-ray d e m o nstrating l eft cervica l r i b (arrow).
C h a p t e r 9 V E N O U S A N D ARTERIAL THORACIC OUTLET S Y N D R O M E 187 1

FIG 5 • CT-A reco nstruction of 1 9-yea r-o l d co l l eg iate te n n i s


p l ayer with cervical r i b (arro ws) t h a t l e d to subclavian a n e u rysm
formati o n . Patient presented with f i n g e rt i p e m b o l i after p l a y i n g
l o n g matches.

SURGICAL MANAGEMENT
Preoperative Planning

• vTOS patients diagnosed with acute axillosubclavian


DVT should be anticoagulated with weight-based dosing
of unfractionated heparin or low-molecular-weight hepa­
rin. Depending on the resource availability, admission for
thrombolysis or urgent referral to a center capable of cath­
eter-directed interventions has been generally accepted as
B
standard of care. 3 There are patients that are simply put on
anticoagulation that get referred much later (more than 2 FIG 6 • A. I n it i a l venogram d e m o nstrat i n g right axi l l os u bc l a v i a n
occl usion w i t h l a rg e co l l atera l deve l o p m ent. W i re was passed
weeks) due to lack of recognition of the TOS etiology of the
t h r o u g h this reg i o n and p h a rmacomech a n ical throm bolysis
DVT and this leads to a diminished success rate of throm­
i n itiated . B. Fo l l ow-u p ve nogram 24 h o u rs l ater with reso l ution
bolysis.4 of majority of thrombus l o a d . Ve i n sti l l sh ows s i g n s of d isease and
• Successful thrombolysis involves a combination of chemical sca rri n g p a rticu l a rly i n the reg i o n of co m p ress i o n .
and mechanical thrombectomy and is often quite effective
in decreasing clot burden and reducing long-term sequelae
of upper extremity DVT ( FIG 6A,B ) . Technical details of
thrombolysis are well described and can be performed with duplex immediately prior to surgery after successful throm­
minimal morbidity.5 bolysis is important to document the status of the vein dur­
• Definitive therapy for vTOS after thrombolysis involves ing the immediate pre-operative period.
thoracic outlet decompression, consisting of anterior and • In contradistinction to the numerous pathways for vTOS
middle scalenectomy, resection of the subclavius tendon, surgery planning aTOS in the presence of an ipsilateral cervi­
1 st rib resection, and venolysis or venous reconstruction. cal rib and subclavian aneurysm presents a strong indication
Timing of definitive surgery after thrombolysis is somewhat for definitive surgical intervention. Preoperative planning
controversial and is limited by anecdotal reports and vari­ consists mainly of ensuring adequate and healthy vascula­
ous surgeon biases.6 Successful outcomes can be achieved ture proximal and distal to the diseased segment and de­
with definitive thoracic outlet decompression performed termining a bypass route that is reasonable. Extraanatomic
during the same hospitalization as the thrombolysis7 and up bypass via a carotid-subclavian or carotid-axillary with in­
to 3 months later with nonresolution of mild venous ob­ terval ligation may be necessary, depending on the size and
structive symptoms/ leading some to adopt a more selective length of the subclavian aneurysm and thrombus. Direct
approach for offering rib resection. This lack of consensus repair of the subclavian aneurysm with interposition graft­
provides some flexibility in offering definitive surgery as ing can be accomplished only when there is a short segment
many of these young patients are often student-athletes and of disease that limits itself to the visualized region in the
cannot miss certain periods of the school year. Management supraclavicular fossa. The preoperative CT-A provides the
of anticoagulation during this time also impacts decisions best road map to help decide amongst these reconstructive
about planning surgery, as intolerance to blood thinners or strategies. Endovascular techniques of the subclavian artery
difficulty with maintaining adequate anticoagulation can af­ such as stent grafting in the setting of a TOS are generally
fect the urgency of the required definitive decompression. not recommended, given the age of the typical patient, the
If there is a delay in scheduling definitive rib resection, a compression that can occur from scarring even after cervical
1872 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

or 1 st rib decompression, and the likely desire to resume in a stocking on the side of the patient to allow full move­
prior activities that often brought about these symptoms in ment during the case. This affords the anterior visualization
the postoperative period. of the 1 st rib and particularly the subclavius tendon and
costoclavicular ligament for safe and effective decompres­
sion. The entire ipsilateral neck, shoulder, arm, and anterior
Positioning
chest wall are prepped into the field as well as a region on
• vTOS decompression will often involve an infraclavicular the lateral chest wall should there be a small pneumothorax
incision (some prefer only this incision; some prefer a para­ postprocedure.
clavicular approach; still others prefer transaxillary), which • aTOS decompression with cervical rib is most often per­
is facilitated by positioning the patient with a small bump formed with a supraclavicular approach. When arterial re­
between the shoulder blades and in a " head up" position construction is planned, preparations should be made for
of 30 degrees. The affected arm is prepped out and placed saphenous or femoral vein harvesting.

VENOUS THORACIC OUTLET SYN DROM E


Infraclavicular Approach

• A 5-cm tra nsverse i n c i s i o n is m a d e o n e f i n g e r b readth


below the c l avicle, sta rt i n g a l o n g the edge of the ster­
n u m trave l l i n g latera l l y, a n d is carried through the subcu­
ta neous tissue a n d pector a l i s fasc i a to expose the u p per
fi bers of the pectora l i s m uscles (FIG 7) . Gentle sprea d i n g
between m uscle fi bers i n t h i s reg i o n exposes t h e a ntero­
m e d i a l q u a d rant of the axi l l a ry fat pad and a l l ows easy
p a l pation of the 1 st r i b . Appropriate retractors can be
p l aced to fu l ly expose the m ost a nte rior portion of the
1 st r i b beneath a layer of axi l l a ry fat (FIG 8).
• W h e n t h e r i b is v i s u a l i ze d , c a u t e ry is used to sepa rate
t h e i n fe r i o r- l y i n g i nte rcosta l m u scu l a t u re from t h e r i b,
with c u rved d i ssect i o n h e a d i n g s u p e r o l atera l l y a l o n g
t h e C c u rve of t h e r i b (FIG 9) . L u n g p l e u ra a re often v i ­
s u a l ized i m med iately beneath t h e rib a n d c a r e s h o u l d FIG 8 • I ncision is ca rried down t h ro u g h pectora l i s fascia,
b e t a k e n to n o t i n j u re l u n g p a re n c hym a . S u p e r i o r ly, then the m uscle fibers a re s p l it u nt i l axi l l a ry fat that covers
t h e s u b c l a v i u s t e n d o n a n d costoc l a v i c u l a r l i g a m e nt the 1 st rib is reach e d .
a re t a k e n d o w n s h a r p l y with c a u t e ry to free u p t h e
a nt e r i o r p o rt i o n of t h e 1 st r i b f r o m t h e ove r h a n g i n g

FIG 9 • F u rther d i ssection a r o u n d the 1 st r i b i n vo lves s h a r p


F I G 7 • I nfraclavi c u l a r i n c i s i o n is m a d e o n e f i n g e rb readth d i ssection of i nte rcosta l m u scu lature a l o n g i nfe rior aspect o f
below clavicle. 1 st r i b (arrows) .
C h a p t e r 9 V E N O U S A N D ARTERIAL THORACIC OUTLET S Y N D R O M E 1873

c l a v i c l e . F o l l o w i n g a l o n g t h e s u p e r i o r a s p ect of t h e 1 st
r i b , t h e a nt e r i o r sca l e n e f i b e rs a re a l so s h a r p l y t a k e n
down a n d f u rt h e r s u p e r i o r d i ssect i o n t a k e s p l ace
a l o n g t h e l atera l e d g e of t h e 1 st rib u n t i l p a l p a t i o n of
t h e s u b c l a vi a n a rtery i s n ote d . This l ev e l i s a s f a r neces­
s a ry to d e co m p ress t h e s u b c l a v i a n vei n . Oft e n , movi n g
t h e a rm i n a s u p e r i o r p o s i t i o n fa c i l itates m o re s u p e r i o r
exposure of t h e 1 st r i b n e a r t h e a rte ry.
• W h e n the r i b is c l e a r on its s u p e r i o r, latera l , a n d i nfe­
rior e d g e, a rib cutter can be i n s e rted s u p e r i o rly, ta k i n g
c a r e to vis u a l ize the j a ws, a n d t h e n t h e s u p e r i o r c u t i s
m a d e i n t h e r i b . The i nf e r i o r cut i s d o n e n e a r the m a ­
n u b r i a l j u n ct i o n , co m m o n l y w i t h a p o w e r saw. A s the
r i b i s p u l l e d away from the body, sharp cautery c a n be
used to fa c i l itate h e m ostas i s of i n d iv i d u a l m u sc l e f i b e rs
(i nte rcosta l s, a nt e r i o r a n d m i d d l e sca l e n e) h o l d i n g the FIG 11 • If more p roxi m a l expos u re is n eeded to c l a m p
1 st r i b i n p l a ce. f o r control, exte nsion of the i n c i s i o n i nto t h e m a n u b r i u m
a n d towa rd ste r n a l n otch a l l ows w i d e r visu a l ization of t h e
Venous Reconstruction orig i n of subclavian ve i n a n d j u n ction w i t h j u g u l a r i nto t h e
i n n o m i n ate.
• With t h e a nt e r i o r h a lf to two-t h i rd s of t h e r i b rem oved
from t h i s i n fraclavi c u l a r a p proach, the ve i n i s often p a l ­
p a b l e i n a b e d of tissue a n d m u s c l e fi b e rs i m m e d i ately
a n d can be pe rfo r m e d with a d e q u ate prox i m a l a n d
b e l o w t h e c l a v i c l e . Ve n o lysis c o n s i sts of free i n g up
d i sta l control of t h e ve i n u n d e r d i rect v i s u a l i za t i o n
t h ese m u s c l e fi b e rs to expose t h e ve i n (FIG 1 0) . M o re
(FIG 1 2) .
prox i m a l expos u re of t h e ve i n c a n be acco m p l i s h e d v i a
a tra n s m a n u b r i a l exte n s i o n of t h e i n f ra c l a vi c u l a r i n c i ­
Closure
s i o n to t h e center of t h e ste r n u m a n d vertica l l y u p t o
t h e ste r n a l n otch (FIG 1 1 ) . T h i s c a n b e n ecessa ry to o b ­ • Ca refu l attention to the stu m p of r i b re m a i n i n g for he­
ta i n a d e q u ate vasc u l a r control for patch i n g of c h r o n i - m ostasis is pe rfo rmed, as we l l as the reg i o n of ve i n after
ca l l y d i seased ve n o u s seg m e nts. W h e n a st r i ct u red veno lysis a n d/o r reco nstruct i o n .
s e g m e n t of ve i n i s l oca l ized, sa p h e n o u s ve i n o r bovi n e • If the p l e u ra or l u n g parenchyma has been i n j u red, a
p e r i c a rd i a ! o r bovi n e p e r i c a rd i a ! patc h i n g p rovides a n s m a l l-ca l i be r ( 1 2 Fr) pediatric ch est tube can be p l a ce i n
exce l l e nt strategy f o r resto rat i o n o f l u m i n a l d i a meter t h e a nterior p l e u r a l space u n d e r d i rect visual izati o n .

FIG 1 0 • After 1 st r i b is resected, ca refu l d i ssection a r o u n d


ve i n w i t h venolysis a n d takedown of fi bers su rrou n d i n g v e i n FIG 12 • Sten otic reg i o n of the su bclavia n ve i n repa i red with
a l l ows a d e q u ate visua l i zation to c h e c k for ste n otic reg ions. patch ve n o p l asty u s i n g g reater saphenous ve i n .
1874 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

ARTE RIAL THORACI C OUTLET SYN D ROME


Supraclavicular Approach

• A 7-cm i n c i s i o n is m a d e o n e f i n g e r b readth a bove t h e


c l a v i c l e, sta rti n g l atera l to t h e p a l p a b l e edge of the
ste r n a l head of t h e ste r n o c l e i d o m asto i d m u scle a n d car­
ried t h r o u g h t h e p l atys m a . T h i s exposes the clavicu l a r
h e a d o f t h e ste r n o c l e i d o m asto i d , w h i c h i s tra n sected
with a cuff to sew back toget h e r later, w h i c h n ow ex­
poses the a nterior sca l e n e fat pad (FIG 1 3) . The fat pad
i s d i ssected along th ree borders, i nferio rly, l atera l ly, a n d
m e d i a l ly, t o a l low i t swi n g n o rthward t o expose t h e a n ­
t e r i o r sca l e n e m u scle a n d the p h r e n i c n e rve (FIG 1 4) .
When o p e rati n g o n t h e l eft s i d e , extra c a r e is t a k e n to
visu a l ize the thoracic d u ct w h e n p resent, w h i c h i s s u ­
t u re l i gated to p revent posto pe rative chyle l e a ks if it
becomes i nj u re d .
• With the p h re n i c n e rve s l u n g a n d p rotected, tra nsect i o n
of the a nte rior sca l e n e m uscle off the su perior edge o f
the 1 st r i b i s d o n e u s i n g b i p o l a r scissors. C a r e is t a k e n t o
stay o n the bone d u r i n g this portion so as n o t to i n j u re
FIG 14 • With the sca l e n e fat pad retracted superiorly, the
a nte rior sca lene m u scle a n d p h r e n i c n e rve a re clearly see n .
the u n d e r l y i n g subclavian a rtery. After the i nfe rior edge
T h e n e rve is s l u n g w i t h a s i l astic loop.
of the a nterior sca l e n e i s removed, a port i o n of m uscle
can be transected to a l low room for f u rther visua l i zation
a n d su bseq uent d i ssect i o n around the brach i a l p l exus
(FIG 1 5) . The long thoracic n e rve is identified latera l ly, surro u n d i n g it, a n d can be fused to the 1 st r i b (FIG 1 6) .
a n d the entire n e rve structures a re s l u n g a r o u n d a t h i c k C a r e is taken t o d i ssect n e rves a n d vesse ls away f r o m t h e
cle a r s i l astic loop. a b n o r m a l r i b o r its osse us portions t h a t may n o t have
• A cervica l r i b, when p resent, is ofte n visual ized at a p pe a red o n r a d i o g r a p hy.
t h i s t i m e, with a b n o r m a l vascu lature or m uscu lature • The 1 st r i b is visua l i zed by m a neuve r i n g the subclavian
a rtery a n d the n e rve bundle back a n d forth while d i ssect­
i n g m i d d l e sca l e n e fi bers a n d i nte rcosta l m uscu lature off
the 1 st r i b (FIG 1 5) . This can be d o n e s h a r p l y w i t h b i po­
lar scissors o r by u s i n g a perioste a l e l evator. One s h o u l d

FIG 1 3 • S u p ra c l a v i c u l a r i n c i s i o n o n e f i n g e rbreadth a bove


the c l a v i c l e cont i n ues after tra nsect i n g clavicu l a r head of t h e FIG 1 5 • The 1 st r i b is clea red o n both s i d e s of the subclavian
sternocl e i d o m asto i d a n d expos u re of t h e a nterior sca l e n e a rtery a n d the b rach i a l p l exus fibers, which a re all slung to
fat pad. a l low easy m o b i l izati o n .
C h a p t e r 9 V E N O U S A N D ARTERIAL THORACIC OUTLET S Y N D R O M E 1875

FIG 1 6 • I n t h i s case, a fused cervical r i b to the 1 st r i b is FIG 17 • Rem ova l of the congen ita l ly fused cervical r i b to
p ro m i n e ntly te nting u p the s u bclavian a rtery a n d brach i a l the 1 st r i b as a n e n b l oc p i ece, a l lowing the n e u rovasc u l a r
p l exus fibers. b u n d l e t o return t o its n o r m a l position without b e i n g k i n ked
o r d i s p l aced .

avo i d the use of cautery i n this a rea as it is l i kely to trans­


Arterial Reconstruction
m i t to the brach i a l p l exus or p h r e n i c n e rve.
• When the rib is clear from the reg i o n i nfe rior to the sub­ • S u bclavian a n e u rysm resection, when needed, consists of
clavian a rtery a n d superior to the u p p e r aspect of the a p propriate bypass p r i n c i p les a n d replacement with a n
brach i a l p l exus, a power saw can be used to tra nsect the a utog enous o r p rosthetic i nterpositi o n g raft o r extra a n a ­
r i b . If there i s a fused portion of cervica l r i b, it should be tom i c bypass o f carotid to d ista l s u b c l a v i a n o r carotid to
attem pted to be rem oved as a s i n g l e piece (FIG 1 7) to axi l l a ry g raft. Typica l sizes a n d types req u i red for p ros­
assure that a l l bony a b n o r m a l ities have been freed u p to thetic g rafts i n c l u d e 6- o r 8-mm r i n g e d polytetrafl u oro­
a l l ow for a d e q u ate decom p ress i o n . ethyl e n e (PTF E) o r Dacro n .

PEARLS AND PITFALLS


I n d i cations • vTOS defi n itive thera py co nsists of prompt d i a g n osis, ve nography a n d su bseq uent thrombo lysis, a n d a p p ro­
pri ate selecti o n of patients to u n dergo thoracic outlet decom p ress i o n .
• aTOS patie nts often p resent w i t h h a n d isc h e m i c sym ptoms t h a t w i l l h a v e s o m e delay i n m a n a g e m ent d u e
t o a wide d i fferenti a l . Abnorm a l b o n y o r m uscu l a r a n atomy a l o n g w i t h p resence of subclavian a n e u rysm a l
d isease req u i res defi n itive repa i r i n c l u d i n g a rte r i a l reco nstruct i o n .
Preope rative • Ve nous d u p l ex, venography, a n d p h a rmacomech a n i ca l t h ro m bolysis provides the opti m a l red u ct i o n of clot
workup b u rd e n to restore fu n cti o n a l venous patency i n patients with vTOS . Ti m i n g of r i b resection and defi n itive
thoracic outlet deco m p ression a re somewhat va r i a b l e and the a p p roach s h o u l d be i n d iv i d u a l ized.
• aTOS patie nts should u n dergo plain rad i o g ra p h y to sea rch for a cervica l r i b a n d CT-A to d ete r m i n e the por­
tions of d iseased subclavian a rtery that m i g ht need resect i o n .
Patient set u p • Pre p p i n g the affected a r m i n the vTOS patie nts affo rds the a b i l ity to m ove the a rm a n d, f r o m the i nfracla­
vicu l a r a p p roach, gain access to the majority of the r i b that is resp o n s i b l e for ve nous compress i o n .
• For cervical r i b a n d a rte r i a l reco nstruct i o ns, the s u p raclavicu l a r a p p roach g i ves n u m e rous options for recon ­
struct ive p u r p oses as we l l as the poss i b i l ity o f the ca rotid a rtery as a n i nflow sou rce.
I nfraclavic u l a r • Visual ization of the subclavius te n d o n and its fi bers as we l l as the costoclavicu l a r l i g a ment i s p a r a m o u n t i n
a p p roach decom p ress i n g t h e reg i o n that co m p resses t h e subclavian ve i n i n vTOS .
• Liberal patc h i n g of the subclavian vein a n d exte nsive ve nolysis provi d e the best l o n g -term pate ncy resu lts
after vTOS deco m p ress i o n .
S u p ra c l avicu l a r • Ca refu l ly m o b i l i z i n g the a nterior sca l e n e f a t pad a l l ows good visua l i zation of the a n t e r i o r sca l e n e m uscle
a pp roach and p h r e n i c n e rve.
• When perform i n g left-sided su praclavicu l a r TOS deco m p ression, o n e m u st be ca ref u l to i d e ntify and l i gate
the thoracic d u ct.
• S l i n g i n g the subclavian a rtery and brach i a l p l exus fi bers a l l ows gentle traction back and forth to exped i­
tiously d i ssect free the entire 1 st rib.
1876 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

POSTOPERATIVE CARE wound issues. Pneumothoraxes are often self-limited and


treated effectively with chest tubes. Wound complications
• At the conclusion of the procedure, patients are extubated can include chyle leaks, seromas, and skin breakdown. Most
and an immediate chest x-ray is obtained to ensure there of these are managed expectantly. Brachial plexus injuries
is no pneumothorax. A small pneumothorax can be treated may also occur, most commonly as a function of not recog­
with oxygen and incentive spirometry, but a 25 % lung vol­ nizing important anatomic structures or not providing suf­
ume reduction requires a chest tube to suction for 24 hours. ficient exposure to eliminate collateral damage during rib
• Patients do not need a sling for their arms. They are given transection and removal.
range-of-motion exercises immediately to encourage • Timing of restarting anticoagulation in vTOS patients
strengthening and are given a taper of muscle relaxant and can lead to postoperative bleeding, which can manifest as
opioid narcotics for pain control. Most patients are dis­ delayed hemothorax. The cause of this bleeding is often re­
charged the following day after surgery. lated to recent thrombolysis and raw surfaces of muscle and
• Anticoagulation for vTOS patients is usually resumed 3 cut bone, and this has led to the general recommendation of
to 4 days postoperatively at home, typically consisting of holding off on restarting anticoagulation until 3 or 4 days
Lovenox for a week, then they return for postoperative ve­ postoperation.
nography to see if further balloon venoplasty is necessary.8
• Anticoagulation for aTOS patients, especially if arterial re­ REFERENCES
construction was performed, consists of anti platelet therapy
with aspirin. 1. Lee JT. Clinical incidence and prevalence. In: lllig KA, Thompson RW,
Freischlag J, et al, eds. Thoracic Outlet Syndrome. London, United
Kingdom: Springer-Verlag; 2013.
OUTCOMES 2. Cassada DC, Lipscomb AL, Stevens SL, et al. The importance of
thrombophilia in the treatment of Paget-Schroetter syndrome. Ann
• Patients treated for vTOS with lysis and subsequent thoracic
Vase Surg. 2006;20:596-601.
outlet decompression have a very low recurrence rate of 3. Urschel HC, Razzuk MA. Paget·Schroetter syndrome: what is the best
thromboembolic disease. Morbidity and mortality is mini­ management? Ann Thorac Surg. 2000;69:1663-1669.
mal, as these are often young and healthy patients, but typi­ 4. Johnston PC, Conte MS, Eichler CM, et al. Infraclavicular first rib
cally revolve around wound issues and bleeding given the resection for focused and effective treatment of venous thoracic outlet
need for a short course of anticoagulation. Satisfactory qual­ syndrome. J Vase Surg. 2010;52:525-526.
5. Lee JT, Karwowski JK, Harris EJ, et al. Long·term thrombotic recur·
ity of life scores and return to full function are reported in
renee after non-operative management of Paget-Schroetter syndrome.
the 8 0 % to 9 0 % range, and most patients can be counseled J Vase Surg. 2006;43:1236-1243.
to expect a near full return to sport.9 6. Lee JT. Timing of first rib resection after thrombolysis. In: Illig KA,
• aTOS and the cervical rib patients often have the most dra­ Thompson RW, Freischlag J, et al, eds. Thoracic Outlet Syndrome.
matic recovery, as they are often the most symptomatic to London, United Kingdom: Springer-Verlag; 2013.
begin with. Although the literature is much sparser with re­ 7. Angle N, Gelabert HA, Farooq MM, et al. Safety and efficacy of early
surgical decompression of the thoracic outlet for Paget·Schroetter syn­
gard to this entity, results are uniformly positive with reso­
drome. Ann Vase Surg. 2001;15:37-42.
lution of hand ischemic symptoms and lack of significant
8. Chang KZ, Likes K, Demos J, et al. Routine venography following
disease recurrence . transaxillary first rib resection and scalenectomy (FRRS) for chronic
subclavian vein thrombosis ensures excellent outcomes and vein pa­
COMPLICATIONS tency. Vase Endovasc Surg. 2012;46:15-20.
9. Chandra V, Little C, Lee JT. Thoracic outlet syndrome in high perfor­
• Perioperative complications related to either form of tho­ mance athletes [published online ahead of print May 14, 2014]. ] Vase
racic outlet decompression revolve around lung injury and Surg. doi:10.1016/j.jvs.2014.04.013.
I

Chapter 10 Proximal to the Wrist: Upper


Extremity Reconstruction/
Revascularization
, _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - �

Mohamed A. Zayed Ronald L. Dalman

DEFINITION PATIENT HISTORY AND PHYSICAL


• The content discussed in the following text assumes the reader FINDINGS
has familiarity with standard upper extremity arterial anatomy • Initial evaluation should include an assessment of associated
and its most common variations. For additional information, comorbidities, including cardiac pathologies (myocardial in­
the reader may refer to excellent existing references.1•2 farction, arrhythmia, heart failure, or prior coronary artery
• Various occlusive and/or aneurysmal disease processes in the revascularization), hypertension, hyperlipidemia, diabetes,
upper extremity arterial system may necessitate revascular­ hypercoagulability, smoking, prior upper or lower extremity
ization or reconstruction (Table 1 ) . arterial intervention, or index extremity trauma.
• Acute upper extremity ischemia i s less common than i n the • Symptoms and signs of acute arterial ischemia include pain,
lower extremity due to the rich preexisting collateral cir­ paresthesia, pulselessness, paralysis, and/or poikilothermia.
culation in both the upper arm and forearm. The maj ority A thorough vascular, sensory, and motor examination will
( 5 0 % ) of acute ischemic complications in the upper extrem­

help assess the severity of arterial insufficiency. Although
ity occur in elderly females as a result of embolic phenomenon dated, the Rutherford classification system remains useful
rather than primary vessel thrombosis (which accounts for for prognostic determinations. 8 For classes 5 and 6 ischemia,
� 25 % of acute ischemic events) . 3 The differential diagnosis urgent or emergent intervention may be necessary to pre­
for embolic sources includes intracardiac sources, proximal serve limb function and viability. Prompt removal of embolic
arterial atherosclerotic plaque, proximal arterial aneurysm debris in limbs with sufficient residual viability produces
thrombus, endocarditis, or paradoxical embolus from venous excellent long-term results. 3
circulation. • Chronic limb ischemia may also present with symptoms of
• Chronic arterial occlusive disease is rarely symptomatic. rest pain, pain with extremity use, paresthesia, pulselessness,
Associated comorbid conditions include diabetes, chronic poikilothermia, and/or ulcerations/wounds/gangrene of fin­
atherosclerotic occlusive disease, subclavian or arteriove­ gers or fingertips. Subjects should be asked to describe what,
nous steal syndromes, or failure of prior arterial repair or if any, activities exacerbate these potential symptoms (i.e., lift­
grafting. 4•5 ing or carrying material with affected arm/hand, arm raising,
• Venous occlusive disorders in the upper extremity are common or repetitive arm/hand movement) . Patients with vocational
and are usually associated with iatrogenic injury, indwelling or recreational activities that require regular or frequent use of
catheters, or thoracic outlet pathology. For further informa­ their upper extremities should describe convincing symptoms
tion regarding venous thoracic outlet disorders. Distal to the they experience in relation to these activities. More commonly,
thoracic outlet, venous occlusive disorders are for the most chronic upper extremity arterial ischemia is asymptomatic,
part managed expectantly with anticoagulation therapy. Open particularly in older and less physically active individuals.
surgical and endovascular therapies are rarely used and, due to In general, revascularization is not necessarily indicated in
high recurrence and failure rates, are not enthusiastically rec­ these circumstances. Discrepancy in upper extremity pulses, or
ommended. For further recommendations regarding upper ex­ brachial blood pressure differential of more than 15 mmHg,
tremity venous disease management, please refer to additional is a hallmark of chronic upper extremity arterial insufficiency
references. 6•7 with or without accompanying symptoms.
• Traumatic or iatrogenic injury accounts for 25 % of patients
presenting with acute upper extremity arterial insufficiency.
Tab l e 1 : Upper Extremity Vascu lar D i sease Consideration of the mechanism of injury ( blunt, penetrat­
ing, hyperextension, or avulsion) will help delineate the likely
Pathology Etiology
nature of the resulting arterial disruption (transection, dissec­
Arterial stenosis or occl usion • Atherosclerosis tion, or thrombosis, with or without ongoing extravasation).
• Dissection/tra u m a Following completion of the trauma primary survey, determi­
• Extrinsic compression nation of extremity arterial continuity should be performed
• Vasculitis
• Hypercoagulable state following reduction of obvious ipsilateral upper extremity frac­
Arterial aneurysmal degeneration • Atherosclerotic degeneration tures and dislocations. In complex injuries, including avulsions
• B l u nt or penetrating tra u m a and crush injuries, baseline sensory and motor status should be
• Connective tissue disorder documented early to formulate the most appropriate course of
• Iatrogenic injury
therapy. When severe arterial injury is associated with transec­
Venous stenosis or occl usion • Deep venous thrombosis
• Hypercoagulable state tion or avulsion of the brachial plexus and compound long
• Extrinsic compression bone fractures, meaningful functional recovery, despite ulti­
mately successful revascularization, may not be possible.9

1877
1878 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

• More commonly, upper extremity arterial injuries can be more prior history of unprovoked deep venous thrombosis preced­
subtle and are frequently missed on primary or secondary ing an arterial event should be considered for a hypercoagu­
surveys. The extensive collateral network present around the lability workup and hematology consultation. Initial testing
elbow often masks the presence of brachial artery thrombosis may include protein C function, free protein S, antithrombin
following posterior elbow dislocation, or dissection and throm­ III activity, anticardiolipin antibodies, factor V Leiden muta­
bosis following brachial artery catheterization. When physical tion, prothrombin mutation, and homocysteine level. 13
signs suggest asymmetric or reduced upper extremity arterial
perfusion, objective imaging should be obtained promptly to SURGICAL MANAGEMENT
direct therapy and maximize long-term function. Depending Preoperative Planning
on hand perfusion and viability, occasionally, immediate re­
vascularization can be at least temporarily deferred to allow • Prior to attempted upper extremity arterial repair or revas­
for more urgent resuscitation and stabilization procedures to cularization, a clear understanding of the extent and loca­
proceed. Similarly, non-flow-limiting dissections may be moni­ tion of arterial pathology is essential. This knowledge guides
tored without immediate intervention, particularly when the the location of arterial exposure or optimal method of arte­
patient's overall condition merits observational management. rial access, the identification of optimal inflow sources and
outflow targets, and the most effective and efficient methods
IMAGING AND OTHER DIAGNOSTIC of reconstruction. When uncertainty persists, intraoperative
arteriography provides essential and timely guidance.
STUDIES
• As in all methods of peripheral arterial reconstruction, hepa­
• Depending on clinical circumstances, revascularization may rin is typically administered when an interventional sheath
be undertaken on the basis of clinically apparent injuries and is first placed, or arterial control is anticipated. Typically,
limb ischemia. More commonly, physiologic assessment is 1 00 units/kg of intravenous heparin is administered, with
indicated and necessary to determine the most efficacious additional anticoagulation guided by the activated clotting
method of revascularization. Arteriography, typically per­ time monitored during the course of the procedure.
formed during or immediately prior to revascularization, • As discussed in Part 6, Chapter 2, the preferred extratho­
remains an essential tool to guide intervention and confirm racic method of innominate or proximal left subclavian
procedural success. As a general observation, physiologic artery surgical reconstruction is carotid subclavian bypass.
testing helps determine when intervention is necessary, Frequently, however, endovascular options are available and
whereas arteriography provides the necessary anatomic preferable in patients who cannot tolerate the risks or mor­
information to ensure procedural and functional success. bidity associated with open reconstruction. For example, in
• Computed tomography (CT) arteriography can poten­ the setting of uncontrolled, life-threatening hemorrhage from
tially add useful information to surgical planning for upper penetrating or crush injuries or limb avulsion, bleeding may
extremity revascularization. However, unlike in the abdomen be controlled by insertion of covered, self-expanding stents
and lower extremities, significant insight into disease local­ across the area of injury in the subclavian or axillary arteries.
ization and severity in the upper extremities can be gleaned However, with few other exceptions (such as lesions associ­
from physical examination and nonionizing imaging modali­ ated with giant cell or Takayasu's arteritis), angioplasty and
ties such as ultrasound. The potential additional diagnostic stenting of arterial lesions at or distal to the clavicle is poorly
benefit associated with CT angiography needs to be balanced tolerated and ill advised. Stents placed in this area are at high
with the not insignificant radiation dosage delivered with risk for fragmentation and subsequent arterial thrombosis,
this imaging modality, particularly in regard to the longer pseudoaneurysm formation, or stent migration.
life expectancy of younger patients. When vascular disease is • Surgical management of arterial pathology distal to the sub­
known to be limited to the extrathoracic upper extremity arte­ clavian artery ( surgical management of arterial disease of the
rial system, CT angiography provides little additional, useful arch vessels and subclavian artery are discussed in Part 6,
information over diagnostic arteriography alone, especially Chapters 1, 2, and 9) and proximal to the wrist (surgical
when the latter can be paired with a therapeutic intervention. management of arterial disease distal to the wrist is discussed
• Noninvasive vascular testing for evaluation of the upper in Part 6, Chapter 1 1 ) will depend on acuity, cause/type of
extremities includes segmental systolic pressure measure­ pathology (penetrating trauma, blunt trauma, occlusion, ste­
ments using a Doppler flow detector, digital plethysmography, nosis, or aneurysm), severity of patient symptoms, patient
and arterial duplex scanning. comorbidities, and required durability of the planned repair.
• Serologic tests are the basis for the workup of patients with • Axillary artery exposure is guided by the nature of the
suspected vasculitic pathologies (e.g., Takayasu's arteritis, planned reconstruction. The proximal artery is most easily
giant cell arteritis, Buerger's disease, and/or scleroderma) . exposed via a transverse infraclavicular incision. Exposure
Customary tests include baseline complete blood count, plate­ of the second and third portions requires deltopectoral or
lets, fibrinogen, C-reactive protein ( CRP), and erythrocyte axillary approaches, respectively. 1
sedimentation rate (ESR } . 1 0 •1 1 In certain circumstances, color • Acute symptomatic embolic occlusion of the axillary or brachial
duplex evaluation may also provide additional clues to aid arteries are best managed by open, preferably image-guided,
in the diagnosis.12 Additional serial serologies and rheumato­ balloon catheter or direct thromboembolectomy.1•2 Essential
logic consultation may be necessary depending on the severity elements required for thromboembolectomy include ( 1 ) de­
and progression of the suspected vasculitic disease process. termination of the optimal treatment environment (operating
• Young patients with acute primary arterial thrombosis, room [OR] with portable vs. fixed imaging), (2) arterial access
patients with recurrent arterial thrombosis, or patients with a (level of incision), ( 3 ) acquisition of catheters and guidewires
C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization 1879

required to transverse the embolus and accumulated luminal equipped with a radiolucent, floating-point carbon fiber oper­
thrombus, (4) availability of balloon and over-the-wire ating table and fluoroscopy radiation source and image inten­
embolectomy catheters, (5) need for adjuncts such as aspira­ sification system, preferably equipped with digital subtraction
tion catheters (ExportTM catheter, Medtronic, Minneapolis, angiography and last-image hold capabilities. When optimal
MN) and thrombolytic agents (tissue plasminogen activator x-ray penetration and resolution is not available, or in cir­
[tPA] ), (6) options for managing postischemic hyperemia cumstances when diagnostic angiography alone is anticipated,
and elevated compartment pressures, and (7) consideration less sophisticated portable imaging systems may suffice.
of treatment alternatives should preexisting atherosclerotic • Elective and emergent upper extremity surgical revascular­
occlusive disease preclude or complicate catheter-directed ization procedures may be performed with either regional or
thromboembolectomy. general anesthesia. Considerations include the overall status
• For symptomatic axillary or brachial artery thrombosis of the patient, ability to tolerate the specific challenges asso­
not amenable to direct or catheter-based, image-guided ciated with either anesthetic techniques, and the abilities of
thromboembolectomy, open surgical bypass or interposi­ the anesthesiologist responsible for anesthetic management.
tion grafting is the preferred method of repair. When con­ • For the maj ority of upper extremity procedures, the opera­
sidering open bypass or interposition grafting distal to the tive limb is typically extended at 90 degrees. For optimal
clavicle, key planning elements include ( 1 ) determination of surgical exposure, we prefer arm positioning systems that
optimal inflow and outflow, (2) conduit ( almost exclusively move freely with the OR table rather than those with sepa­
autogenous vein), and ( 3 ) assessment of distal compartment rate floor extensions. To avoid exacerbation of potential
pressures and potential need for fascial release. Commonly, brachial plexus injuries in appropriate clinical settings, care
more vasospasm is engendered by injury and surgical manip­ should be taken to avoid hyperabduction and extension of
ulation in the upper extremity arteries as compared to those the limb. The operative field should include, at a minimum,
of the lower extremities, and accommodations may need to the ipsilateral axilla, chest, and neck, with the head rotated
be made to ensure graft and bypass patency in this context. and extended to the contralateral side. A shoulder roll may
• Branch vessel injuries and aneurysms, particularly those be positioned under the ipsilateral shoulder to aid with neck
arising from the axillary and brachial arteries, are best treated and shoulder extension ( FIG 1 A) . Alternatively, for optimal
with ligation and excision.14 Preoperative planning of these deltopectoral exposure of the axillary artery, the arm can be
procedures involves selection of an appropriate exposure externally rotated and abducted at 3 0 degrees relative to the
through the muscles of the upper extremity that will facilitate lateral chest.
rapid recovery and minimize risk of disability in a usually • In situations where venous interposition conduit may be
young and active patient cohort. needed, a lower extremity should also be prepared into the
• The relatively superficial location of the brachial artery in surgical field to allow for greater or lesser saphenous vein
the antecubital fossa increases its vulnerability to traumatic harvest as indicated by the estimated diameter of the target
and iatrogenic injuryY Most brachial inj uries are associated artery. In the setting of extensive traumatic injuries, vein
with penetrating trauma; however, blunt injuries also occur, should be harvested from the least affected lower extremity.
particularly in the distal brachial artery, following posterior
elbow dislocations and supracondylar fractures (the latter
more commonly in children). 16 In these situations, key ele­
ments for repair will include inspection of injured arterial
segment on preoperative imaging for possible intimal dis­
ruption, short segment thrombosis, or thrombosis extending
distally into the forearm.
• An increasing number of cardiac catheterizations and coronary
interventions are performed via radial or brachial accessY
Cannulation site complications, including thrombosis or pseu­
doaneurysm formation, often necessitate operative repair.17•18
For these patients, preoperative planning will include identi­
fying the extent of injury, options for graft conduit (smaller
diameter vein), and alternative management options including
arterial ligation in extenuating circumstances.
• The ulnar artery at the wrist is the dominant hand artery in
the maj ority of patients. Achieving or maintaining sufficient
arterial outflow at the wrist is essential to the hemodynamic
and clinical success of forearm revascularization procedures.
The status of the radial and ulnar arteries at the wrist should
be confirmed in the course of evaluating all patients for
upper extremity revascularization options.
A

Operating Room Setup FIG 1 • A. With the patient s u p i ne, the a r m of i nte rest is
pronated a n d exte nded at 90 deg rees rel ative to the ch est. The
• The majority of upper extremity revascularization procedures head is externa l ly rotated to the contra latera l side to expose the
are suited for a hybrid operating environment, or an OR i psi latera l neck seg m e nt. (contin ued)
1880 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

Cephalic vein Pectoralis m ajor


Thoracoacromial Lateral Axillary
Clavi pectoral fascia artery cord artery

Pectoralis minor

Lateral pectoral Clavi pectoral


c nerve fascia

B
Interposition
graft repair

Injured
axillary
artery

FIG 1 • (continued) B. I nfraclavicu l a r expos u re of the proxi m a l


axi l l a ry a rte ry. C. Components of the i nfraclavicu l a r axi l l a ry sheath.
vein D. I nterpos ition g raft repa i r of a proxi m a l axi l l a ry a rtery tra u matic
D p a rt i a l transect i o n .

• Syste m i c a nticoa g u lation s h o u l d be considered whenever • Open surgical revasc u l a rization a n d repa i r tec h n i q ues
major open or e n d ovascu l a r revasc u l a r izations a re u n d e r­ are described i n the sections in the following text rela­
take n . Exceptions i n c l u d e profo u n d syste m i c coag u lopa- tive to u pper extrem ity a nato m i c l ocat i o n .
thy o r concern rel ated to conco m ita nt risks such as occult • T h e last sect i o n descri bes general e n d ovasc u l a r tech­
i ntracra n i a l hemorrhage. S ufficient i ntraven o u s u nfrac­ n i q ues used for upper extrem ity i nte rventions.
tionated h e p a r i n s h o u l d be a d m i n istered to a c h i eve a n
activated clott i n g t i m e o f m o re t h a n 2 5 0 seco nds.

PROXI MAL AXI L LARY ARTERY is a i ded by l atera l retract i o n or d ivision of the pecto ra l i s
m i n o r m uscle.
First Step
Second Step
• Exposu re of the p roxi m a l (fi rst) portion of the axi l l a ry
a rtery is best ach ieved t h r o u g h a n i n c i s i o n p l a ced o n e • F i n e d i ssection s h o u l d be used to expose a n d control the
f i n g e rb readth below the m i d d l e t h i rd of the clavicle axi l l a ry a rtery deep to the clavi pecto ral fasc i a . Ca refu l
(FIG 1 8) . Deep to the su bcuta neous tissue, the pecto- d i ssection a n d retraction m i n i m izes i n j u ry to the cords
ral fascia is opened l o n g itud i n a l ly. The pectora l i s major of the brach i a l p l exus su rrou n d i n g the a rte ry. The latera l
m u scle is d ivided with a m uscle-sp l itt i n g i n ci s i o n . The pecto ral n e rve a n d prox i m a l cepha l i c ve i n a re a l so prone
u n d erlying clavi pecto ral fascia is then sharply i n cised to to i n j u ry d u r i n g d i ssection o r tract i o n from m i spl aced
expose the proxi m a l axi l l a ry sh eath . Ad d it i o n a l exposu re self-reta i n i n g retraction devices.
C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization 1881

T hird Step • For u p per extrem ity revascu l a rization p roced u res, tun­
neling is extended d ista l ly t h ro u g h su bcuta neous p l a nes
• The axi l l a ry ve i n l i es a nterior a n d ca u d a l to the a rtery a l o n g the arm and forearm as n ecessa ry to reach the
with i n the axi l l a ry sheath. M o b i l ity of the ve i n is ach ieved ta rget a rte ry. I n the case of axi l l ofe moral bypass g rafting,
with gentle d i ssection, l i gation of associated ve nous trib­ the ePTFE g raft t u n n e l is created retrog rade, exte n d i n g
utari es, a n d mild ca u d a l retraction with a c i rcu mferent i a l f r o m the fe moral i ncision su periorly to the exposed a x i l ­
vessel l o o p o r s m a l l h a n d h e l d retractor (FIG 1 C) . l a ry a rtery, w i t h ca re bei ng t a k e n to position the g raft
• I n s m a l l e r patients, d ivision of the thoracoacro m i a l a rtery a nterior to the a nterior su perior i l iac crest a n d advanced
a n d ve i n may be req u i red to fa c i l itate p roxi m a l axi l l a ry u pward along the anterior axi l l a ry l i n e . The t u n n e l m ust
exposure. O n ce a g a i n , i n j u ry to the latera l pecto ral n e rve n ot breach the a b d om i n a l fascia or thoracic cavity. With
is avoid e d by gentle, d e l i be rate d i ssect i o n . a t u n n e l i n g device of sufficient length, a counterincision
is n ot usu a l ly n ecessa ry to reach the axi l l a ry a rte ry. At the
Fourth Step i nferior border of the pectora l i s m uscle, the t u n n e l transi­
• O n ce c i rcu mferent i a l d i ssect i o n a n d expos u re of the tions to a su bfasc i a l plane exte n d i n g below the pectora l i s
prox i m a l axi l l a ry a rtery is co m p l ete, the a rtery is opti­ m a j o r m uscle to reach the exposed axi l l a ry a rtery m ed i a l
m a l l y contro l led with s i l asti c vessel loops (FIG 1 C) . t o its i ntersection with t h e pectora l i s m i n o r m uscle. U s e of
• Fa m i l i a r a n ato m i c relati onsh i ps may be l ess recog n iz a b l e a p u rpose-specific t u n n e l i n g device for this m a n euver wi l l
d u r i n g r e d o o r com p l ex exposu res, o r i n the sett i n g o f n ot o n l y o bviate the need for a cou nteri ncision b ut a lso
tra u m atic i n j u ries, o n g o i n g extravasation, a n d h e m a ­ m i n i m ize risks of k i n king, twisting, o r g raft co m p ress i o n .
to m a format i o n . The risk of associ ated brach i a l p l exopa­ • The co n d u it s h o u l d be beve led a p p ro p riately for e n d -to­
thy is h e i g htened i n these situations. Exte n d i n g expos u re side a n a stom oses at both ends. At the axi l l a ry a n a sto­
t h r o u g h the d e ltopecto ra l g roove may h e l p d e l i n eate m osis, s l i g htly m o re g raft l e n gth red u n d a n cy is needed
otherwise i n d ist i n ct tissue p l a n es. Reposit i o n i n g the a r m to prevent excessive tract i o n o n the a n asto mosis and
t h r o u g h o u t the range of ava i l a b l e a b d uction may a lso l ate g raft o r a rte r i a l i nj u ry. The use of stretch po lytetra­
red uce position-related a n ato m i c d i storti o n . f l u o roethy l e n e (PTFE) is a l so p refe rred for this reaso n .

Fifth Step Sixth Step

• For axi l l ofe moral bypass g raft in g , the fi rst or most p roxi- • Tra u m atized, t h ro m bosed, o r a n e u rysm a l p roxi m a l a x i l ­
m a l axi l l a ry seg ment is chosen for a n asto motic access l a ry a rtery seg m e nts may be tra n sected o r resected as
to m i n i m ize the risk of traction a n d potential g raft d is­ n ecessa ry, reconstituted by i nterpositi o n g raft i n g with
r u pt i o n from s h o u l d e r a n d arm m ovement. Locat i n g ve nous o r p rosthetic co n d u it (FIG 1 0) .
t h e a n asto m osis as prox i m ate t o the clavicle as possi b l e • F o r i nterposition g rafting, the d a maged o r d iseased a rte­
opti m i zes l o n g-term pe rfo r m a n ce a n d d u ra b i l ity. Based r i a l seg ment is fu l ly tra nsected and remove d . The l u m e n
o n the patie nt's body ha bitus and p l a n ned g raft con­ with i n the p rox i m a l a n d d ista l a rte r i a l seg m e nts s h o u l d b e
fig u ration (uni- o r bifemoral), a n a p p ro p riately sized (6, i n spected f o r tra u ma, d i ssection, o r thrombus formati o n .
8, o r 1 0 m m ) externa l ly s u p p o rted expanded polytetra­ I n t h e case of the d ista l a rtery, f l u s h i n g w i t h h e p a r i n ized
f l u o roethyl e n e (ePTFE) is e m p l oyed . For m ost patie nts, sa l i n e may help confi rm patency and sufficient r u n off.
in most situations, an 8-m m d i a m eter, rem ova b l e r i n g Retrog rade f l u s h i n g of d iseased o r damaged b rach i a l ,
g raft is opti m a l . The axi l l a ry a rteriotomy is a lways cre­ axi l l a ry, o r s u b c l a v i a n a rteries i s n o t reco m m ended g iven
ated p roxi m a l to the overlyi n g pectora l i s m i n o r m u scle, the potent i a l risk for verte bral a rtery e m b o l ization of
whic h is itse lf usua l ly d ivided to f u rther m i n i m i ze u n d u e res i d u a l l u m i n a l detritus and su bseq uent centra l n e rvous
traction o n t h e g raft. system (CNS) i nfa rction o r i nj u ry.
• When co nsidering d i rect i p s i l atera l axi l l o-ax i l l o o r axi l l o- • When uncerta i nty exists rega rd i n g the extent of axi l l a ry
brach i a l bypass g rafting, co n d u it choice depends on surgi- injury, f u rther exposu re may be necessa ry to ensure success.
ca l context. I n conta m i n ated fields (with open penetrati n g In ra re and exte n u ating c i rcu msta nces, clavicu l a r resection
o r avulsion i nj u ries of the axi l l a ry a rte ry), ve i n is p referred a n d replacement (or remova l) may be req u i red for satis­
and is sou rced from the l o n g o r short sa phenous o r super­ factory a rterial exposu re. S i m i l a rly, when fragmented o r
ficial femora l ve i n s in the (least i nvolved) lower extre m ity, chro n ica l ly infected, the clavicle should be removed a s
o r contra l atera l a r m ve i n . For e l ective revasc u l a r i zation necessa ry t o optim ize long-term g raft patency a n d l i m b
p roced u res, depe n d i n g on the age of the patient, bypass viabil ity.
length, target a rtery d i a m eter, and i n d ications for reco n- • For u p p e r extrem ity a rte r i a l reco nstruction, once expo­
struction, ePTFE or kn itted po lyeste r p rosthetic g rafts s u re i s co m p l ete and the a p p ropri ate t u n n e l i s created,
may provide accepta b l e a ltern atives. H owever, in nearly the a p p ropriate co n d u it is selected for use and p repa red
all situations req u i ri n g u p per extrem ity bypass at o r d is- for i nterposit i o n g raft i n g (FIG 1 D) . The co n d u it shou l d
ta l to the clavicle, a utogenous ve i n is o pti m a l and h i g h ly be fashioned t o a n a p p ro p ri ate l e n gth t o avo i d potenti a l
p refe rred. k i n k i n g d u ri n g futu re a r m motions. Prox i m a l a n d d ista l
• For i p s i l atera l revasc u l a rization, g raft is tun neled p a ra l l e l a n astomoses a re performed end-to-e n d or e n d -to-s i d e
t o the existing axi l l a ry a rtery ben eath the pectora l i s major d e pe n d i n g o n the respective d i a m eters of the i nflow a n d
a n d minor m uscles to the a nterior axi l la ry l i n e . outflow seg me nts.
1882 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Seventh Step a nteg rade e m b o l ecto my proxi m a l l y from an a ntec u b ital


b rach i a l access incision risks tra u matic i n j u ry to the axi l­
• Catheter e m b o l ecto my s h o u l d be pe rfo rmed as necessa ry, l a ry o r b rach i a l a rtery at the origin of the deep b rach i a l
often u s i n g over-the-wi re, i m a g e-g u i ded tech n i q u es, to a rtery, where t h e d i a meter o f t h e b rach i a l a rtery de­
remove l u m i n a l thrombus from i nflow or outflow a rte­ creases s i g n ificant ly, j u st d ista l to the axi l l a ry fossa .
r i a l seg m e nts as necessa ry. Ca re s h o u l d be taken with • Appropriately sized Fog a rty throm becto my catheters for
proxi m a l l y d i rected e m b o l ecto my to avo i d d i s l od g i n g u p p e r extrem ity e m bo l ecto my i n c l u d e si zes 2 throu g h
c l ot fra g m e nts i nto t h e ve rte b ra l a rte ry. 5 Fr, d e p e n d i n g o n t h e d i a m eter o f the a rtery b e i n g
• To m i n i m ize iatroge n i c i n j u ry from e m b o l ecto my cath­ i n st r u m e nted a n d the tech n i q u e (antegrade o r retro­
eters, proxi m a l e m b o l ecto my i s best i n itiated at the l evel g ra d e) b e i n g e m p l oyed .
of the axi l l a ry rath e r than brach i a l a rte ry. Attem pt i n g

M I D-D ISTAL AXI L LARY ARTERY superior aspect o f t h e surgical i n cision, t h e coracobrachi­
a l is m uscle wi l l be visual ized at 90 deg rees rel ative to the
First Step med i a l ly retracted pecto ra l i s major m uscle. With i n this
• The m i d-d ista l axi l l a ry a rtery may be exposed via an ax­ a n g le, gentle b l u nt d i ssection is a p p l ied to i d e ntify the
i l l a ry o r d e lto pecto ral i n c i s i o n . For d i stal exposu re, the axi l l a ry sheath r u n n i ng along the i n feroposteri or border
i ncision is exte nded through the poste rolatera l border of of the coracobrac h i a l i s m uscle.
the pectora l i s major m uscle to a l low for pa rti a l m o b i l iza­ • For d e ltopecto ral exposu re, d i ssect i o n is performed a l o n g
t i o n a n d m ed i a l retraction of that m uscle (FIG 2A) . I n the the a nte r i o r border of the d e ltoid m uscle, exte n d i n g

A
Muscu locutaneous
Coracobrachialis Axi llary sheath Clavicle nerve
muscle Coracoid Deltoid
Biceps process muscle
(short head)

Coracobrachialis
muscle

Median nerve

Axillary artery

Course of
axi llay artery

Clavi pectoral fascia


Pectoralis Pectoralis
major Axi l lary Clavi pectoral
B mi nor
c muscle vein fascia muscle

FIG 2 • A. R i g ht u pper extrem ity a rteriogram demonstrati n g d ista l axi l l a ry a n d brach i a l a rtery occl usion, with su bsta nti a l fi l l i n g of
u n named co l l atera l a rterioles. B. Axi l l a ry exposu re of the m id-d ista l axi l l a ry a rtery. C. Deltopectora l expos u re of a long seg ment
of axi l l a ry a rtery. (continued)
C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization 1883

Medial Lateral Pectoralis


minor
Ligated
thoracoacrom ial
Pectoral lis minor artery
insertion (cut)

Axillary artery

\
vein
Coracobrachialis
muscle Posterior cord U l nar nerve
D E
FIG 2 • (continued) D. Expos u re of the d i sta l axi l l a ry a rte ry a n d associ ated axi l l a ry sheath struct u res. E. Exposure of the
m i daxi l l a ry a rtery via reflection of the pectora l i s m i n o r m uscle.

t h ro u g h the su bcuta neous tissue i n the d e ltopecto r a l d u r i n g m o b i l ization of the axi l l a ry a rtery seg m e nt, care
g roove (FIG 28) . W i t h m e d i a l retract i o n of the pectora l i s s h o u l d be taken to not i nj u re the l atera l thoracic a rtery
major, the n e u rovascu l a r b u n d l e is t h e n exposed i n t h e and the latera l and m ed i a l cords as they j o i n over the
u n d e rl y i n g clavi pecto ral fasc i a . d ista l axi l l a ry a rte ry to form the m ed i a n n e rve.

Second Step Fourth Step


• U p o n entry of the axi l l a ry sheath, t h e axi l l a ry a rtery is • S i m i l a r to the steps o ut l i ned for reco nstruction of i n j u ries
visu a l i zed d i rect ly u n d e r the m e d i a n n e rve. At the l at­ to the fi rst o r seco n d portion, tra u m atized, throm bosed,
e r a l border of the pectora l i s m a j o r m u scle, the m e d i a l o r a n e u rysm a l seg m e nts in the seco n d o r t h i rd portions
a n d latera l cords f o r m t h e med i a n n e rve f o r m ove r t h e of the axi l l a ry a rtery may be tra n sected o r bypassed, with
a nterior su rface o f the axi l l a ry a rte ry. The u l n a r n e rve i nterposition g raft i n g o r bypass as n ecessa ry.
a n d axi l l a ry a rtery a re visu a l i zed a l o n g the i nferopos­ • Repa i r of axi l l a ry branch i n j u ries a n d a n e u rysms req u i res
terior border of the m i d - d i sta l axi l l a ry a rtery i n this ex­ sufficient seg mental exposure of the axi l l a ry a rtery itse lf,
posure. I d e ntificat i o n of s u rrou n d i n g st ructu res d u ri n g as we l l as the branch a rte ry of co ncern. S u bsca p u l a r, me­
axi l l a ry expos u re m i n i m izes risks o f i n a dvertent i nj u ry. d i a l h u m era l circumflex, o r latera l h u meral c i rcu mfl ex
E l evat i o n a n d ca u d a l retract i o n of the exposed axi l l a ry branch a rtery a n e u rysms can be exposed t h r o u g h the ax­
a rtery with vessel loops a l so a u g m e nts expos u re a n d i l l a ry fossa a n d d ivided free from the axi l l a ry a rtery once
red u ces r i s k of adjacent n e rve i n j u ry d u r i n g a rt e r i a l l i g ated to p revent persistent d i sta l a rte r i a l e m b o l i zation
c l a m p i n g (FIG 2C) . a n d hand isch e m i a i n the sett i n g of c h ro n i c overuse o r
ath l etic i n j u ries. Occasi o n a l ly, a n e u rysm a l degen eration
T hird Step
of the branch co m p ro m ises the i nteg rity of the axi l l a ry
• When f u rther expos u re of the seco n d portion of the a rtery itse lf, a n d i nterposition g raft i n g may be req u i red
axi l l a ry is req u i red, the pectora l i s minor m uscle is d ivided for o pti m a l reconstitution of d ista l l i m b b l ood fl ow.
n e a r its i n se rtion o n the coraco i d p rocess. The pecto ral Autogenous ve i n (or a rtery h a rvested from the d i stal i n ­
n e rves should be i d e ntified a n d p rotected d u ri n g t h i s te r n a l i l i a c circulation i n the pelvis) i s the opti m a l cond u it
m a n e uver. Ca u d a l retraction of the m uscle a l l ows for ex­ choice for this a p p l ication (FIG 3) .
pos u re of the u n derlyi n g n e u rovasc u l a r b u n d l e (FIG 20) . • Axi l l a ry o r b r a n c h a rte ry i n j u ries resu lting i n su bsta nti a l
• I n the seco n d portion, the axi l l a ry a rtery is s u rrounded d ista l a n d sym pto matic u p p e r extrem ity a rte r i a l emboli
o n t h ree sides by b rach i a l p l exus n e rves, leavi n g the an­ a n d d i g ita l isch e m i a may benefit from a t r i a l of i ntra a r­
te rior su rface of the a rtery u n cove red . For sufficient c i r­ te r i a l thrombo lytic thera py, a d m i n istered preoperative ly,
cu mferential expos u re of the vessel, the thoracoacro m i a l to i m p rove r u n off, g raft paten cy, h a n d perfus ion, a n d
a rtery ca n be l i g ated a n d d ivided at its orig i n . H owever, fu ncti o n a l status.
1884 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

A
B

Axi llary
artery

Subscapular /""
artery

Anterior
circu mflex Posterior
artery circumflex
artery
E

Microembolus
c

D
FIG 3 • A. Relative a n atomy of the d ista l axi l l a ry a rtery and associated anterior and poste rior
c i rcu mflex h u m eral a rteries. B. Axi l l a ry a rtery i n j u ry at the origin of a c i rcu mflex h u meral branch
repa i red with a n i nterposit i o n ve i n g raft. C. Ci rcu mflex h u meral branch a n e u rysm . D. CTA of r i g ht
u p p e r extrem ity ci rcumflex h u meral branch a rtery a n e u rysm (arrow). Catheter-based a n g iogram
d e m o n strates hypodens ity i n the circumflex h u meral branch, consistent with i ntra l u m i n a l
thrombus (middle panel). O p e n operative expos u re o f t h e ci rcu mflex h u meral branch o r i g i nating
from the axi l l a ry a rtery (isola ted b y red silastic sling). E. B ra n c h a n e u rysm thrombus ca u s i n g d ista l
m icroem b o l i can be treated with resect i o n a n d i nte rva l l i gation of the branch vesse l .

BRACH IAL ARTERY tered i n t h i s d i ssect i o n a n d s h o u l d be p rotected from


i n j u ry.
First Step
Second Step
• I n the u p pe r a rm, the prox i m a l brach i a l a rtery is opti-
m a l ly exposed via a 5- to 8-cm l o n g itud i n a l i n cision in the • By i n c i s i n g the deep fasc i a at the m ed i a l border of the
med i a l g roove between the b i ceps a n d triceps m uscles b i ceps m uscle, the n e u rovasc u l a r b u n d l e may be f u rther
(FIG 4A) . expose d . The median n e rve will be the fi rst struct u re to
• As the su bcuta neous tissue is d i ssected, care s h o u l d be be encou ntered i n the b rach i a l sheath with this expo­
taken to vis u a l i ze a n d avo i d i nj u ry to the bas i l i c ve i n as it sure. Wide m o b i l ization of the n e rve a l l ows for its gentle
crosses n e a r the b rach i a l sheath in the d i sta l u p per a r m . retra cti o n i nto the a nte rior wound (FIG 48).
To a i d i n exposu re, the bas i l ic ve i n can be retracted i nto • J ust deep to the m e d i a n n e rve, the b rach i a l a rtery w i l l be
the poste r i o r wo u n d , a n d vein b ra n ches cross i n g over visu a l i zed a l o n g with two f l a n k i n g brach i a l ve i n s . I nter­
the brach i a l a rtery sheath can be l i gated and d i v i d e d . co n n ecti n g com m u n ications between these ve i n s may be
S i g n ificant p l exus of sensory n e rves a re a l s o e n c o u n - l i g ated to aid i n f u rther expos u re of the b rach i a l a rte ry.
C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization 1885

Median Brachial
nerve artery

c
FIG 4 • A. I ncision created for exposure of the p roxi m a l brach i a l a rtery in the u p p e r a r m . B. The b rach i a l a rtery in the u p per
a r m is adjacent to the m ed i a n a n d u l n a r n e rves. C. Tra u m atic transect i o n of the brach i a l a rtery with associated inti m a l d a m a ge,
a l o n g with p a rt i a l i nj u ry to the m e d i a n n e rve. S u bseq uent repa i r is perfo rmed with a b rach i a l a rtery i nterposition g raft u s i n g
a ve i n co n d u it a n d m ed i a n nerve repa i r.

T hird Step brach i a l a rte ry with vessel loops prior to c l a m p i n g can


decrease the cha nce of n e rve i n j u ries during t h i s p rocess.
• Exposure of the brach i a l a rtery i n the m i d-upper arm may
req u i re identification and control of the deep brac h i a l Fifth Step
a rtery, w h i c h a rises o n the postero m ed i a l s u rface o f t h e
• Pse u d o a n e u rysm o r tra nsection of the brach i a l a rtery can
brach i a l a rtery, j u st d ista l to the l atera l border o f the teres
be repa i red fo l l owi n g p roxi m a l and d i sta l b rach i a l a rtery
major m uscle in the d ista l axi l l a ry fossa. In the d ista l upper
expos u re a n d contro l . In the sett i n g i m m i n e n t r u pt u re
arm, the superior a n d inferior ulnar collatera l a rteries
or exsa n g u i nation, prox i m a l control in this a rea may be
may a lso req u i re control d u r i n g brach i a l a rtery exposure.
o bta i n e d with a proxi m a l ste r i l e to u r n i q u et. Fol lowing
to u r n i q u et control, the i n j u red b rach i a l a rtery seg ment
Fourth Step
o r pse u d o a n e u rysm sac can be isolated a n d exp l o red
• Alternatively, the b rach i a l exposu re can be g a i ned with confidence. This tech n i q u e is p a rtic u l a rly usefu l in
through a n o b l i q u e i ncision along the a ntici pated cou rse p reventing catastro p h i c r u pt u re and conta m i nation of
of the brach i a l a rte ry in the d ista l u p per arm p rox i m a l to the OR envi ro n m ent with b l ood-borne pathogens in the
the a ntec u b ital fossa . sett i n g of iatrog e n i c o r self- i n f l i cted mycotic a n e u rysms.
• O n ce a g a i n , ca re s h o u l d be taken to avo i d i n j u ry of the • P u n ct u re wo u n d s may be a m e n a b l e to p r i m a ry suture
m e d i a n n e rve, wh ich can be found postero med i a l rel ative repa i r o r m i n i m a l resection of the i n j u red seg ment a n d
to the brach i a l a rtery i n this a rea (FIG 5) . E l evati o n of the p r i m a ry reapprox i m ati o n . La rger d efects a n d p a rt i a l
1886 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

Biceps brachii
muscle

Brachialis

Brachiorad ialis

nerve

Brachial
artery

A
B

Radial Acute embolic


artery

U l nar Brachial
artery artery

c
FIG S • A. Typical i n c i s i o n s used for expos u re of the d i sta l b rach i a l a rtery a n d proxi m a l ra d i a l a n d u l n a r a rteries at the
a ntec u b ita l fossa . B. R e l ative a n atomy of the brach i a l , rad i a l , a n d u l n a r a rteries a n d adjacent median n e rve. C. Acute
e m b o l i c occl usion of the brach i a l a rtery bifu rcation can be treated fo l l owi n g p roxi m a l and d i stal control of the b rach i a l ,
rad i a l , a n d u l n a r a rteries. Arte riotomy is created over the occ l u d e d vasc u l a r seg ment. Fol l ow i n g d i sta l t h ro m becto my o f
the u l n a r a n d ra d i a l a rteri es, a Fog a rty throm becto my catheter can a lso be u s e d t o extract t h r o m b u s f r o m the b rach i a l
a rte ry.
C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization 1887

tra nsections may req u i re patch a n g i o p l asty for satisfac­ fo l l owi n g text) may be req u i red to opti m a l ly restore d is­
tory repa i r (FIG 4C) . ta l a rte r i a l perfusion.
• When u n certa i n as to whether a p r i m a ry repa i r is i n d i - • Apropos the prior d i scussion reg a r d i n g axi l l a ry expos u re
cated or even poss i b le, the m ost re l i a b l e cou rse of a ction a n d e m b o l ecto my, atte m pt i n g remova l of p rox i m a l e m ­
i s i nterposition ve i n g raft in g , usu a l l y h a rvested from a b o l i f r o m a ntec u b ital brach i a l access (e . g . , " retrograde"
l o n g saphenous ve i n , with ca re taken to account for d if­ posit i o n i n g of the e m b o l ecto my catheter i nto the p roxi­
ferences in l e n gth based o n m ovement at the e l bow (e.g., mal b rach i a l and axi l l a ry a rteri es) carries a s i g n ificant risk
avo i d kinking while l i m it i n g te nsion). Risk of k i n k i n g is of cathete r-re lated i n j u ry to the prox i m a l brach i a l a rtery
a l s o red u ced by reconstruct i n g oth e r i n j u red structures at the o r i g i n of the deep b rach i a l a rte ry, where a sig­
in the a ntecu bita l fossa (e . g . , b i ceps brach i a l i s te n d o n) to n ificant d i a m eter red uction occu rs d u e to the b i f u rcation
l i m it g raft motion d u ri n g e l bow flexi o n . of su perfi c i a l and deep brach i a l a rteries. For prox i m a l
• D i sta l forea rm throm becto my is best pe rfo rmed t h ro u g h e m b o l ecto my, the safer a p p roach i s t o g e n e ra l ly g a i n ac­
a b rach i a l i n c i s i o n created i n the a ntec u b ital fossa . cess in the axi l l a ry rath e r than a ntec u b ital fossa.
Exposu re of the d ista l brach i a l a rtery may be n ecessa ry to • B rach i a l occ l u s i o n associated with e l bow o r shoulder d is­
seq uenti a l ly cath ete rize the i n d ivid u a l forea rm a rteries. l ocat ion typica l l y res u l ts from i nti m a l d i s r u ption o r d is­
Alternatively, proxi m a l sheath access i n the axi l l a ry section beg i n n i n g at the p o i nt of i nj u ry a n d exte n d i n g
fossa may fac i l itate i m a g e-g u i ded access of the forea rm d i sta l l y. Accord i n g ly, w h e n foca l a rte r i a l i n j u ry i s present
a rteries a n d ove r-the-wi re e m b o l ecto my. in the sett i n g of co m p l ete occl usion, the i n j u red seg­
• I n the a ntecu b ita l fossa, d ista l throm boem b o l ecto my may ment is opti m a l ly re p a i red by resection and replacement
be pe rfo rmed with a 2- or 3-Fr Fog a rty catheter (FIG SC) . rath e r t h a n atte m pts at a nticoa g u lation or e m b o l ecto my
F u rther e n d ovascu l a r i m a g i n g a n d treatment (see in the alone.

RAD IAL ARTERY i n g from the m i d po i n t of the a ntec u b ital crease to the
styloi d p rocess of the radi us, whi c h often a n ato m i ca l ly
First Step corresponds to the g roove of the m e d i a l edge of the bra­
• D i rect open exposure of the rad i a l a rtery can be performed c h i o ra d i a l i s m u scle.
at a l m ost every level proxi m a l to the wrist. As with other
a rterial seg m ents, exposure of the rad i a l a rtery should be Second Step
sufficient to a l low both p roxi m a l and d ista l a rterial contro l . • S u perfi c i a l , su bcuta neous ve i n s overlyi n g the ta rget
• T h e b rach i a l a rtery typ i ca l l y bifu rcates to g ive r i s e t o t h e a rteries (med i a l a ntecu b ita l ve i n in the a ntec u b ital fossa
ra d i a l a rtery a n d u l n a r/inte rosse us tru n k at the level o f a n d cepha l i c ve i n branches in the forea rm) may be m o b i ­
the ra d i a l t u b e rosity (FIG SB) . H owever, n o t infrequently, l i zed o r l i g ated to a i d with the expos u re p rocess. Prior t o
the ra d i a l a rtery orig i n ates from the u p p e r a r m brach i a l
l i gation, ca re s h o u l d be t a k e n to consider the tota l ity o f
a rtery o r eve n t h e axi l l a ry a rtery ( u p to 1 5 % i n ci d e n ce re m a i n i n g forea rm r u n off vei ns, especia l ly i n the sett i n g
i n cadaveric stud i es) . 1 9 Seve ra l c l i n ical circumstances of b l u nt o r avu lsive tra u matic i n j u ries.
h i g h l ight the s i g n ifica nce of t h i s a n o m a ly, i n c l u d i n g the • I n the proxi m a l forearm, the a ntebrach i a l fasc i a w i l l need
need to base d ista l bypass o r a rterioven o u s a ccess p roce­ to be excised a l o n g the m ed i a l edge of the brach i o ra d i a l is
d u res off the " b rach i a l " a rtery in the a ntecu bita l fossa. m uscle a l o n g the l e n gth of the i n c i s i o n . The ra d i a l a rte ry
To e n s u re a d e q u ate a rte r i a l i nfl ow, it is esse n t ial to iden­ ca n then be visual ized with latera l retraction of the b ra­
tify which a rte r i a l co n d u its are p resent and i d e ntified c h i orad i a l is m uscle.
i n the a ntecubital fossa. Preoperative CT a n g iog raphy, • S i m i l a r ly, i n the m idforea rm, the ra d i a l a rtery can be vi­
catheter-based contrast a rteriograp hy, or u ltrasonog ra­ s u a l ized fo l l owi n g excision of the overlyi n g a ntebrach i a l
phy can provide essenti a l i nformation i n this reg a r d . fasc i a a n d retract i n g a p a rt the brach i o ra d i a l is a n d prona­
• Alternative expos u re o p t i o n s exist f o r the brach i a l tor teres m uscles (FIG 6A) .
bifu rcation a n d proxi m a l rad i a l a rtery i n t h e a ntec u b ital • D u ri n g exposu re maneuvers, ca re shou ld be taken to vi­
fossa. A 4- to 5-cm tra nsve rse i ncision, two f i n g e rb readths sual ize and avoid injury to closely associated rad i a l a rtery
d ista l to the a ntec u b ital crease, p rovides opti m a l expo­ structures. This incl udes the paired rad ial a rtery veins that
s u re for the d i stal b rach i a l a rtery as we l l as the o r i g i n s
acco m pany the rad i a l a rtery throug hout its cou rse i n the
of the forea rm a rteries (i nte rosseus, ra d i a l , a n d u l n a r) . forearm. The superficia l rad i a l nerve is a lso closely associ­
Alternative ly, for m o r e extensive brach i a l a rtery expo­ ated with the latera l aspect of the rad i a l a rtery in the mid­
su re, an 5-shaped i n cision is e m p l oyed exte n d i n g from forearm a n d can be preserved with gentle latera l retraction.
the m e d i a l aspect of the b i ceps m uscle te ndon, through
the m i d po i nt of the a ntecubita l fossa, a n d toward the
Third Step
latera l aspect of the vo l a r forea rm (FIG SA) .
• Exposu re of the m i d - or d i stal rad i a l a rtery can be per- • G iven the d o m i n a nce of the u l n a r circulation i n most p a ­
formed t h ro u g h 4- to 5-cm l o n g itu d i n a l i n cisions a l o n g tients, isol ated d ista l ra d i a l reco nstruction may be optional,
the latera l aspect of the vo l a r forea rm (FIG 6A) . A usefu l depen d i n g on the tota l ity of coexisting conditions a n d
l a n d m a rk for these i ncisions is the i m a g i n a ry l i n e exten d - inju ries. S u perim posed acute o r c h ro n i c tra u m atic inju ry,
1888 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Pseudoaneurysm sac

Radial artery

Su perficial rad ial nerve

Radial artery

Brachiorad ialis
muscle ----1=----

B
A

U l nar artery

U l nar nerve

Flexor carpi
FIG 6 • A. Exposure of the ra d i a l a rtery in the proxi m a l a n d
ulnaris muscle
d i sta l forea r m . B. F o l l o w i n g proxi m a l a n d d i stal ra d i a l a rtery
control, a p r i m a ry repa i r of a ra d i a l a rte ry pse u d o a n e u rysm is
pe rfo rmed. C. Exposure of the p roxi m a l m i d u l n a r a rtery i n the
c forea r m .

ren a l fa i l u re, d i a betes m e l l itus, o r chronic embol ization case more p roxi m a l ly i n the u pper extrem ity a rterial sys­
may j u stify rad i a l reconstruction, p a rticu larly i n circum­ tem, image-g u ided, over-the-wi re embol ectomy, com b i ned
sta nces where hand via b i l ity is at s i g n ificant risk. with j u d icious use of i ntra a rterial throm bolytic agents such
• Rad i a l a rtery transections o r pseudoa n e u rysms, l i ke a l l as tPA (see " U pper extrem ity a n g iography a n d stent i n g "
types o f a rterial reconstruction, a re best a p p roached fol­ section i n the fol l owing text), may be n ecessa ry t o achieve
lowing adequate exposure and p roxima l/d ista l contro l . satisfactory runoff a n d h a n d a n d d i g ital perfusion. Th us,
Deta iled exp loration a n d a rterial expos u re fo l l ows shortly arra ngements should be made p reoperatively to i n itiate
thereafter. Depend i n g o n extent of injury and i nteg rity of the e m bolectomy proced u re in an ope rati n g environment
the a rterial l u men at the site of inju ry, either p r i m a ry repa i r that can support image-gu ided i ntervention.
or i nterposition g rafting may be considered (FIG 68). • Both forea rm a rteries at the wrist may provide a p p ropri­
• Acute embolic occl usions of the rad i a l a rtery can be ate i n f l ow for d i a lysis access p roced u res. Considerations
removed through retrog rade embol ectomy, performed for a rteriovenous a ccess creati o n a n d m a i nte n a nce a re
thro u g h a control led p roxi m a l , tra nsverse a rterioto my. beyo n d the scope of t h i s c h a pter. I nte rested rea d e rs a re
G iven the ca l i ber of the forearm a rterial system, a 2-Fr refe rred to other refe ren ces for options reg a rd i n g d i a ly­
Fog a rty catheter is best su ited for this p u rpose. As was the sis access creat i o n .
C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization 1889

U LNAR ARTERY the flexor ca rpi u l n a ris m uscle. The u l n a r n e rve l ies me­
dial to the a rtery at this level and is prone to i nj u ry with
First Step this exposure. Care s h o u l d be taken to i d entify and mo­
• S i m i l a r to the rad i a l a rte ry, the u l n a r a rtery may a lso be b i l ize it safely. The su perfi c i a l pa l m a r branch of the u l n a r
exposed a l o n g its cou rse i n the forea rm, a n d the exte nt a rtery a n d n e rve a lso crosses su perfi c i a l t o t h e a ntecu b i ­
of expos u re w i l l depend o n the site and type of path o l ­ ta l fascia at the wrist l e v e l , a n d c a r e s h o u l d be t a k e n t o
o g y as we l l as a b i l ity to o bta i n a d e q u ate proxi m a l a n d p revent traction o r co m p ression i n j u ries to these struc­
d i sta l a rte r i a l control (FIG 6C) . tu res d u r i n g u l n a r a rtery exposure.
• The p roxi m a l u l n a r a rtery can a lso be exposed at the
Second Step
b rach i a l b i f u rcation i n the a ntecu bital fossa t h ro u g h an
S-shaped incision (see " R a d i a l a rtery" e a r l i e r; FIG SA,B) . • Throm becto my of the u l n a r a rte ry p roceeds i n a fas h i o n
• Alth o u g h m o re cha l l e n g i n g, the proxi m a l u l n a r a rtery s i m i l a r to t h a t p reviously described for the rad i a l a rte ry.
may a l so be exposed in the m ed i a l aspect of the proxi m a l • U l n a r a rtery tra u matic tra nsections may be repa i red pri­
forea r m . F o u r f i n g e rbreadths below t h e med i a l epicon­ m a r i ly o r with a n a p p ropriately sized i nterposition ve i n
dyle, a 7- to 9-cm l o n g itud i n a l i n c i s i o n can be created g raft. Ve i n ha rvested from t h e dorsum o f t h e foot fre­
a l o n g a l i n e exte n d i n g from the m ed i a l e p icondyle to q u ently serves this p u rpose wel l .
the pisiform bone. I n c i s i n g the deep fasci a fac i l itates ex­ • U l n a r a rtery a rteriovenous d i a lysis accesses a re rarely
posure of the u l n a r a rtery t h ro u g h the space between performed due to t h i s vesse l 's rel ative d ifficu lty i n ex­
the fl exor carpi u l n a r i s and flexor d i g itorum s u p erfi c i a l i s posure compared to the ra d i a l a rte ry, its cl ose proxi m ity
m uscles (FIG 6C). to the u l n a r n e rve t h ro u g h out its l e n gth, a n d its rel ative
• The d ista l u l n a r a rte ry, proxi m a l to the wrist, is opti m a l ly d o m i n a n ce in m a i nta i n i n g a d e q u ate perfu sion to the
exposed through a l o n g itud i n a l i n c i s i o n j ust l atera l to hand.

UPPER EXTRE M ITY A N G I OGRAPHY AND • S i m i l a rly, the u pper extrem ity a rte r i a l system is particu­
l a rly prone to vasospasm d u ri n g catheterizat i o n . D u r i n g
STENTI N G
d i a g n ostic exa m i nations, p a rticula rly i n yo u n g e r patie nts,
First Step care s h o u l d be taken to avo i d catheterization d ista l to the
a ntecu bita l fossa to m i n i m ize a rtifact u a l degradation of
• Access depends l a rgely on the a rea a n d type of a ntici pated the a n g iogra p h i c i m a g e due to vasospasm. S i m i l a rly, usi n g
a rte r i a l path o l ogy. For i n n o m i nate o r proxi m a l subcla­ warm flush so l utions may m i n i m ize this effect. When the
v i a n a rtery d i sease o r i n j u ry, retro g rade transbrach i a l o r rad i o g r a p h i c a p pearance of vasospasm is encou ntered
transfe m o ra l a rtery a p p roach may both suffice. For d ista l ("str i n g s i g n " or " stri n g of beads" a p pearance), d i rect i n ­
d i a g nostic or i nterventi o n a l proce d u res, retrog rade ra­ tra a rteri a l i nfusion o f papaveri ne ( 1 0 t o 50 mg) or n itro­
d i a l o r a ntegrade access may be co nsidered. g lyceri ne (50 to 200 J.Lg) may i m p rove i m a g e reso l ution i n
• Sta n d a rd S e l d i n g e r tech n i q u e is used for percuta neous h a n d o r d i g ita l a rteries. Papaveri ne w i l l prec i p itate o u t of
a rte r i a l access, u s i n g either u ltraso n o g r a p h i c o r f l u o ro­ so l ution when exposed to heparin and may not be opti­
sco p i c g u i d a n ce. Placement of a 4-Fr m icrosheath may mal for all potential c l i n ical a p p l ications for this reaso n .
h e l p sta b i l ize the i n it i a l ca n n u l ation s ite a n d a l low for
prel i m i n a ry d i a g n ostic i m a g i n g . T hird Step

• If further endovascu l a r diag nostic or i nterventiona l


Second Step
procedu res a re plan ned, wire access with a 0.0 1 8-in o r
• I ntraarterial pharmacologic adj u n cts may be a d m i n istered 0.035-in g u i dewi re t o t h e a rteria l seg ment o f i nterest must
through appropriately positioned a rteria l i nfusion systems. be achieved .
• For a rterial throm bosis, catheter-d i rected, l i m b-specific, • From a brach i a l a rtery a p p roach, a short g u i d e sheath
i ntra a rterial tPA is a d m i n istered in doses rel ated to the ex­ and a g u ide catheter co m b i nation usua l ly a l l ows for
tent of thrombus load, ra n g i n g from 0.25 to 2.0 mg per successf u l catheterization of adjacent proxi m a l u p pe r
hour, fo l lowi ng a n i n itial "seed i n g " dose of 4 mg across the extrem ity a rte r i a l seg m e nts.
reg ion i n q u estion over 10 to 30 m i n utes. Combined phar­ • From a fe moral a rtery a p p roach, a long (90 em) 6- or 7-Fr
macolog idmech a n i ca l thrombus disruption systems usefu l sheath is typica l l y adva nced over the g u idew i re to faci l i ­
in other a rterial a n d venous beds, i n c l u d i n g the Tre l l isTM tate sta b l e catheterization o f i n n o m i n ate o r prox i m a l l eft
system (Covid ien, M a nsfi eld, MA), may be too large or u n ­ subclavian a rte ry. Long, c u rved 5-Fr catheters (i.e., a n g led,
w i e l d y f o r t h e upper extrem ity a rterial vasc u l ature. Newer JB 2, h e a d h u nter, or verteb r a l catheter) may be used to
l ow-profile systems, however, such as the M icrolysUSTM aid i n successf u l ca n n u lation a n d su bseq uent cath ete riza­
i nfusion catheter (EKOS Corporation, Bothell, WA), may tion of the a rch vesse l of i nterest. Confi rmatory a n g ie­
be more usefu l a n d appropriate i n this a p p l icatio n . Care g ra m s will h e l p co nfirm successf u l ca n n u lation a n d a i d in
should always be taken to account for risk of particulate i d e ntify i n g the a rteri a l seg ment of i nte rest (FIG 7A) .
embolus in the vertebral a rtery when p l a n n i n g embolec­ • O n c e sta b l e catheterization of the ta rget vessel i s
tomy or throm bectomy proced u res in the upper extrem ity. a c h i eved, m a g n ified a n g i og ra m s may be o bta i n e d i n the
1890 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

a ppropriate o b l i q u ities to accu rately a ssess the a rte r i a l advancing snare a n d wire from opposite d i rections s i m u l ­
seg m e nts o f i nterest. Additi o n a l r u n off i m a g i n g may b e ta neously, e m ployi n g m u ltiple-a n g led view m a y a l low for
necess a ry to eva l u ate the a rte r i a l o utflow d ista l to t h e successful snaring i n perivasc u l a r soft tissue and su bse­
d i seased seg ment. The operator s h o u l d i nspect these q uent spa n n i n g of the a rteria l tissue defect with a flexible
a n g iograms to determ i n e once a g a i n the ca n d idacy for covered stent (e.g., Viabah nTM). This tech n i q u e may gener­
e n d ovasc u l a r treatment and o bta i n a d d i t i o n a l measu re­ ate i m mediate a n d effective hemostasis whi le m a i nta i n i n g
m e nts to fac i l itate a p p ro p riate device select i o n . l u m i n a l patency a n d l i m b viabil ity, especia l ly as a n a lterna­
tive to l igation or emergency embol ization (FIG 7).
Fourth Step
Fifth Step
• S u ccessf u l w i re adva ncement across the lesion of i nte rest
is the n ext step in order to fac i l itate any p l a n ned treat­ • Proxi mal subclavian a rtery and i n n o m i nate stenoses a re typ­
m e nts with a n g i o p l asty o r stent i n g . ica l ly wel l managed by precise p lacement of stiff, bal loon­
• With t h e g u i d a nce o f a 4 - or 5-Fr g u ide catheter, a O.D1 8-i n or expa ndable stents or stent g rafts. Compared to the axi l l a ry
0.035-in hydrophilic wire ca n be advanced across a hemody­ a rtery, proximal to the costoclavicu lar j u nction, there is l ittle
nam ica l ly sign ificant stenosis (e.g., i n nomi nate a rtery, proxi­ or no movement i n the proximal su bclavia n a rtery. I n the
mal subclavian a rtery, or u pper a rm brach ial a rtery) . During setting of a prior i nternal mammary-to-coronary a rtery
adva ncement, care should be taken to rema i n i ntra l u m i n a l revascula rization, or a history of vertebra l-basilar insuf­
as m uch as possible t o m i n i m ize t h e risk o f dissection and re­ ficiency, precise stent placement is tantamount to proce­
entry. Adeq uate wire p u rchase should be acq u i red past the d u ra l success. For this reason, appropriately sized covered
stenosis after crossing the lesion of interest to decrease the (e.g., Atrium iCASD or bare meta l (e.g., O m n i l i n k, Abbott,
cha nce of losing subseq uent wire access across the lesio n . Redwood City, CA; Pa l maz, Cordis Endovascu lar, Wa rren,
• I n s i t u a t i o n s w h e r e ste noses o r occl usions p rec l u d e ac- NJ.) balloon-expa ndable stents a re genera l ly preferred.
cess from a " p refe rred " side, cross i n g the lesion from the • Appropriately size-matched, covered ste nts a re a l so es­
a lternate side a n d adva n c i n g a w i re f r o m the opposite senti a l a dj u ncts for m a nagem ent of proxi m a l s u bclavian
d i rection u s i n g a s n a re tech n i q u e may be req u i re d . a rtery i n j u ries o r c h ro n i c pse u d o a n e u rysms (FIG 7) .
• S i m u ltaneous a ntegrade a n d retrog rade, t h r o u g h and • As n oted e a r l i e r, however, stents of a n y k i n d s h o u l d n ot
through (" body floss") ca n n u l ation may faci l itate l ifesavi ng be d e p l oyed in p roxi m ity to the j u n ction of the 1 st r i b
management of tra u m atic subclavian a rtery inju ries. I n d i re a n d clavicle, as c h r o n i c tra u matic d a m a g e f r o m c ompres­
circu msta nces where a rterial cont i n u ity has been com­ s i o n between th ese bony struct u re w i l l cause ce rta i n
pletely lost, and tra nsl u m i n a l wire passage is not possib le, stent fa i l u re a n d f u rther comprom ise l i m b v i a b i l ity.

Hematoma
Anterior
scalene
muscle

I njured
subclavian
artery

Clavicle
B

Nondeployed Deployed
Tri lobed snare
stent graft stent graft

c D E
FIG 7 • A- Retrog rade ca n n u l ation of the p roxi m a l l eft s u bclavian a rte ry u s i n g a triaxi a l flex i b l e
sheath, a n g led catheter, a n d g l idewire co m b i nation. B- Tra u m atic i n j u ry to the l eft subclavi a n
a rte ry. C . Th ro u g h a n d through (body fl oss) w i re accesses t h e i n j u red s u bclavian a rtery. D,E.
Posit i o n i n g a n d d e p l oyment of a cove red stent to seal the s u bclavian a rte r i a l wa l l d i s r u pt i o n
w h i l e m a i nta i n i n g l u m i n a l fl ow.
C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization 1 89 1

PEARLS AND PITFALLS


U p per extrem ity n e rve • U p per extrem ity a rte r i a l i n j u ries freq uently a re associated with concomitant n e rve i n j u ries.20
i n j u ries Early recog n ition a n d d i a g nosis of these associated i n j u ries is p a r a m o u n t to l o n g -term f u n cti o n a l
restorat i o n .
• When n e rve i n j u ry is ide ntified o r suspected, prompt repa i r i n the same sett i n g is reco m m e n d e d .
P l astic s u rg e ry co nsu ltat i o n i n these circumstances is usua l ly req u i re d .
Iatrog e n i c n e rve i n j u ry • A s a g e n e r a l r u l e of t h u m b, whenever poss i b le, axi l l a ry expos u re proxi m a l to the axi l l a s h o u l d be
d u ri n g axi l l a ry a rtery acq u i red as p rox i m a l as poss i b le, to l i m it the risk of n e rve i n j u ry, as the cords of the brach i a l p l exus
expos u re become m o re i n t i m ately rel ated to the axi l l a ry a rtery as it p roceeds l atera l ly from the clavicle.
Also, the a m o u nt of axi l l a ry a rtery d isplacement a n d tract i o n as a result of a r m m ovement is m i n i ­
m i zed with fa r proxi m a l a n a stomotic positi o n i n g .
• U n l ess repa i r o f t h e axi l l a ry a rtery req u i res a d e ltopecto ra l exposu re, t h e p referred choices for
axi l l a ry a rtery exposure are prox i m a l o r d ista l to the seco n d portion of the axi l l a ry a rte ry.
Arte r i a l repa i r fo l l owi n g • I n the sett i n g of a rte r i a l tra u m a , the extent of a rte r i a l i n j u ry s h o u l d be p recisely determ i n e d pri or
seg m enta l resection to attem pts at reco nstruct i o n . Fa i l u re to co m p l etely d e l i neate the extent of i n j u ry wi ll co m p l i cate
atte m pts at repa i r.
• As a g e n era l r u l e of t h u m b, a l l i nvolved a rte r i a l seg ment s h o u l d be resected a n d/o r bypassed prior
to attem pts at reco nstruct i o n . Alth o u g h p r i m a ry repa i r with native a rte r i a l preservati o n is ofte n
a p pea l i ng, l o n g-te rm success typ i ca l ly req u i res i nterposition ve i n g raft i n g for a nyth i n g m o re t h a n
the s i m p l est of i nj u ries. 1 5•21
I nflow assessment • Prior to comp letion of a n u p pe r extrem ity a rte r i a l repa i r, the o perator m ust e n s u re that a rte r i a l
in fl ow is a d e q u ate.
• This can be confirmed o n preoperative CTA if ava i l a b l e, o r a lternatively, with an i ntraoperative
a n g i o g ra m .
O utflow assessment • Adeq u ate a rteri a l outflow is p a ra m o u nt t o m a i nta i n patency o f proxi m a l re pa i rs a n d h e l p a l l evi ate
potential extrem ity isch e m i c symptoms.
• Some a uthors reco m m e n d ro uti n e outflow assessm e nts fo l l owi n g u p per extrem ity revasc u l a riza­
t i o n . 22 H oweve r, if t h i s strategy is n ot reg u l a rly e m p l oyed, i ntraoperative outflow assessment
should be performed i n c i rcu msta nces where the d i sta l arm a n d/o r wrist vascu l a r exa m i nation is
a b n o r m a l fo l l owi n g ope rative revasc u l a rizat i o n .
• B e c a u s e the u l n a r a rtery is the d o m i n a nt vessel of the d i stal forearm a n d h a n d , restoration of flow
to this o utflow vessel is often n ecessa ry to avo i d su bseq uent com p l ications.
C o m p a rtment syn d ro m e • With prolonged acute i sc h e m i a (>4-6 h o u rs), u p pe r extrem ity c o m p a rtment release via fasci oto­
of the up p e r extrem ity m i es is h i g h ly reco m m e n d e d .
• U p per arm fasci oto m i es i n c l u d e two i n cisions i nto the brach i u m 's two compartments.
• Forea rm fasci oto m i es a re performed with th ree o r m o re d i screte i n cisions to deco m p ress the vo l a r
forea rm, d o rsa l forea rm, a n d m o b i l e wad n
• The h a n d may a lso req u i re deco m p ression via m u lt i p l e i ncisions.24 A carpal t u n n e l release may be
n ecessa ry if med i a n a n d u l n a r nerve dysfu nct i o n is evident. Consu ltation with h a n d or p l astic s u r­
geons is reco m m e n d e d when cons i d e r i n g the potenti a l benefit of h a n d fasciotomy to maxi m i ze
compartmenta l release a n d l o ng -term f u n ct i o n a l a n d cosmetic recove ry.

POSTOPERATIVE CARE During this period, the patient is observed for bleeding, he­
matomas, or change in serial vascular examinations.
• At the conclusion of arterial reconstructive procedures, re­ • Patients treated for primary thrombosis or occlusion of an
versal of heparin-induced coagulopathy with protamine may arterial segment are typically managed with long-term, ad­
or may not be indicated, depending on the status of the limb, j unctive systemic anticoagulation. The length of treatment
the patient, and the reconstructive procedure itself. Care period is debated and is variable between practitioners but
should be taken to provide a test dose of protamine before may be directed by severity of presenting symptoms, fre­
full reversal, if indicated, to minimize associated hypoten­ quency of prior occurrences, or history of a hypercoagulable
sion when antiprotamine antibodies are present. condition.25
• Motor and sensory examination as well as determination • Patients who presented with a presumed embolic occlusion
of upper extremity arterial status (including a Doppler and of an arterial segment should undergo a medical workup for
pulse examination) should be performed immediately post­ possible cardiac, proximal arterial atherosclerotic, endocar­
operatively to determine the new baseline for subsequent ditis, paradoxical, or tumor embolic sources.
serial examinations and to document improvement. • Patients who underwent angioplasty or stenting of an arte­
• Patients are typically observed for an extended period ( at least rial segment in the upper extremity are typically initiated
several hours) following upper extremity arterial intervention on a single-agent antiplatelet regimen with either aspirin or
to ensure procedural success and recovery from anesthesia. clopidogrel.
1 892 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

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• Wound or graft site infection Res. 1981;(1 6 1 ):252-26 1 .
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• Digital or vertebral artery embolization, complicating
20 1 2;27:38-42.
thromboembolectomy
25. Guyatt GH, Akl EA, Crowther M, et a!. Executive summary: anti­
• Postrevascularization compartment syndrome in the arm thrombotic therapy and prevention of thrombosis, 9th ed: American
or hand College of Chest Physicians evidence-based clinical practice guidelines.
• Stent failure when deployed in proximity to the clavicle/1st rib Chest. 20 1 2;141:7S-47S.
C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization 1 893

26. Hughes K, Cubangbang M, Blackman K, e t al. Upper extremity bypass 2 9 . Patel S N , White CJ, Collins TJ, e t al. Catheter-based treatment o f
for chronic ischemia-a national surgical quality improvement pro­ the subclavian and innominate arteries. Catheter Cardiovase Interv.
gram study database study. Vase Endovaseular Surg. 2 0 1 3 ;47: 1 92-194. 200 8 ; 7 1 : 963-9 6 8 .
27. Hughes K, Hamdan A, Schermerhorn M, et al. Bypass for chronic 30. Carrafiello G , Lagana D, Mangini M, et a l . Percutaneous treatment o f
ischemia of the upper extremity: results in 20 patients. J Vase Surg. traumatic upper-extremity arterial injuries: a single-center experience.
2007;46 : 3 03-307. J Vase Interv Radio/. 2 0 1 1 ;22:34-3 9 .
28. Licht PB, Balezantis T, Wolff B, et al. Long-term outcome following 3 1 . Xenos ES, Freeman M, Stevens S, et al. Covered stents for
thromboembolectomy in the upper extremity. Eur J Vase Endovase inj uries of subclavian and axillary arteries. J Vase Surg. 2 0 0 3 ; 3 8 :
Surg. 2004;2 8 : 5 0 8-5 1 2 . 4 5 1 -4 5 4 .
-

Chapter 11 Upper Extrem ity Arterial


Reconstruction and
Revascularization Distal
I
to the Wrist
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - r - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - •

Michael G. Galvez James Chang

DEFINITION is most commonly made based on digital ulceration and


tissue loss, conditions which uniformly develop in second­
• Arterial reconstruction and revascularization distal to the ary Raynaud's syndrome.
wrist requires reconstituting the complex vascular supply to CREST syndrome encompasses the most common phe­
the hand. This includes the ulnar and radial arteries, superfi­ notypic presentation of systemic scleroderma/sclerosis:
cial and deep palmar arches, and common and proper digital halcinosis, Raynaud's phenomenon, �sophageal stenosis,
arteries. This reconstitution is performed with either end­ �clerodactyly, and associated telangiectasias.
to-end primary vascular repair, interposition vascular graft Buerger's disease, or thromboangiitis obliterans, rep­
bypass with proximal and distal anastomoses, or address­ resents a progressive, recurring necrotizing arteritis
ing the digital arteries individually. Additionally, fasciotomy of small and medium vessels closely linked to tobacco
for compartment syndrome following trauma or reperfusion exposure.
inj ury may be a necessary adjunct. • Compartment syndrome occurs in response to increased
pressure within a fixed osteofascial anatomic space, lead­
DIFFERENTIAL DIAGNOSIS/PRECIPITATING ing to decreased arterial perfusion, irreversible myonecrosis,
CAUSES OF HAND ISCHEMIA neuropathy, and potential limb loss. In the hand, compart­
ment syndrome most commonly develops following crush
• Arterial inj ury
injuries; however, intravenous infiltration, external compres­
Traumatic (laceration, high energy or crush injury, etc . )
sion, and other mechanisms may also induce increased com­
or iatrogenic inj ury ( including inadvertent o r intentional
partment pressure.
cannulation for vascular access).
• Proximal embolization PATIENT HISTORY AND
• Intraluminal thrombosis
PHYSICAL FINDINGS
Hypothenar hammer syndrome occurs when the base of
the hypothenar eminence sustains repeated blunt trauma • Determine the hand dominance of the patient and relevant
resulting in chronic inj ury to the distal ulnar artery and history of trauma, tobacco use, medical history (coagulo­
the superficial palmar arch. In this scenario, compression pathic disorders ), and occupational exposures. Additionally,
occurs between the roof of Guyon's canal and the hook the presence of palpable masses, pain, sensory changes, or
of the hamate bone, resulting in aneurysmal degeneration color changes should be evaluated.
of the ulnar artery, luminal thrombus accumulation, and • An Allen's test may provide additional information regard­
digital embolization (typically the ring and small finger) . ing the relative contribution of the ulnar and radial arteries
This typically occurs o n the dominant hand o f individu­ to hand perfusion. This test is performed by manual com­
als participating in vocational or avocational activities pression of both the radial and ulnar arteries, with eleva­
involving repeated palmar impact (e.g., pipe fitters and tion and successive opening and closing performed to drain
mountain bike riders) . venous blood from the hand. The time differential to reper­
Spontaneous radial artery thrombosis may b e associated fusion, following respective arterial release, provides quali­
with Buerger's disease and is not as common as ulnar tative insight into relative radial or ulnar dominance. In most
artery thrombosis. cases, however, the ulnar artery is dominant, and modern
• Chronic digital ischemia secondary to vasospastic and rheu- quantitative arterial perfusion assessment by duplex imaging
matologic disease: and digital plethysmography has largely supplanted subjec­
Primary Raynaud's syndrome refers to cold-induced va­ tive physical exam findings in the assessment of adequacy of
sospasm present in the absence of concomitant disease. arterial inflow.
The etiology of this condition remains uncertain but is • Patients with hypothenar hammer syndrome can have com­
likely due to an exaggerated adrenergic receptor-mediated plaints of pain and tenderness of the hypothenar mass, with
response to cold exposure. cold sensitivity and numbness of the ring and small finger
Secondary Raynaud's syndrome refers to digital vasospasm secondary to digital embolization and direct ulnar nerve
which occurs in the setting of known autoimmune colla­ compression. A pulsatile mass may, on occasion, be appre­
gen vascular diseases and related rheumatologic disorders ciable in the palm. Discoloration of the lateral three fingers
(such as rheumatoid arthritis) . In this circumstance, a nor­ of the hand may also be present as a result of chronic digital
mal vasospastic response to cold or environmental stimuli embolization.
is superimposed on chronic digital artery occlusive dis­ • Patients with spontaneous radial artery thrombosis present
ease. Differentiation from primary Raynaud's syndrome with pain, numbness, and discoloration of the tips of the
1894
C h a pt e r 1 1 UPPER EXTREM ITY ARTE RIAL RECONSTRUCTION A N D REVASC U LARIZAT I O N 1 89 5

radial-sided digits. The area o f occlusion i s commonly be­


neath the first and third extensor compartments and can be
related to compression of the radial artery by the extensor
pollicis longus. 1
• Patients with Raynaud's syndrome report ischemic symp­
toms and digital discoloration on exposure to cold. Cold­
induced vasospasm may be elicited by cold emersion testing
in an ice bath. A positive test is elicited by the elimination of
plethysmographic pulsatile phasicity on exposure to cold, in
addition to the onset of symptoms. Most patients, however,
cannot tolerate this provocative test, and the clinical use of
eliciting vasospastic symptoms, particularly in the presence
of existing digital ulceration, is uncertain.
• Compartment syndrome is a clinical diagnosis. Cardinal
signs include persistent and progressive pain unrelieved with
immobilization/elevation, tightness of skin, pain with pas­
FIG 1 • Anatomy of the h a n d i l l u strat i o n : schematic d ra w i n g of
sive extension, and decreased sensation. Reduced skin tem­
the vascu l a r s u p p l y of the h a n d , d e m o n strati n g the u l n a r a rtery as
perature, pallor, and pulselessness are often late findings. it passes G uyo n 's ca n a l and becomes the superfi c i a l pa l m a r a rch,
The intrinsic compartments are tested for pain with pas­ ra d i a l a rtery as it becomes the deep pa l m a r a rch, the co m m o n
sive adduction and abduction of the fingers. The thenar d i g ita l a rteri es, a n d the proper d i g ita l a rteries.
compartment is tested by adduction of the thumb. The
adductor of the thumb is tested by passive palmar abduc­
tion. The hypothenar compartment is tested by adduction completed by the superior branch of the ulnar artery, the
of the small finger. inferior branch of the ulnar artery, or both in about 97% of
Normal intracompartment pressures are less than patients.
1 0 mmHg; between 10 and 20 mmHg is considered high • The main branches from the superficial palmar arch are the
but not enough to cause muscle necrosis. An acute com­ three common digital arteries, which go to the index-middle,
partment syndrome is assumed if the measured interstitial middle-ring, and ring-small finger webspaces, as well as the
tissue pressures are within 30 mmHg of the mean arte­ proper digital artery to the ulnar aspect of the small finger.
rial pressure or 20 mmHg of the diastolic blood pressure.2 Each digit has a dual blood supply from the radial and ulnar
Hand pressures are typically difficult to assess on the basis proper digital vessels.
of direct measurement, given the extensive septation of • The thumb has blood supply from the princeps pollicis
the fascial compartments, underscoring the importance of artery, which variably arises from the radial artery, the deep
clinical diagnosis. When in doubt, it is prudent to proceed palmar, or superficial palmar arch.
with operative fasciotomy. • Catheter-directed, contrast-enhanced, digital subtraction
hand arteriography provides highly detailed anatomic in­
IMAGING AND OTHER DIAGNOSTIC formation and represents the gold standard in vascular im­
STUDIES aging { FIG 2 ) . However, there are risks from this invasive
procedure, which include contrast allergic reaction, vaso­
• As previously mentioned, noninvasive vascular imaging and spasm, contrast-induced nephropathy, thromboembolic
physiologic assessment are essential to establishing the di­ events including digital embolization and stroke, and drug
agnosis of hand and digital ischemia as well as providing a reactions precipitated by intraarterial inj ection of vasoac­
physiologic corollary to subsequent arterial imaging studies tive agents including Priscoline and nitroglycerin. Hence,
obtained to outline the relevant anatomy. Noninvasive test­ catheter-based arteriography is best suited to operative
ing informs and should always precede anatomic imaging planning in patients already determined to need reconstruc­
studies regardless of modality. tive surgery.
• Imaging provides essential identification of normal and
variant arterial anatomy, recognition of the location and
extent of obstructive and aneurysmal disease, and operative
planning.
• The vascular anatomy of the hand includes the ulnar artery,
radial artery, and sometimes a persistent median artery ( 5 %
o f the population). The ulnar and radial arteries anastomose
to form the superficial and deep palmar arches, with the
ulnar artery being the main contributor to the superficial
arch and the radial artery the main contributor to the deep
palmar arch { FIG 1 ) . There is significant variation in the vas­
cular patterns of the superficial and deep palmar arches.
• The superficial palmar arch is completed by either the
branches of the deep palmar arch, radial artery, or median FIG 2 • Hand a n g i ogram: normal hand ang iogram demonstrating
artery in about 8 0 % of patients. The deep palmar arch is com plete superficial a n d deep palmar a rches.
1 896 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

• Magnetic resonance arteriography (MRA) is another op­ attempted first, prior to surgical management.5 Evidence of
tion for imaging that is noninvasive, eliminating risks of gangrene, osteomyelitis, and so forth of the involved digit
radiation, contrast reaction, and vasospasm. However, the may require debridement or digital amputation.
resolution of MRA is not sufficient for detailed surgical • Periarterial sympathectomy in the hand, which involves
planning. stripping the adventitial layers from affected arteries,
• Computed tomographic arteriography ( CTA) is also nonin­ removes sympathetic nerve input to the media and has
vasive, although contrast and (significant) radiation exposure proven effective in promoting distal finger lesion healing in
are required for image acquisition. Similar to MRA imaging, scleroderma patients. In scleroderma specifically, the thick­
the resolution of CTA is typically not sufficient to support ened adventitia apparently contributes to decreased digital
detailed surgical planning. arterial flow. 6•7
• Measuring compartment pressures of the hand can be per­
formed with the Stryker Intra-Compartmental Pressure Positioning
Monitor (Kalamazoo, Michigan), which involves placing the
• Hand surgery is usually performed with the patient in the
device needle perpendicular to the skin and evaluating indi­
supine position. The operated hand is placed on a hand sur­
vidual compartments including sites of maximum swelling
gery table, which is stabilized by two legs. Reconstructive
of the thenar, hypothenar, and interosseous compartments.
surgery may be performed under tourniquet, depending on
The compartment being measured should be at the level of
systemic comorbidities and the adequacy of arterial inflow.
the heart. In an intensive care unit setting, using an arterial
For tourniquet control, the upper arm is well padded with
pressure line connected to a strain gauge, zeroed at the level
Webril (cotton) wrapped circumferentially, and then an 1 8-in
of needle entry into the hand, can also provide rapid and
(or appropriately sized) pneumatic tourniquet is secured
accurate compartmental measurements. A 20-gauge needle
around the upper arm ( FIG 3 ) . Alternatively, depending on
is inserted into the compartment and flushed, with measure­
inflow status, the tourniquet may be placed at the forearm or
ment acquired after the flush bolus has disseminated in the
wrist. Finally, an impervious barrier (3M Steri-Drape 1 000)
compartment and the pressure spike from the flush returns
is placed circumferentially j ust distal to the tourniquet to
to baseline.
prevent see page of the sterile prep solution. The arm/hand
are then sterilely prepped and draped.
SURGICAL MANAGEMENT
• Intraoperatively, the arm is exsanguinated with an elastic ban­
Preoperative Planning dage (Esmarch bandage) wrap and elevation immediately prior
to tourniquet inflation. In adults, the tourniquet is typically in­
• The overall goal is to restore distal blood flow to baseline/
flated to 250 mmHg; in children, it is set 1 00 mmHg above the
maximal levels, given anatomic constraints, available arte­
systolic pressure. The tourniquet inflation should last no more
rial conduit, central arterial perfusion pressure and cardiac
output, and end-organ (hand) viability.
• Treatment of thromboembolic disease can include medical
management and catheter-based chemical and mechanical
thrombolysis, angioplasty, and scenting to maximize arte­
riolar outflow and arterial inflow, respectively. Upper ex­
tremity revascularization techniques are discussed in Part 6,
Chapter 1 0 .
• End-to-end primary vascular repair can be performed i f ar­
teries are tension free after mobilization, and the zone of
inj ury is accurately identified to be uninvolved in the site of
anastomosis. If there is any difficulty in approximating the
vessels ends, then vascular grafts are preferred.
• In ulnar or radial artery thrombosis, reconstruction is pre­
ferred over ligation. Proximal reconstructions are attempted
even in the setting of more distal occlusions, based on the
rationale of augmenting collateral flow via direct or indirect
means. 3
• Determining venous or arterial graft harvest site is impor­
tant for preoperative planning. Dorsal hand or foot veins
provide the most appropriate size match for intrinsic arter­
ies of the hand (and feet ) . Donor sites for arterial graft con­
duits include the deep inferior epigastric artery, subscapular
artery, thoracodorsal artery, or descending branch of the
lateral femoral circumflex artery. Typically, arterial grafts
FIG 3 • Position i n g i l l ustrat i o n : s u p i n e pos1t 1 o n i n g of patient
patency rates are superior to those obtained with venous with a r m being operated o n p l aced out o n hand ta b l e . We bri l
grafts.4 g a u z e is wrapped c i rcu mferent i a l l y a r o u n d the a r m a n d fo l l owed
• For chronic ischemia, medical management including phar­ by to u r n i q u et p l acement. Appropriate to u r n i q u et p ress u re is
macologic treatment with vasodilators, topical nitroglycerin, set. F i n a l ly (not pictu red) a 3 M Ste ri-D rape 1 000 is wrapped
calcium channel blockers, or botulinum toxin should be ci rcu mferent i a l ly.
C h a pt e r 1 1 UPPER EXTREM ITY ARTE RIAL RECONSTRUCTION A N D REVASC U LARIZAT I O N 1 897

than 2 hours and must be deflated for a 20-minute interval padding support of the wrists with stacks of surgical towels),
to allow reperfusion prior to reinflation, if needed. Consider­ and sitting position. Microsurgery instruments should be
ation should be made to establishing systemic anticoagulation available as necessary, depending on the level of revascular­
prior to tourniquet inflation when indicated. ization considered. 9-0 and 1 0-0 sutures are employed for
• Appropriate concurrent sterile prep should be performed on more distal reconstructive procedures and digital reimplan­
graft harvest sites as necessary. tation. For proximal radial and ulnar reconstruction proce­
• Microsurgery prep includes ensuring that the operating scope dures, at or immediately adj acent to the wrist, 2 . 5 X to 3 . 5 X
is working properly and sterilely draped. Positioning is ex­ surgical loupe magnification will provide adequate anatomic
tremely important to reduce surgeon fatigue, which includes resolution and suture placement for operators with normal
ensuring good table height, working height (with appropriate visual acuity.

U LNAR ARTERY RECON STRUCTION Resection of Ulnar Aneurysm

Placement o f Incision • O n ce the deep pa l m a r fascia is i n cised, the a n e u rysm i s


g e n e ra l ly recog n iz a b l e (FIG 48 AND FIG SA) . The a n e u ­
• I d e ntify the u l n a r a rtery a n e u rysm (FIG 4A), a n d i n cise
rysm itse lf may be throm bosed o r tortuous o r e l o n g ated
the skin l o n g itu d i n a l ly over the u l n a r a rtery as it crosses
as a result of c h r o n i c posttra u matic remod e l i n g . M icro­
G uyo n 's ca n a l . Exte nsion across the m i d pa l m a r crease
vasc u l a r c l a m ps a re p l a ced o n the u l n a r a rte ry p roxi m a l
may be n ecessa ry to expose the d ista l u l n a r a rtery as it
a n d d ista l t o the a n e u rys m .
cu rves ra d i a l ly to become the su perfi c i a l p a l m a r a rc h . • Prese rve t h e co m m o n d i g ital a rteries a n d oth e r l a rg e
• The vo l a r carpa l l i g a m e nt, the roof of G uyon's ca n a l , i s
b r a n c h e s d i sta l to the t h ro m bosed seg ment. P l a ce
a conti n u ation of the deep pa l m a r fascia a n d fi bers o f
m i c rovasc u l a r c l a m ps a n d vessel loops as needed on ves­
the flexor carpi u l n a r i s a n d m ust be ca refu l ly i ncised f o r
sels that w i l l req u i re revasc u l a rizat i o n .
access to the u l n a r a rtery a n d n e rve. • Resect the affected a rtery a n d trim the ends sharply.
• The u l n a r n e rve, p a rticu l a rly the motor branch, m ust be • The adventitia is excised as needed, and the intima i nspected
ca refu l l y p rotected .
at the proxi mal and d ista l end of the a nastomoses to ensure

c D
FIG 4 • U l n a r a rtery reco nstruct i o n : A. H a n d a n g i o g r a m d e m o n strat i n g a l a rge u l n a r a rtery a n e u rysm i n G uyon's
ca n a l . B. U l n a r a n e u rysm seg m e nt is isolated p roxi m a l ly a n d d ista l ly. C. A d i rect e n d -to-en d a n a stom oses was
performed. D. In a n other patie nt, a long ve i n g raft i s used to exte n d from a m o re proxi m a l u l n a r a rte ry.
1 898 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

that the entire disease seg ment is removed . Fa i l u re to A B


remove the enti rety of diseased a rtery may precipitate early
g raft throm bosis and recu rrent d i g ita l embol ization.

Vein Graft Interposition

• Occasi o n a l ly, suffi cient red u n d a ncy is p resent i n the u l n a r


a rtery t o a l l ow d i rect p r i m a ry repa i r (FIG 4C); i n m ost
cases, i nterposition ve i n g raft i n g (FIG 40) is req u i red to
co m p l ete the reco nstruction without tensi o n .
• When the s u p erfi c i a l pa l m a r a rch a n d adjacent common
d i g ita l a rteries a re i nvolved, then a m o re co m p l ex
" p a l m a r a rc h " reconstruct i o n may be necessa ry to restore
Interposition
perfus i o n to the dependant d i g its (FIG 58), with end-to­ Throo>bosed
Vein Graft
Segment
side a n astomoses of the c o m m o n d i g ital a rteries i nto the
d ista l extent of the ve i n g raft. FIG 5 • U l n a r a rtery reco nstruction i l l ustrat i o n . Exploration
of the u l n a r a rtery co nfirms f i n d i ngs of a n g iogram
• Ve i n h a rvest is typica l ly chosen from the h a n d a n d foot
d e m o nstrat i n g (A) u l n a r a rte ry throm bosis to the orig i n of the
ve i n s . Length of ve i n ha rvest s h o u l d be several centime­
common d i g ita l a rteries. Reconstruction req u i res h a rvest i n g a
te rs longer to a l l ow for tri m m i n g . Y branch of a saphenous ve i n g raft, whi c h is then reversed
• M a r k i n g t h e s u p erfi c i a l su rface o f t h e ve i n h e l p s avoid pri or to i nterposit i o n . B. E n d -to-side d ista l a n a stomosis, end­
twist i n g o r k i n k i n g of the ve i n g raft. M a r k i n g o n e end to-e n d a n asto mosis of the ve i n branch to the co m m o n d i g ital
(typica l l y d i stal) p rovi d es a re m i n d e r to reverse the g raft a rte ry, a n d end-to-s ide a n a stomosis to c o m m o n d i g ital a rtery
p rior to i m p l a ntati o n . If needed, ends with valves a re ex­ a re performed.
cised . Arte r i a l g raft may a lso be used when ava i l a b l e a n d
o f suitable d i a meter a n d length.
• Longer g rafts may a lso be used (FIG 40) when m o re
proxi m a l a rte r i a l i nflow is req u i re d . • After i rrigation with h e p a r i n ized s a l i ne, i nterru pted
• M i c rovasc u l a r a n asto m osis of vessel g raft. sutu res a re p l a ced c i rcu mferenti a l ly u s i n g a t r i a n g u ­
• Anastomosis co m p l et i o n may req u i re m i crosu rgical lation tech n i q u e .
tec h n i q ue, g iven that com m o n d i g ital a rteries may • The p rox i m a l a n asto mosis is pe rfo rmed fi rst, then
be 1 to 2 m m i n d i a m eter. flushed with hepa r i n and c l a m ped to a l l ow the ve i n
• Both ends of the vessels a re held in pl ace by an appro­ g raft to exte n d t o l e n gth before prepa r i n g a n d
priately tensioned microvascu l ar doub le-armed clamp. co m p l et i n g the d i sta l a n a stom os(e)s.

S N U FFBOX RADIAL runs betwee n the fi rst and t h i rd extensor co m p a rtments


(extensor p o l l icis l o n g us) in the a rea known as the " a n a ­
ARTERY RECON STRUCTI O N
tomic sn uffbox. " The d i seased seg ment a n d d i sta l targets
Placement o f Incision shou l d be confi rmed by refe rence to the specific p reoper­
ative i m a g i n g stu d i es (FIG 6A, B) . A s k i n i ncision is m a d e
• At the level of wrist, the ra d i a l a rte ry turns d o rsa l l y u n ­ o n the d o rs u m of the h a n d d i rectly o v e r the a n ato m i c
d e rneath t h e fi rst extensor c o m p a rtment (conta i n i n g t h e snuffbox p a ra l l e l to the seco n d m etaca rpal (FIG 7A) .
a b d ucto r p o l l icis l o n g u s a n d exte nsor p o l l icis b revis), then • T h e su perfi c i a l ra d i a l n e rve is i d e ntified a n d preserved .

B
6 • S n uffbox ra d i a l a rtery reco nstruction a n g i o g rams: A.B. Angiograms d e m o nstrating cutoff of
ra d i a l a rtery (arrow d e m o n strates fi l l i n g d efect correspo n d i n g to occ l u d e d segment) at the level of the
a n atomic sn uffbox.
C h a pt e r 1 1 UPPER EXTREM ITY ARTE RIAL RECONSTRUCTION A N D REVASC U LARIZAT I O N 1 899

A
B

FIG 7 • S n u ffbox rad i a l a rtery reco nstruct i o n : A.


I n c i s i o n over the ra d i a l a rtery over the a n ato m i c
sn uffbox w i t h m i cro backgro u n d p l aced u n d e r
a rtery. B. Rad i a l a rtery is c l a m ped d i sta l ly. C. Vesse l
is c l a m ped proxi m a l ly a n d isol ated w i t h vessel loops
c p r i o r to ve i n g raft i n g .

Resection/Bypass of Diseased Segment Vein Graft Interposition

• This d i ssection is conti n u e d d i sta l ly betwee n the heads of • The ve i n g raft s h o u l d be reversed a n d p l aced s u p e rfi c i a l
the fi rst d o rsa l i nterosseous m uscle, a l lowi n g f u rther mo­ to the exte nsor p o l l icis l o n g u s a n d exte nsor p o l l icis brevis
b i l ization of the d ista l ra d i a l a rtery a n d visua l ization of ( m a k i n g the g raft i m med iately ben eath the skin) a n d
the o r i g i n of the deep p a l m a r a rc h . t h e n sutu red e n d -to-e n d t o the ra d i a l a rtery proxi m a l l y
• M icrovasc u l a r c l a m ps a re p l aced proxi m a l a n d d i sta l t o a n d e n d -to-en d t o t h e d e e p a rch d ista l ly (FIG 7C) . See
the throm bosed seg ment of the ra d i a l a rte ry. the " U l n a r Artery Reco n struct i o n " sect i o n for f u rther de­
• A l l branches from the t h ro m bosed seg m e nt s h o u l d be script i o n o n vein ha rvest and m icrovasc u l a r a n a stomosis
l ig ated a n d rem oved e n bloc (FIG 7B) . tech n i q u e .

HAN D FASCIOTOMY
Placement of Incisions

• The 1 0 co m p a rtm ents of the h a n d i n c l u d e the t h e n a r, hy­ """"'


poth e n a r, a d d u ctor, a n d 4 d o rsa l and 3 vo l a r i nterosse i lnlefoeaei

co m p a rtments. Four i n c i s i o n s a re req u i red to release a l l


1 0 compartments.
• The dorsa l a n d vo l a r i nterosseous com p a rtme nts a re de­
co m p ressed with two d o rsa l i n cisions over the i n d ex f i n g e r
a n d r i n g f i n g e r m etaca rpal (FIG SA) . These i ncisions a re
carried down to either side of the m etaca rpal to release a

the d o rsa l i nterosse i . D i ssection along the u l n a r and rad i a l


aspects o f t h e i n dex metaca rpal m ust be suffi ciently deep
(FIG SC) to release the fi rst d o rsal p a l m a r i nterosseous
and the a d d u ctor com p a rtments. S i m i l a rly, to release the
rema i n i n g p a l m a r i nterosse i, deep d i ssection is req u i red
a l o n g the u l n a r and rad i a l aspects of the ring m etaca rpa l .
M eti c u l o u s release a l o n g t h e length o f t h e metaca rpal i s
FIG S • H a n d fasciotomy i l l u strat i o n : fasciotomy i n c i s i o n s of
the h a n d . A. Dorsa l i n c i s i o n s over the i n dex (c) a n d r i n g (b)
essential t o e n s u re adequate deco m p ress i o n .
f i n g e r metaca r pa l . B. Vo l a r i n c i s i o n s over the hypoth e n a r (d)
• The t h e n a r co m p a rtment is b o u n d by t h e n a r fasc i a a n d
a n d t h e n a r (a) m u scles. C. Cross sect i o n at the level of the
conta i n s the a b d u ctor pol l icis b revis, flexor p o l l icis b revis, m etaca rpals of the hand d e m o n strat i n g that both d o rs a l and
and the opponens pol l icis. This co m p a rtment is decom­ i nte rosseo u s co m p a rtments a n d the a d d ucto r com p a rtment
p ressed with a l o n g itu d i n a l i n c i s i o n along the ra d i a l/ to the thumb can be released t h ro u g h these four i n cisions
vo l a r (FIG SA) aspect of the t h u m b metaca r pa l . with a p p ropri ate d i rection a n d d e pth as o ut l i ned (a-d) .
1 900 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

• The hypot h e n a r c o m p a rtment is b o u n d by the hypothe- • A l o n g itud i n a l pa l m a r i n c i s i o n is m a d e j ust d i sta l to the


n a r fasc ia a n d conta i n s the a b d u ctor d i g iti m i n i m i , flexor vo l a r wrist crease a n d exte n d i n g d i sta l ly for 3 to 4 em in
d i g iti m i n i m i , and opponens d i g iti m i n i m i . This c o m p a rt­ the p rox i m a l p a l m a l o n g the cou rse of the rad i a l aspect
m e nt is deco m p ressed with a l o n g itud i n a l i n cision a l o n g of the r i n g f i n g e r.
the u l n a r/vo l a r (FIG 88) aspect of the sm a l l m etaca rpa l . • The p a l m a ris fasci a is d ivided l o n g itu d i n a l ly to expose
• The finger ca n a lso have com p a rtment syn d rome if there the u n d e r l y i n g tra nsve rse carpal l i g a m e nt, whi c h is then
is excessive swe l l i ng a n d depend i n g on c l i n ical assessment. i ncised u n d e r d i rect visu a l izatio n .
H e re, the fasc i a l com p a rtments a re bound by C l e l a n d 's and • The i n ci si on is exte nded at least 2 em i nto the forearm to
G rayson 's l i g a m ents. The finger fasciotomy is performed e n s u re release of the deep a ntebrach i a l fasc i a .
by m a k i n g m idaxial i ncisions along the u l n a r aspect of • The carpa l t u n n e l release i n cision is cl osed p r i m a r i l y with
the i n d ex, ring, and long fingers and o n the rad i a l aspects i nterru pted nylon sutu res.
of the t h u m b a n d s m a l l finger. O nce i n cisions a re made,
b l u nt d issection is cont i n ued through C l e l a nd 's l i ga m ent Wound Care
(fi rm fascia bands that r u n from side of the p h a l a n ges • Fasciotomy wounds a re left open for a m i n i m u m of
to the skin and a re d o rsa l to the neu rovascu l a r b u n d le), 48 h o u rs o r u nt i l swe l l i n g has resolved .
retract i n g the n e u rovasc u l a r b u n d l es i n a vo l a r d i rection • Seco n d a ry closure with wet-to-d ry d ress i n g s may occ u r
a n d re m a i n i n g vo l a r to the flexor tendon sheath. over open i ncisions.
• Event u a l ly, these wo u n d s may need spl it-thickness s k i n
Carpal Tunnel Release
g raft i n g .
• If a n y compartment press u re is e l evated in the h a n d , • The h a n d s h o u l d be s p l i nted i n a safe position (70 to
then a l l c o m p a rtme nts s h o u l d be rel eased i n c l u d i n g t h e 90 deg rees of m etaca rpo p h a l a n g e a l [ M C P] flexion a n d
carpa l t u n n e l . p roxi m a l i nte rpha l a n g e a l [ P I P] j o i nts stra i g ht) .

PEARLS AND PITFALLS


• Alth o u g h a throm bosed u l n a r a rtery ca n be l i g ated, reco nstruction of the u l n a r a rtery can reconstitute n o r m a l flow a n d s h o u l d
be atte m pted .
• H a n d vasc u l a r repa i r a n d g raft i n g req u i res meticu l ous m icrovascu l a r tech n i q u e .
• T h e d o rsal s i d es of t h e h a n d a n d foot have ve i n s of s i m i l a r s i z e t h a t a re i d e a l f o r ve i n g raft reco nstruct i o n .
• Periarte r i a l sym path ecto my is p a rticu l a r l y effective i n scleroderma because the vessels a re encased i n adventit i a l sca rri n g .
• E a r l y d i a g nosis a n d treatment f o r h a n d c o m p a rtment syn d ro m e i s critica l : W h e n i n d o u bt, release a l l compartme nts.

POSTOPERATIVE CARE
• Postoperative monitoring of the hand after vascular re­
construction is similar to finger replantations and can be
performed with pencil Doppler monitoring or with pulse
oximetry ( FIG 9) .
• Aspirin 8 1 m g i s given for 6 weeks postoperatively after
vessel reconstruction.
• For periarterial sympathectomy, immediate digital range of
motion is encouraged, and cold temperature and vasocon­
strictive drugs or substances (smoking, caffeine, etc . ) are
avoided for at least 6 weeks.
• For compartment syndrome, aggressive strengthening and
range of motion should be started once wounds have stabilized.

OUTCOMES
• Radial artery reconstruction patency in a study of 1 3 patients
found that all vein grafts were patent after mean follow-up
of 22 months, with a significant decrease in pain; however, FIG 9 • H a n d postope rative m o n itori n g : Revasc u l a rizat i o n of
no difference in numbness was seen. 3 In another study of d i g its can be m o n itored with basic p u lse oxi m etry at the tip of
145 patients, an overall patency of vein grafts of 8 5 % over the d i g its.
C h a pt e r 1 1 UPPER EXTREM ITY ARTE RIAL RECON STRUCTI O N A N D REVASCULARIZAT I O N 1 90 1

a n average follow-up period o f 34 months was found a s well • Stiffness of the fingers
as 1 0 0 % with arterial grafts.4 • Continued ischemia, pain, and ulcerations
• Long-term recovery after compartment syndrome release
depends on the extent of inj ury and requires long-term hand REFERENCES
therapy for recovery of hand function. Compartment release
1. Pomahac B, Hagan R, Blazar P, et al. Spontaneous thrombosis of the ra­
of the hand can result in normal function; however, contrac­ dial artery at the wrist level. Plast Reconstr Surg. 2004;1 14(4):943-946.
tures can develop, which may need eventual reoperation for 2. Leversedge FJ, Moore TJ, Peterson BC, et al. Compartment syndrome
contracture release. of the upper extremity. J Hand Surg Am. 20 1 1 ;3 6 ( 3 ) :544-559.
3 . Ruch DS, Aldridge M, Holden M, et al. Arterial reconstruction for
COMPLICATIONS radial artery occlusion. J Hand Surg Am. 2000;25 (2):2 82-290.
4. Masden DL, Seruya M, Higgins JP. A systematic review of the out­
• Infection comes of distal upper extremity bypass surgery with arterial and
• Dehiscence of incisions and other wound healing complica- venous conduits. J Hand Surg Am. 2012;37( 1 1 ) :23 62-2367.
5 . Porter SB, Murray PM. Raynaud phenomenon. J Hand Surg Am.
tions
2 0 1 3 ; 3 8 ( 2 ) : 3 75-3 77. doi: 1 0 . 1 0 1 6/j .jhsa.20 1 2 . 0 8 . 0 3 5 .
• Failure of revascularization
6. Hartzell T L , Makhni E C , Sampson C. Long-term results of periarterial
• Distal emboli sympathectomy. J Hand Surg Am. 2009;34 ( 8 ) : 1454-1460.
• Thrombosis at anastomosis 7. Bogoch ER, Gross DK. Surgery of the hand in patients with systemic scle­
• Long-term patency rosis: outcomes and considerations. J Rheumatol. 2005;32(4):642-648 .
-

Chapter 12 Exposure and Open Surgical


Reconstruction in the Chest:
' The Thoracoabdominal Aorta
'
------------------------------------ � ---------------------------------------------------- ·
Germ a n o Melissa n o Efrem Civilini Enrico Rina ldi
Roberto Chiesa

DEFINITION data in particular has benefited from spectacular progress,


including multirow detectors, higher rotation and transla­
• A thoracoabdominal aortic aneurysm (TAAA) involves the tion speeds with reduced scan times (single breath-hold),
aorta at the diaphragmatic crura and extends variable dis­ cardiac cycle synchronization, and better postprocessing
tances proximally and/or distally from this point ( FIG 1 ) . 1 capabilities.
TAAAs can be classified in terms of their causes, the two • D igital Imaging and Communications in Medicine
most common being medial degeneration and dissection. (DICOM) slices of adequate thickness (s::l mm) should
• Open treatment of TAAAs consists of graft replacement with be postprocessed on a digital workstation using a multi­
reattachment of the main aortic branches: The inclusion tech­ planar reformatting (MPR) tool to visualize a scan which
nique was introduced by S. E. Crawford in the 70s and refined angulation matches that of the aorta or the vessel under
by subsequent surgeons in the following decades. TAAA re­ investigation. Postprocessing may be performed on a
pair, especially in extensive aortic disease, is associated with dedicated workstation (AquariusNet®, TeraRecon, Inc)
greater operative risk than repair of other aortic segments. The or desktop computer with open source software ( O siriX
main sources of morbidity are spinal cord (SC) ischemia and and others ) in a user-friendly and time/resources-efficient
renal as well as respiratory and cardiac complications. way ( FIG 2 ) .
• Experienced surgical centers now report lower mortality and • Beyond analysis o f aortic diameter and the extent o f patho­
morbidity rates for TAAA repair,2 largely due to multimodal logic involvement, reformatted images are particularly
approaches to reduce surgical trauma and maximize organ useful for evaluating the presence, extension, and charac­
protection. 3 teristics of dissection and thrombus, particularly at pro­
posed sites of clamp placement and the infradiaphragmatic
IMAGING AND OTHER DIAGNOSTIC aorta when direct aneurysm cannulation is considered for
STUDIES distal aortic perfusion. The exact location and geometry

of aortic branches is obtained to reveal possible anatomic
To plan the best possible treatment strategy for each patient,
variations or anomalies, which are particularly common
our preferred modality is computed tomographic arteriogra­
at the level of the renal arteries and arch vessels. Vessel
phy ( CTA ) . The acquisition of computed tomography ( CT)
patency is also routinely evaluated; in particular, obstruc­
tion of the superior and inferior mesenteric artery and the
hypogastric arteries and dominance of one vertebral artery
are assessed.
• Three-dimensional rendering tools such as maximum inten­
sity projection (MIP ) , volume rendering, surface rendering,
and so forth produce realistic imaging of the anatomic struc­
tures that may expand anatomic understanding, including,
for instance, the most appropriate intercostal space to per­
form thoracotomy ( FIG 3 ) .
• Perioperative SC ischemia may precipitate paraparesis or
paraplegia. Prior knowledge of the SC arterial supply in­
forms both procedural planning and risk stratification.

FIG 1 • An a n e u rysm is defi ned as thoracoabd o m i n a l when


the h i g h l i g hted reg i o n i s i nvolved . Crawfo rd's cl assificati o n was
deve loped to i m p rove stratification of perio perative p a ra p l e g i a
r i s k . S u bcl assificat i o n s i n c l u d e the fo l l ow i n g : Exte nt I i n c l udes
the t h o racic and a bdom i n a l a o rta, from the l eft subclavian a rtery
to the level of the r e n a l a rteries; extent I I i n c l udes the enti re
desce n d i n g a o rta from the level of the l eft subclavian a rtery to
t h e a o rtic bifu rcation; extent I l l i n c l udes a o rta beg i n n i n g at the FIG 2 • M P R tools a l l ow the sag itta l reco nstruction to properly
T6 level exte n d i n g to the bifurcat i o n o r l ower; extent IV i n c l udes fo l l ow the major axis of the t h o racic a o rta. I n this refo rmatted
t h e enti re abdom i n a l a o rta sta rt i n g at the level of the d i a p h ra g m i m a ge, the e n t i re t h o racic a o rta is i n c l uded despite s i g n ificant
(T 1 2) to the a o rtic bifu rcati o n o r lower. tortuosity.
1902
C h a p t e r 1 2 EXPO S U R E A N D OPEN S U R G I CAL RECON STRUCT I O N I N T H E C H E S T 1 903

FIG 5 • O n ce t h e d u ra h a s b e e n p u nctured w i t h t h e i ntrod u c e r


n e e d l e , a d r a i n a g e c a t h e t e r i s i n se rted 8 to 1 0 e m a l o n g t h e
i nt ra d u ra l s p a c e . T h e catheter i s t h e n co n n ected to a press u re
FIG 3 • B e y o n d a o rtic i m a g i ng, the C T provides extensive t r a n s d u c e r, a n d t h e fl u i d is d r a i n e d to keep t h e p ressure
a n ato m i c information to g u i d e exposu re and surgical decision b e l ow 10 e m H 2 0. Autom ated syste m s a re a va i l a b l e for t h i s
making. p u rpose.

Recent advances i n imaging techniques, especially nonin­ Pulmonary function evaluation with arterial blood gases
vasive techniques, increased the likelihood that patient­ and spirometry is used to evaluate the respiratory reserve
specific risk criteria may soon be recognized and be widely of all patients undergoing open surgery of the descend­
available4 ( FIG 4). ing aorta. In patients with a forced expiratory volume in
1 second ( FEV ) of less than 1 L and a partial pressure
1
of carbon dioxide (PC0 ) greater than 45 mmHg, opera­
SURGICAL MANAGEMENT 2
tive risk may be improved by cessation of cigarette smok­
Preoperative Workup and Patient Optimization ing, treatment of chronic bronchitis (if present) , weight
loss, and participation in a supervised exercise program
• Preoperative transthoracic echocardiography is a satisfac­
for a period of up to 6 months prior to surgery. How­
tory noninvasive screening method to evaluate both valvular
ever, in patients with aneurysm-related symptoms, this
and biventricular function. Stress testing identifies patients
type of respiratory rehabilitation may not be practical or
who require coronary catheterization and possible interven­
possible.
tion.5 Electrocardiographically (EKG) gated CT has recently
emerged as a less invasive method of visualizing coronary
Positioning
anatomy. For severe, symptomatic coronary disease requir­
ing percutaneous transluminal angioplasty prior to aneu­ • After inserting a cerebrospinal fluid drainage ( CSFD ) 8 cath­
rysm repair, use of drug-eluting stems requiring prolonged eter into the subarachnoid space between L2 and L3 or L3
double antiplatelet therapy should be avoided to reduce sub­ and L4 ( FIG 5), the patient is turned to a right lateral decu­
sequent perioperative bleeding. bitus position, with the shoulders at 60 degrees and the hips
• The use of estimated glomerular filtration rate (eGFR) , flexed back to 30 degrees.
rather than serum creatinine levels alone, is recommended • Preparation should allow for access to the entire left tho­
to assess renal function. 6 Based on the eGFR metric, chronic rax, abdomen, and both inguinal regions. Patient position
kidney disease has been shown to be a strong predictor of is maintained with a moldable beanbag attached to a suc­
death following open or endovascular thoracic aneurysm re­ tion line for vacuum creation. A circulating water mattress
pair, even in patients without other clinical evidence of pre­ is placed between the beanbag and the patient in order to
operative renal disease? modify body temperature as necessary ( FIG 6 ) .

FIG 6 • Pre p p i n g a n d d r a p i n g for TAAA. Poste rol atera l a spect of


FIG 4 • U s i n g a custo m ized c u rve p l a n , the w h o l e path of the the l eft t h o rax, the a bd o m e n , a n d l eft g r o i n a re i n c l uded in the
a rteri a l feeder to the spi n a l cord (a rte ria ra d i c u l a ris m a g na) can ste r i l e ope rato ry f i e l d . P l ease n ote the gentle cu rvatu re of the
be visu a l i zed from the a o rta to the a nterior spi n a l a rte ry. line i n d icat i n g the s k i n i n c i s i o n to avoid f l a p necrosis.
1 904 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

THORACO-PHRENO-LAPAROTOMY
• The thoracic i n c i s i o n varies i n l e n gt h a n d l eve l , d e p e n d ­
i n g o n exposure req u i re m e nts. U s u a l ly, t h e 5 t h , 6 t h , o r
7 t h i nte rcost a l space is e m p l oyed accord i n g to t h e a n e u ­
rysm a n atomy. The poste r i o r sect i o n of t h e r i b s i s gently
s p read to reduce thoracic wa l l t r a u m a a n d fractu res;
a nterol atera l ly, the i n c i s i o n c u rves gently as it crosses
the cost a l m a r g i n to m i n i m i ze su bse q u e n t tissue n ecro­
sis. The p l e u r a l space i s e ntered after s i n g l e r i g ht l u n g
venti l a t i o n i s i n itiate d . M o n o p u l m o n a ry vent i l at i o n
i s m a i nta i n ed t h ro u g h o ut t h o r a c i c a o rta r e p l a c e m e n t
(FIG 7) .
• P a r a lysis of t h e l eft h e m i d i a p h ra g m cont r i b utes s i g n ifi­ FIG 8 • The d i a p h r a g m is ci rcumferentia l ly d ivided (arrows)
cantly to posto pe rative res p i ratory fa i l u re; t h e refore, for seve ral ce ntimeters n e a r its p e r i p h e r a l atta c h m ent to the
a l i m ited c i rc u mfere n t i a l rather t h a n rad i a l sect i o n a nterior ch est wa l l sparing the p h r e n i c center (asterisk).
of t h e d i a p h ra g m i s routi n e l y p e rformed, s p a r i n g
t h e p h re n i c center. U n d e r favora b l e a n a to m i c co n d i ­
t i o n s, t h i s a p p ro a c h reduces res p i ratory wea n i n g t i m e 9
(FIG 8) .
• Speci a l ca re m ust be taken when iso l a t i n g the p roxi m a l
a n e u rysm n e c k . The i nsertion o f a l a rg e ca l i be r eso p h ­
agea l p robe m a kes it easier to d i sti n g u is h the eso p h a ­
g u s at t h i s leve l . The va g u s n e rve a n d the o r i g i n of the
recu rrent l a ry n g e a l n e rve m ust a l so be identified because
they can a lso be damaged d u r i n g isolation and c l a m p i n g
m a n euvers (FIG 9) . I d e ntification a n d c l i p p i n g o f some
" h i g h " i ntercosta l a rteries can sometimes fac i l itate t h e
prepa rati o n for the proxi m a l a n asto mosis, t h u s red u c i n g
a o rtic bleed i n g .
• T h e u p pe r a b d o m i n a l a o rt i c seg m e n t is exposed v i a a
t r a n s pe rito n e a l a p p ro a c h ; after e n te r i n g t h e p e r i to­
FIG 9 • The va g u s n e rve (bla ck a rro w) a n d the ongm of
n e u m , m e d i a l vi scera l rotat i o n i s p e rformed to retract the recu rrent l a ry n g e a l n e rve a re m o b i l ized a n d i d e ntified
t h e l eft c o l o n , s p l e e n , a n d l eft k i d ney a nt e r i o r l y a n d to with vessel loops to p revent i nj u ry d u r i n g a o rt i c c l a m p i n g
t h e right (FIG 1 0) . Use of a t r a n s p e r i to n e a l a p p r o a c h m a n euvers o r suture p l acement. When a n a o rtic cross­
a l l ows d i rect assess m e n t of t h e a b d o m i n a l o r g a n s c l a m p i n g between l eft carotid and subclavian a rtery is
at t h e e n d of p roced u re . Extra c a r e m u st be t a k e n req u i red, these vesse l s a re a l so i d e ntified and contro l led with
to avo i d d a m a g e to t h e s p l e e n , w h i c h i s p a rt i c u l a r l y vesse l loops (white arrows).
p r o n e to b l e ed i n g aft e r c a p s u l a r i n j u r i e s reg a r d l ess
of s i z e .

FIG 10 • M ed i a l viscera l rotat i o n : The left colon, the s p l een,


a n d t h e l eft kid ney a re retracted a nteriorly a n d to the r i g h t
FIG 7 • Thoraco-p h re n o - l a p a rotomy i n the 6 t h i ntercosta l to v i s u a l ize the viscera l a n d i nfra renal a o rta. Tra nsperito n e a l
space. A ci rcumferent i a l i ncision of the d i a p h ra g m is carried a p proach a l l ows d i rect eva l u at i o n of the a b d o m i n a l o rg a n s
out (d otted l i ne). t h rou g h out the p roced u re .
C h a p t e r 1 2 EXPO S U R E A N D OPEN S U R G I CAL RECON STRUCT I O N I N T H E C H E S T 1 90 5

DISTAL AORTIC PERFUSION


• Cross-c l a m p i n g of the desce n d i n g thoracic a o rta pro­
d u ces i m med iate and s i g n ificant i n c reases in left ven­
tricu l a r afterload, myocard i a l oxygen co nsu m ption, a n d
viscera l a n d r e n a l isch e m i a . Tec h n i q ues i n co rporat i n g d is­
ta l a o rtic perfus i o n with l eft h e a rt bypass (LH B P) have s i g ­
n ificantly i m p roved outcomes i n t h o r a c i c a o rt i c s u rg e ry. 1 0
I n preparation for L H B P a n d a o rtic cross-cl a m p i n g , l ow­
dose i ntrave n o u s h e p a r i n is a d m i n istered. If cessati o n of
p u m p s u p port i s a ntici pated d u ri n g the case, a d d i t i o n a l
h e p a r i n s h o u l d be a d m i n istered at that t i m e to p rovide
fu l l a nticoa g u lati o n .
• The u p p e r l eft p u l m o n a ry ve i n is usua l ly ca n n u l ated for
i nflow of oxyg e n ated b l ood, w h i c h i s routed t h r o u g h a
centrifu g a l p u m p ( B i o - M e d icus®) i nto the l eft fe moral
a rtery (FIG 1 1 ) . A " Y " c o n nector i n c l uded i n the c i rc u i t
provides t w o occl usion/perfusion catheters (9 F r) for
sel ective viscera l perfu s i o n when necessa ry.

FIG 11 • S c h e m a t i c view of d ista l a o rtic perfu s i o n . A 20-Fr


ca n n u l a is i n serted i n l eft s u pe r i o r p u l m o n a ry ve i n fo r the
a rte r i a l b l ood drainage (up) . N o n occlusive fem o r a l ca n n u l a
(1 4 t o 1 8 F r) a l l ows synchronous p roxi m a l a n d d ista l perfus i o n
f r o m the fe moral axis (down).

AORTIC REPAIR
• Once the neck of the TAAA is isolated and control led be­
tween clam ps, the descending thoracic aorta is tra nsected
and sepa rated from the esophagus (FIG 1 2). The g raft is su­
tu red proxi m a l ly to the descending thoracic aorta using 2-0
polypropylene sutu re in a r u n n i n g fashion. The a nastomosis
is rei nforced with Teflon felt (individual pledgets or single
strip) (FIG 1 3). An additional aortic clamp is appl ied onto
the abdom i n a l aorta above the celiac axis before the proxi­
mal aortic c l a m p is rem oved (seq uential cross-c l a m p i ng).
• I ntercostal a rtery re i m p l a ntation i nto the aortic g raft p l ays
a critica l role in SC p rotect i o n . Patent i ntercosta l a rteries
from T7 to L2 a re temporarily occluded to p reve nt back­
bleed i n g/max i m ize cord perfusion p ress u re 1 1 then sel ec­
tively reattached to the g raft by means of aortic patch or
FIG 13 • The p roxi m a l a n astomosis routi n e l y rei nforced with
g raft i nterposition (FIG 14). When ready, the d i stal c l a m p a Tef l o n str i p .

FIG 14 • Critica l i ntercosta l a rteries reatta c h m e nt . H e re


visua l i zed a re two d iffe rent tec h n i q ues: On the left, an aortic
i s l a n d i n c l u d i n g t h e orig i n of seve ral i ntercosta l a rteries is
FIG 1 2 • The p roxi m a l desce n d i n g t h o r a c i c a o rta is contro l led reattached to a fen estrati o n created o n the a o rtic g raft; o n
a n d co m p l etely tra n sected to avo i d accidenta l i n j u ry to the the right, i n te rcosta l a rteries a re reattached sel ectively to t h e
adjacent eso p h a g u s . g raft via 6/8-m m i nterpos ition g rafts.
1 906 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 1 7 • A mod ified tech n i q u e to s e p a rate ly reatta ch


t h e l eft re n a l a rt e ry i s deta i l ed h e r e : T h e use of a hybrid
t u b e g raft t h a t i n c l u d e s a s e l f-expa n d a b l e covered ste n t
a l lows for a s u t u r e l ess a n a st o m o s i s . T h e a d v a n t a g e s a re t h e
FIG 1 5 • Visce ral a rteries perfusion with b l ood, renal red uced isc h e m i a t i m e of t h e k i d n ey a n d k i n k p reve n t i o n o f
perfus i o n with co ld Custod i a l ® solution during branch a rtery t h e g raft after v i scera l d e rotat i o n at t h e e n d of t h e a o rt i c
re i m p l a ntat i o n . repa i r.

is m oved below t h e ren a l a rteri es, a n d t h e a n e u rysm is


opened across the d i a p h ra g m . The centrifu g a l p u m p
m a i nta ins visce ral perfusion (400 m l p e r m i n ute) fo l l ow­
i n g i n se rtion of the 9-Fr i rrigation-pe rfusion cath eters
(Le M a itre Vasc u l a r) i nto the ce l i a c tru n k and the superior
mesenteric a rtery. Cold perfusion of Custod iol1 2 (histid i ne­
tryptophane-ketogl uta rate) is d i rected i nto the ren a l
a rteries (FIG 1 5) . F o r visce ral a rtery re i m p l a ntation, a fen­
estration is created i n the g raft and the viscera l vessels a re
reattached as a s i n g l e patc h . Usual ly, the left ren a l a rtery
is reco n nected with an 8-mm polyester i nterposition g raft.
If viscera l a rtery orifi c i a l stenosis is encou ntered, before
placing the i rrigation perfusion catheter, the stenosis may
FIG 1 8 • Visce ral vessels a n d ren a l a rteries a re reattached
be resolved by d i rect p l acement of an a ppropriate-sized
sepa rate ly i n this patient with M a rfan syn d ro m e to red u ce a s
b a l l oo n-expa n d a b l e ste nt with i n the a rtery1 3 (FIGS 16 and m u c h a s poss i b l e the a o rtic native t i s s u e a n d p reve nt recu rrent
1 7). If creation of the viscera l patch req u i res reta i n i n g a a o rtic a n e u rysm format i o n .
l a rge seg ment of n ative aorta, we p refer to p l ace a m u l­
t i b ra nched g raft i nstead. This p rosthesis, although some­
what more time cons u m i ng, s i g n ificantly red uces the risk
of recurrent aortic patch a n e u rysm (FIG 1 8) . F i n a l ly, the
d i sta l end-to-end a n astomosis with the d i stal aorta is per­
formed, the g raft fl ushed, a n d c l a m ps rem oved (FIG 1 9) .

FIG 1 9 • End-to-end d ista l anastomosis at t h e aortic b ifu rcation.

FIG 1 6 • From left t o rig ht. I n case o f orifi c i a l stenosis,


intra l u m i n a l stents a re p l aced under d i rect visu a l ization before
i nsertion of the perfusion catheter and u ltimate re i m p l a ntati o n .
C h a p t e r 1 2 EXPO S U R E A N D OPEN S U R G I CAL RECON STRUCT I O N I N T H E C H E S T 1 907

CLOSURE
• The entire a o rt i c repa i r (FIG 20) is i n s pected . A l l exposed
a o rtic branch p u lses a re p a l pated after derotati o n a n d
re p l acement o f the a b d o m i n a l viscera. A n y bleed i n g o r
k i n k i n g of the a o rtic b r a n c h e s i s add ressed at t h i s j u n c­
t u re . The atri a l a n d fe m o ra l ca n n u lae a re removed; the
pu rse-st r i n g sutu res a re tied a n d rei nforced. Antico­
a g u lation is reversed with p rota m i n e . The crus of the
d i a p h ra g m is rea p p roxi m ated to restore the a o rtic h i a­
tus (FIG 2 1 ) a n d the l eft h e m i d i a p h ra g m loosely sutu red
with a r u n n i n g polypropy l e n e suture. The l eft l u n g is
tempora r i ly i nfl ated to check for a i r leakage.
• A c l osed-suct i o n a b d o m i n a l d r a i n is p l aced n ext to the
a o rtic g raft i n the l eft retro perito n e a l spa ce, a n d two FIG 21 • The p i l l a rs of the d i a p h ra g m (arrows) a re approximated

ch est tu bes a re p l aced in the posteroa pical a n d basal with a bsorba ble sutu res to reshape the aortic hiatus.
pleural space. Absorba b l e pericosta l sutu res a re p l aced
to a p prox i m ate the ribs (FIG 22), and two stee l wi res a re
used to sta b i l i ze the costa l m a rg i n . The l u n g is i nflated,
and the correct expa n s i o n of a l l the segm ents is ca refu l ly
ch ecked; the pericosta l a n d d i a p h ra g matic sutu res a re
tig htened a n d l i gated . The steel wi res a re twisted a n d
bu ried i n the carti l a g i n o u s costa l m a rg i n . T h e a b d o m i ­
n a l fascia is cl osed w i t h a ru n n i n g suture. The a b d o m i n a l
a n d t h o ra c i c d r a i n s a re c o n nected t o suct i o n . T h e serra­
tus and latissi m u s dorsi m u scles a re a p p roxi m ated with
sepa rate a bsorba b l e sutu res. S u b d e r m a l l ayer is sutu red,
and the skin is cl osed with sta ples (FIG 23) .

FIG 22 • The thoracic wa l l i s repai red with pericosta l sutu res.


The l eft l u n g is i nfl ated and checked for a i r leakage; two ch est
tu bes a re positioned to d r a i n the u p p e r a n d lower thoracic
space.

FIG 23 • The a b d o m i n a l a n d thoracic wa l ls a re sutu red; skin


is closed with sta ples.

B
FIG 20 • F i n a l repa i r of a type I I TAAA. A. Sta n d a rd i n c l u s i o n
tec h n i q u e . B. Sel ective rei m p l a ntation w i t h m u ltibranched
g raft.
1 908 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

PEARLS AND PITFALLS


I n d i cations • Aortic d i a m eter a n d a n e u rysm m o r p h o l ogy
• Signs a n d sym ptoms of acute a o rtic syn d ro m e
Preoperative p l a n n i n g • Leve l o f i ntercosta l i n c i s i o n
• G raft sel ection
• I d e ntification of accessory ren a l a rteries a n d other viscera l a n o m a l ies (e . g . , h o rseshoe k i d n ey)
• Pote nti a l need for m u ltibranch g raft vs. Carrel patch
S u r g i c a l access • Avo i d s k i n f l a p necrosis.
• R i b sect i o n
• L i m ited p h re n otomy (circumferent i a l d i a p h ra g matic i n cision)
• Tra nsperito n e a l a p p roach
• Careful a n d l i m ited lung m a n i p u lation
• N o n occlusive fe moral ca n n u l at i o n
Tec h n ical adj u n cts fo r organ • Spinal cord drainage
p rotect i o n • Left h e a rt bypass
• Sequenti a l a o rtic c l a m p i n g
• Critica l i ntercosta l a rtery reattachment
• Viscera l perfus i o n from l eft h e a rt bypass ca n n u las
• Re n a l perfus i o n with cold Custo d i a l ® o r s i m i l a r sol ution
• D i rect stenti n g of ren a l and visce ral orifi c i a l lesions a s needed

POSTOPERATIVE CARE renal replacement therapy may also be necessary in the early
postoperative period.
• The main focus of immediate postoperative management is
the early detection of neurologic or cardiovascular compli­ COMPLICATIONS
cation as prompt intervention may prevent substantial long­
term morbidity. As soon as baseline blood pressure and body • Bleeding
temperature are restored, sedation is lightened regardless of • Multiorgan failure
ventilatory status. When SC or cerebral neurologic inj ury is • Dialysis
suspected, CT imaging is performed immediately to address • Paraplegia
the possibility of intracranial or intradural SC hematoma. • Stroke
In case of paraparesis or paraplegia, mean arterial pressure • Death
is chemically maintained above 80 mmHg, CSFD is drained • Aneurysm recurrence
in order to lower the cerebrospinal fluid pressure below
10 mmHg, and methylprednisolone ( 1 g bolus followed by REFERENCES
4 g per 24 hours continuous infusion) and 1 8 % mannitol 1. Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards
(5 mg/kg, four times a day) are administrated. for reporting on arterial aneurysms. Subcommittee on Reporting
• If malperfusion develops in the lower limbs, renal or visceral Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting
circulation, efforts should be made to restore normal cir­ Standards, Society for Vascular Surgery and North American Chap­
culation immediately. For a precise visualization of visceral ter, International Society for Cardiovascular Surgery. J Vase Surg.
1 9 9 1 ; 1 3 :452-4 5 8 .
organ perfusion, emergency arteriography (catheter-based
2. Coselli J S , Bozinovski J , LeMaire SA. Open surgical repair of 2 2 8 6 thora­
or CT) is required. coabdominal aortic aneurysms. Ann Thorae Surg. 2007;83:S862-S864.
• Blood pressure fluctuations, including recalcitrant hyperten­ 3. MacArthur RG, Carter SA, Coselli JS, et al. Organ protection dur­
sion, is common in the early postoperative period, especially ing thoracoabdominal aortic surgery: rationale for a multimodality
in the chronically hypertensive patient; prompt attention approach. Semin Cardiothorae Vase Anesth . 2005;9: 143-149.
should be paid to regulating the mean arterial pressure in a 4 . Melissano G, Civilini E, Bertoglio L, et al. Angio-CT imaging of the
spinal cord vascularisation: a pictorial essay. Eur J Vase Endovase
physiologic range. Immediate intervention may be required
Surg. 2 0 1 0;39:436-440.
to reduce the risk of anastomotic bleeding, especially in the 5 . Kieffer E, Chiche L, Baron JF, et al. Coronary and carotid artery dis­
setting of dissection. ease in patients with degenerative aneurysm of the descending tho­
• In uncomplicated cases, drainage tubes are removed at 3 6 racic or thoracoabdominal aorta: prevalence and impact on operative
t o 4 8 hours postoperatively, whereas the intrathecal CSFD mortality. Ann Vase Surg. 2002; 1 6 : 679-6 84.
catheter is removed usually after 72 hours. A prolonged re­ 6 . Stevens LA, Coresh ], Greene T, et al. Assessing kidney function­
measured and estimated glomerular filtration rate. N Eng/ J Med.
quirement for ventilatory support is not unusual, especially
2006;354:2473-248 3 .
after emergency operations, in patients with significant blood
7. Mills JL Sr, Duong ST, Leon L R Jr, e t a l . Comparison of the effects
loss and after longer periods of circulatory arrest (if neces­ of open and endovascular aortic aneurysm repair on long-term renal
sary for concurrent arch or ascending aortic reconstruction ) . function using chronic kidney disease staging based on glomerular
I n case o f severe chronic kidney disease, transient temporary filtration rate. J Vase Surg. 2008;47: 1 14 1 - 1 1 4 9 .
C h a p t e r 1 2 EXPO S U R E A N D OPEN S U R G I CAL RECON STRUCT I O N I N T H E C H E S T 1 909

8 . Cina C S , Abouzahr L, Arena G O , e t a l . Cerebrospinal fluid drainage 1 1 . Etz CD, Homann TM, Plestis KA, et al. Spinal cord perfusion after
to prevent paraplegia during thoracic and thoracoabdominal aortic extensive segmental artery sacrifice: can paraplegia be prevented?
aneurysm surgery: a systematic review and meta-analysis. J Vase Surg. Eur J Cardiothorae Surg. 2007;3 1 (4 ) : 643-648 .
2004;40: 3 6-44. 12. Schmitto J D , Fatehpur S, Tezval H , e t a l . Hypothermic renal protec­
9. Engle J, Safi HJ, Miller CC III, et al. The impact of diaphragm manage­ tion using cold histidine-tryptophan-ketoglutarate solution perfusion
ment on prolonged ventilator support after thoracoabdominal aortic in suprarenal aortic surgery. Ann Vase Surg. 2008;22(4 ) :520-524.
repair. J Vase Surg. 1999;29 ( 1 ) : 1 50-1 56. 1 3 . LeMaire SA, Jamison AL, Carter SA, et al. Deployment of balloon
1 0 . Caselli JS. The use of left heart bypass in the repair of thoracoabdomi­ expandable stents during open repair of thoracoabdominal aortic
nal aortic aneurysms: current techniques and results. Semin Thorae aneurysms: a new strategy for managing renal and mesenteric artery
Cardiovase Surg. 2003 ; 1 5 : 326-332. lesions. Eur J Cardiothorae Surg. 2004;26:599-607.
-

Chapter 13 Thoracic Aortic Stent Graft


Repair for Aneurysm, Dissection,
I
and Traumatic Transection
- ----------------------------------- � ----------------------------------------------------- �

Bra n t W Ullery Jason T. Lee

DEFINITION atherosclerosis, and connective tissue diseases. Indica­


tions for repair of descending TAAs are similar to those
• In 1 994, Dake and colleagues/ at Stanford University, were for conventional open repair: maximum aortic diameter
the first to report the use of custom-designed thoracic aortic greater than 6 em, rapid aneurysmal growth ( > 5 mm of
stem grafts for the treatment of descending thoracic aortic growth over 6 months ) , or symptoms such as persistent
aneurysms in patients deemed high risk for conventional chest or back pain, rupture, or dissection. In most patients
open surgery. Each of these devices was deployed through with TAA, the aneurysms were diagnosed following rou­
peripheral arterial access, successfully excluding the aneu­ tine imaging ordered for other reasons and are therefore
rysm from systemic pressurization. This groundbreaking most commonly asymptomatic.
minimally invasive technique thereby avoided many of the • Aortic dissection occurs when an intimal tear in the aorta
physiologic insults associated with open surgery, including causes blood to flow between the layers of the wall of the
the need for thoracotomy, aortic cross-clamping, reperfusion aorta and most often presents as tearing chest pain that
inj ury, and acute hemodynamic changes. radiates to the back. Potential etiologic factors leading to
• Results from the first multicenter U . S . Food and Drug aortic dissection include poorly controlled hypertension,
Administration-sponsored trial for thoracic aortic stem connective tissue disorders, trauma, or vasculitis. Medi­
grafts demonstrated significantly less perioperative mortal­ cal management of uncomplicated type B thoracic aortic
ity, respiratory failure, renal insufficiency, and spinal cord dissection serves as the current standard of care. These
ischemia in patients after thoracic endovascular aortic re­ practice guidelines stem from the results of the INvestiga­
pair (TEVAR) compared to a matched cohort of patients tion of STEm grafts in patients with type B Aortic Dis­
undergoing open descending thoracic aortic aneurysm section (INSTEAD ) trial, the first prospective, multicenter
repair.2 randomized trial comparing optimal medical therapy ( e . g . ,
• After two decades of surgeon experience and endovascu­ b l o o d pressure control) to TEVAR for uncomplicated type
lar technologic advancement, TEVAR has evolved to serve B dissection.3 This trial demonstrated no significant im­
as a primary treatment strategy for an increasingly diverse provement in 2-year survival or adverse event rates with
group of acute and chronic aortic pathologies including TEVAR despite favorable aortic remodeling, although re­
thoracic aortic aneurysms, dissections, and traumatic tran­ cently reported 5-year data suggest improved long-term
sections . survival in patients undergoing TEVAR. In contrast, for
patients with complicated type B dissections involving
DIFFERENTIAL DIAGNOSIS rupture, malperfusion ( e . g . , visceral or limb ischemi a ) , or
• Depending on the type and extent of pathology, TEVAR refractory back pain despite optimal medical management,
may include the use of fenestrated or branched stent TEVAR is indicated. The goal of TEVAR in this setting is
grafts, advanced snorkel/chimney/periscope techniques, to cover, or exclude, the primary entry tear and reexpand
or the need for hybrid debranching procedures . The deci­ the true lumen while promoting thrombosis of the false
sion to treat thoracic aortic pathology with stent grafts lumen.
• Traumatic aortic transection results from a high-velocity or
is based on individual patient comorbidity burden, de­
tailed analysis of thoracic aortic anatomy, and physician deceleration injury to the aorta. The tethering of the aorta
experience. by the ligamentum arteriosum makes this site most suscep­
• Acute thoracic aortic pathologies often present with chest tible to shearing forces during sudden deceleration. A high
pain and therefore must be considered in the workup for index of suspicion is necessary to help make the diagnosis.
acute coronary syndrome. The ubiquitous use of computed Trauma workups most often involve whole-body CT scan­
tomography ( CT) scanning for pain, shortness of breath, ning, which allows rapid triage for possible treatment. CT-A
trauma, and to " rule out" many pathologies has led to an commonly demonstrates an irregular outpouching beyond
increase in the recognition of thoracic aortic pathology po­ the takeoff of the left subclavian artery at the aortic isthmus,
tentially benefitting from TEVAR technology. which corresponds to the presence of an aortic pseudoan­
eurysm caused by the traumatic event. Extent of blunt trau­
matic aortic injury and the corresponding physiologic insult
PATIENT HISTORY AND PHYSICAL FINDINGS
may range from clinically occult intimal inj ury to life-threat­
• Thoracic aortic aneurysms (TAAs ) are defined as local­ ening complete transection and rupture ( FIG 1 ) .4 Early diag­
ized or diffuse dilation of 50% or more relative to the nosis and endovascular treatment is generally recommended
diameter of the adj acent normal-sized aorta. Common for those presenting with a traumatic aortic transection, par­
risk factors for aneurysmal degeneration include smok­ ticularly when there is a contour abnormality visualized on
ing, hypertension, chronic obstructive pulmonary disease, cross-sectional imaging.

1910
C h a p t e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R 1 91 1

GRADEl GRADE II

GRADE Ill GRADE V


I
Pseudoaneurysm Rupture

FIG 1 • Society for Vasc u l a r S u rgery cl assification


of b l u nt tra u m atic a o rtic i nj u ry. (Ada pted from Lee
WA, M atsu m u ra J S, M itch e l l RS, et a l . E n d ovasc u l a r
repa i r o f tra u m atic t h o racic a o rt i c i nj u ry: c l i n ical
p ractice g u i d e l i n es of the Soci ety for Vasc u l a r
S u rg e ry. J Vase Surg. 2 0 1 1 ; 5 3 : 1 87-1 92.)

IMAGING AND OTHER DIAGNOSTIC STUDIES profile, symptomatology, and presence of electrocardiogram
abnormalities, selected patients undergo further evaluation
• Transesophageal echocardiography (TEE) may serve as in the form of an exercise stress test, dobutamine stress echo­
a useful imaging tool, particularly in the setting of acute cardiography, or Persantine thallium stress testing. Coro­
thoracic aortic pathology. TEE can confirm the presence of nary angiography is pursued in cases involving extensive or
aortic dissection, distinguish between types A and B dissec­ symptomatic coronary artery disease.
tions, identify involvement of supra-aortic vessels, and as­ • Aortic transections or symptomatic dissections and an­
sess for contained rupture. eurysms should have early and aggressive blood pressure
• High-resolution computed tomography angiography ( CT-A) control using intravenous beta-blocker or calcium channel
with three-dimensional reconstructive software allows for the blocker medications. After obtaining a reliable clinical ex­
most complete anatomic analysis, including details regarding amination, refractory chest, back, or abdominal pain should
aneurysm morphology, diameter, dissection flap characteriza­ be treated with narcotic analgesics.
tion, thrombus burden, calcification, angulation, and branch • Renal protective strategies should be employed preopera­
vessel orientation. tively to minimize the risk of contrast-induced nephropathy.
• Familiarity and routine usage of three-dimensional worksta­ Intravenous hydration is initiated preoperatively and, in the
tions and the ability to customize measurements provide an setting of baseline renal insufficiency, may warrant early
accurate road map to guide endovascular strategy, device se­ hospital preadmission and concomitant administration of
lection, and stent graft sizing. Mucomyst and bicarbonate infusion.
• Suspected blunt aortic injury should prompt a referral to a
SURGICAL MANAGEMENT level I trauma center in order to facilitate early evaluation
by a vascular specialist and other pertinent members of a
Preoperative Planning
multidisciplinary trauma team.
• Patients scheduled for elective TEVAR undergo routine pre­ • General anesthesia is routinely performed in TEVAR cases.
operative cardiac evaluation. Based on cardiovascular risk Prophylactic lumbar cerebrospinal fluid (CSF) drainage is
1 912 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

considered in every case based on the relative risk of spinal Selection and Sizing of Thoracic Stent Graft
cord ischemia, hemodynamic status, and acuity of clinical
presentation. Arterial monitoring is performed via a right
Landing zones
radial artery approach. Peripheral intravenous lines are • Proximal and distal landing zones must be of sufficient
typically adequate; however, more intensive central venous length (usually at least 2 em) to enable safe and accurate
monitoring may be required in cases involving unstable trau­ deployment bracketing the area of thoracic aortic pathology,
matic transections, patients with significant baseline cardio­ which often includes the subclavian artery proximally or the
vascular comorbidities, or any case involving hemodynamic celiac artery distally.
instability. • Intentional coverage of the left subclavian artery is some­
• Preoperative imaging should be heavily scrutinized for the times required due to a very proximal extent of aortic pa­
adequacy of iliofemoral access anatomy. An iliac conduit thology, especially transections. Left subclavian artery
may be required in cases involving small-caliber, tortuous, or revascularization may be required in select cases. The celiac
heavily calcified access vessels. Anticipated use of a conduit artery rarely requires intentional coverage.
should prompt consideration of an autotransfusion or cell • Significant tortuosity, circumferential mural thrombus, and
saver machine to be available during the procedure. extensive calcification can compromise the proximal or dis­
• Numerous variables have been identified as risk factors tal landing zone, thereby predisposing to inadequate fixa­
for the development of spinal cord ischemia after TEVAR. tion and subsequent development of endoleak or migration.
Given that hypoperfusion represents the primary etiol­ Site of proximal and distal landing zones should be selected
ogy of spinal cord inj ury following TEVAR, commonly in order to minimize the impact of these anatomic features,
cited risk factors involve those relating to the extent of even if it requires extending the length of aortic coverage.
impairment or exclusion of the collateral perfusion to the • A variety of anatomic measurements are taken from preop­
spinal cord. The European Collaborators on Stent/Graft erative CT-A imaging to assist in the sizing and selection of
Techniques for Aortic Aneurysm Repair ( EUROSTAR) the thoracic stent graft ( FIG 2 ) . Interventionalists should be
investigators reported results from the largest multicenter proficient in accurate sizing and measuring of key thoracic
registry to date (N = 6 0 6 ) . 5 In the EURO STAR registry, aortic locations that influence device selection and ultimately
the incidence of spinal cord ischemia was 2 . 5 % and inde­ determine patient outcomes.
pendent risk factors included left subclavian artery cover­
age without revascularization (odds ratio [OR], 3 . 9 ; p = Sizing of stent grafts
. 0 3 7 ) , concomitant open abdominal aortic surgery (OR,
• The degree of stent graft oversizing can vary based on the in­
5.5; p = .037), and the use of three or more stent grafts
dication for intervention. Stent grafts are generally oversized
(OR, 3 . 5 ; p = .043 ) .

by 1 0 % to 2 0 % based on the aortic diameter at the proximal
Based o n the principle that spinal cord perfusion pressure
and distal fixation sites for aneurysmal disease. Insufficient
is approximated by the difference between the mean arte­
oversizing for the treatment of TAAs may predispose to in­
rial pressure (MAP) and CSF pressure, placement of a pro­
adequate exclusion and the potential for endoleak or migra­
phylactic lumbar drain has the potential to increase spinal
tion. Aggressive oversizing, on the other hand, increases the
cord perfusion pressure by decreasing CSF pressure and may
risk for stent graft collapse, graft thrombosis, access arterial
be beneficial in select patients at high risk for spinal cord
injury, and potential for peri- or postprocedural iatrogenic
ischemia. Percutaneous drainage of CSF is performed by in­
retrograde type A dissection.
serting a silastic catheter 10 to 15 em into the subarachnoid
• Chronic type B dissections are frequently characterized by a
space through a 1 4-gauge Tuohy needle at the L3-L4 verte­
thick, nonmobile dissection flap, or septum, that separates
bral interspace. The open end of the catheter is attached to a
true and false lumens into concave or convex discs of flow
sterile closed circuit reservoir and the lumbar CSF pressure
lumen. Such dissection flaps have limited compliance; there­
is measured with a pressure transducer zero-referenced to
fore, minimal or no oversizing may be required in order to
the midline of the brain. Lumbar CSF can be drained con­
achieve a suitable proximal or distal seal.
tinuously or intermittently in the operating room to achieve
• Aortic transections frequently occur in young trauma pa­
target CSF pressures of 10 to 12 mmHg. Postoperatively,
tients with normal or minimally diseased aortas. As such,
intermittent or continuous CSF drainage can be contin­
minimal oversizing is needed to achieve an adequate seal
ued in the intensive care unit for CSF pressures exceeding
and only recently did device manufacturers create devices
10 mmHg or at the first sign of lower extremity weakness. In
meant for smaller diameter aortas. Note also that under­
the absence of neurologic deficits, the lumbar CSF drainage
rescucitated patients on admission will have smaller aortic
catheter can be clamped 24 hours postprocedure followed
diameters on their CT-A.
by continued monitoring of CSF pressure together with se­
• Currently available stent grafts range in diameter from 22 to
rial neurologic assessments. The CSF drain can then be re­
46 mm. Given the traditional 1 0 % to 20% rule of device over­
moved at 4 8 hours after operation. Although prophylactic
sizing, these devices are designed to safely treat aortas with
or therapeutic lumbar CSF drainage has an established re­
landing zones ranging from 19 to 43 mm in diameter.
cord of safety, complications have been reported to occur
in approximately 1 % of patients, which may include neur­
Access vessel anatomy
axial hematoma, subdural hematoma, catheter fracture,
meningitis, intracranial hypotension, chronic CSF leak, and • Current thoracic aortic stent grafts require large-caliber deliv­
spinal headache. ery systems, ranging from 1 8 to 26 Fr in outer diameter. Small,
Ch a pt e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R 1 913

Measu rements t o b e taken during the pretreatment


assessment of isolated lesions are described below:

A, B, C. Proximal aortic neck diameter (minimum of 1 em


apart)
D. Maximum lesion d i ameter
E, F, G. Distal aortic neck d i ameter (min imum of 1 em apart)
H. R ight common i l i ac artery d i ameter
I . Left common iliac artery diameter
J. Right external i l i ac/femoral artery d i ameter
K. Left external i l i ac/femoral artery d i ameter
L. Distance between the left subclavian/left common carotid
artery and the proximal end of the lesion (mi n imum of 2 em)
M. Length of the lesion measu red along the g reater
cu rvature of the flow l umen
N. Distance between the d i stal end of the lesion and the
cel i ac axis (min imum of 2 em)
0. Total treatment length

Measu rements to be taken d u ring the pretreatment


assessment of dissections are described below:

01. Diameter a t proximal extent o f proximal landing zone


(must be i n nondissected aorta)
02. Maximum transverse aortic diameter (combined true
A and false l umen)
T1. Maximum true l umen diameter i n DTA
T2. Min imum true l umen diameter in DTA
F. Maximum false lumen d i ameter in DTA
A1. Right access vessel diameter (common iliac, external
i l i ac, femoral)
A2. Left access vessel d i amter (common i l i ac, external i l i ac,
femoral)
L1. Proximal landing zone length from proximal end of
primary entry tear to left subclavian or left common carotid
L2. Distal neck length from distal end of primary entry tear
to cel i ac
TTL. Total treatment length from left subclavian or left
common carotid

B
FIG 2 • Anatomic measurements to assist i n tho racic stent graft device siz i ng and selectio n f o r the treatment of aneu rysms (A) a n d
d issect i o ns (B) . DTA, descen ding tho racic ao rta.
1 914 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

tortuous, and heavily calcified iliofemoral arteries may prohibit


sheath advancement and predispose to access site-related com­
plications, including groin hematoma, dissection, or rupture.
• Careful evaluation of access vessel anatomy on preopera­
tive imaging should be performed in order to assess the cali­
ber, tortuosity, thrombus burden, and extent of calcification
of the iliofemoral arteries. Such anatomic information will
A
serve as the basis for deciding laterality of femoral access as
well as to determine the need for an iliac conduit.
• Serial dilation may be attempted for patients with small il­
iofemoral vessels. Iliac atherosclerotic lesions may be pre­
treated with balloon angioplasty and/or stent grafting in
order to facilitate sheath advancement and introduction of
the thoracic stent graft components.
• Iliac conduits serve as a safe and reliable technique to circum­
vent issues related to suboptimal access vessel anatomy. From B
either flank incision, a retroperitoneal exposure provides visu­ FIG 3 • A. 1 0- m m Dacron c o n d u i t b isected l o n g itu d i n a l ly to
alization of the common iliac artery or distal abdominal aorta. create a sew i n g patc h . B. Dacron i l i a c co n d u it sewn to native i l i a c
A 10- or 1 2-mm Dacron graft is commonly used as the conduit a rtery a l l ows easy m o b i l ity of the c o n d u i t at m u lt i p l e a n g les o f
of choice. The conduit can be modified by creating a patch at entry for l a rge-ca l i be r device o r sheath. ( F r o m L e e JT, L e e G K,
the distal end in order to further facilitate the delivery of large­ C h a n d ra V, et a l . Compa rison of fen estrated endog rafts a n d the
caliber sheath and enable additional degrees of torqueability s n o rkel/ch i m ney tec h n i q u e [ p u b l ished o n l i n e a h e a d of p r i n t Apri l
27, 2 0 1 4 ] . J Vase Surg. doi:1 0 . 1 0 1 6/j .jvs . 2 0 1 4.03.255.)
( FIG 3) . This modification involves creating a patch by cutting
the Dacron graft along its long access, thereby enlarging the
transition zone from the graft to artery.

• The fe m o r a l a rtery is p u nctured u s i n g a sta n d a rd m i cro­


EARLY PROCEDURAL CONSIDERATIONS
p u n ct u re set, and if a rte r i a l access is obta i ned percuta ne­
Positioning ously, a s h eath ogram is performed to confirm a d e q u ate
• The C-a rm is typica l l y confi g u red i n the " h ead " posit i o n . p u n ct u re site location ( m i d-co m m o n fe m o ra l a rte ry) . A
The left a r m may be a b d u cted to 75 to 90 deg rees a n d c i r­ sta n d a rd l e n gth B e ntson w i re is i n se rted i nto the a o rta
cu mferenti a l l y prepped i nto the field if an e m b o l izat i o n t h r o u g h m icropu ncture sheath a n d exc h a n g e for a 7-Fr
o r s n o rkel/c h i m ney p roced u re involvi n g the l eft s u b c l a ­ sh eath is then performed u s i n g S e l d i n g e r tech n i q u e .
v i a n a rtery is a ntici pated. The chest, a bdomen, a n d b i ­ W i re exc h a n g e is t h e n d o n e f o r a 260-cm stiff L u n d e r­
l atera l g r o i n s s h o u l d be prepped . A s freq uently o n ly one q u i st wire. The L u n d e rq u i st w i re s h o u l d h ave a flexi b l e,
g r o i n access i s req u i red for the perfo rmance of a rout i n e cu rved prox i m a l e n d that s h o u l d be adva nced u n d e r
TEVAR, latera l ity of the o perator p o s i t i o n may vary based f l u o roscopy across the a o rtic a rch to a b ut t h e a o rt i c
o n su rgeon p reference o r a ntici pated access site l ocat i o n . va l u e . The l o c a t i o n of t h e d ista l end of t h e Lunderqu ist
w i re s h o u l d be m a rked o n the operat i n g ta b l e and t h i s
Establishing Vascular Access w i re position s h o u l d be m a i ntained t h ro u g hout t h e
p roced u re .
• The i psi l ateral fe moral a rtery is accessed either percuta ne­
• O v e r the stiff Lu n d e rq u ist w i re p l atfo rm, the 7-Fr s h eath
ously o r from a n open exposure. Seco n d a ry access may
is removed and seri a l d i lators are adva n ced to g ra d u a l l y
be o bta i n ed from the contra l atera l femoral a rtery o r bra­
e n l a rg e the su bcuta neous tract a n d a rteriotomy site i n
c h i a l a rtery as needed fo r a 5-Fr sh eath a n d flush catheter.
order t o acco m m o d ate either t h e ste nt g raft device itse lf
S u rg i c a l exposure is obta i ned from a s m a l l o b l i q u e i nci­
o r a l a rg e r 1 8- to 26-Fr i ntrod ucer s h eath req u i red for
sion at the level of the i n g u i n a l l i g a ment. The common
device d e l ive ry.
femoral a rtery is exposed, with p roxi m a l control o bta i ned
• After p l acement of the l a rg e r sheath, syste m i c h e p a r i n
at the l eve l of the exte r n a l i l iac a rtery and d ista l control
is a d m i n istered at a d o s e of 1 00 u n its/kg (g o a l activated
at the l eve l of the fe moral bifu rcation o r prox i m a l su perfi­
c l ott i n g t i m e of >2 50 seco nds). Concom itant t ra u matic
cial femora l and p rofu nda fe moral a rteries. Heavy calcifi­
i nj u ri es, p a rticu l a r l y i n t racra n i a l h e m o rrhage, may a lter
cation may req u i re preem ptive e n d a rterectomy and patch
the dose o r decision to a d m i n ister h e p a ri n .
a n g i o p l asty i n order to fac i l itate safe sheath p l acement.

INITIAL AORTOGRAM T h i s catheter m a y b e advanced v i a a contra latera l 5-Fr


sheath o r it may be i nserted i nto a n a d d i t i o n a l i p s i l atera l
• A 5-Fr 1 00-cm O m n iflush or p i gta i l catheter is i n se rted 5-Fr sheath p l a ced d i st a l to the a rteriotomy for t h e m a i n
i nto a o rta and adva n ced to the level of the a o rtic a rch . body del ivery sheath.
C h a p t e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R 1 91 5

• If satisfied w i t h ste nt g raft s i z i n g based o n ava i l a b l e pre­ Device Deployment


operative i m a g i ng, the thoracic a o rtic ste nt g raft may be
• Precise prox i m a l positi o n i n g of the ste nt g raft is fa­
adva nced over the L u n d e rq u i st w i re and be positioned i n
t h e p roxi m a l t o m i d portion o f t h e t h o racic a o rta p r i o r to c i l itated by either m a r k i n g the location of the l eft sub­
i n it i a l a o rtog ra m . clavian a rtery o n the view i n g screen a n d/or u s i n g the
• O pti m a l a n g i o g ra p h i c i m a g i n g o f t h e a o rtic a rch is ob­ road-m a p p i n g feature. The d ista l rad i o p a q u e line of the
t a i n e d by placing the f l u o rosco p i c C-a rm i n a l eft a nte­ e n d otrach e a l t u b e seen o n f l u o roscopy at a bout 45 de­
rior o b l i q u e o r i e ntation, often 3 5 to 6 5 deg rees, and can g rees l eft a nterior o b l i q u e can sometimes corre l ate to
be optim ized by refere n c i n g the preoperative CT-A. The the position of the l eft c o m m o n ca rotid a rte ry, t h ereby
l ocat i o n of the s u p ra-aortic vessels, p a rticu l a rly the left servi n g as a conve n i e n t l a n d m a r k in cases req u i r i n g l eft
s u bclavian a rte ry, s h o u l d be n oted a n d m a rked on view­ s u bclavian a rtery cove rage.
• I m m ed iately prior to ste nt g raft d e p l oyme nt, syste m i c
i n g m o n itors (FIG 4A) .
• I ntravasc u l a r u ltraso u n d ( I V U S ) may be u s e d a n adju nct a rte r i a l b l ood pressu re is red uced below 1 00 m m H g to
i n cases i nvo l v i n g d i ssection to assist i n the i d e ntification reduce risk of ca u d a l m i g rati o n .
• T h e stent g rafts a re g e n e ra l ly d e p l oyed i n a p roxi m a l -to­
of true a n d false l u m e n s, a s we l l as to gain a d d i t i o n a l
i nfo rmation o n a o rtic d i a m eter, branch vessel location, d ista l sequence. H owever, a d i stal-to-prox i m a l sequence
a n d m o r p h o l ogy of prox i m a l a n d d ista l l a n d i n g zones. may be p refe rred i n cases i nvolvi n g precise d e p l oyment
IVUS a l so a i d s i n l i m it i n g i ntrave n o u s contrast exposure n e a r the ce l i a c a rtery o r i n a o rtas with s i g n ificant d i a m ­
in t h ose patie nts with base l i n e i m p a i red re n a l f u n ct i o n . eter t a p e r a n d a l a rg e r p roxi m a l l a n d i n g z o n e compa red
• If n ecessa ry to g u ide d ista l exte nt of ste nt g raft p l ace­ to the d ista l l a n d i n g zone (wh e re devices of d i ffe rent d i ­
m ent, the ce l i a c a rtery is best i m a g e d from a fu l l latera l a m eter may n e e d t o be sta cked u p o n e a c h other).
• D e p l oyed endog rafts w i l l natu ra l ly exte n d toward the
p roj ect i o n . Ad d iti o n a l structu res to n ote a re l a rge, pa­
tent i ntercosta l a rteries at the level of the a o rtic h i atus. outer cu rvature of the a o rta and p recision d e p l oyment
Efforts should be m a d e to avoid cove r i n g t h ese if at a l l is fac i l itated by gently p rovi d i n g forwa rd tract i o n o n the
poss i b l e d u r i n g t h e cou rse o f t h e repa i r. w i re toward the outer cu rve during d e p l oyment. This

A B

FIG 4 • A. I n it i a l thoracic a o rtogram performed with C-a rm i n a


45-deg ree l eft a nterior o b l i q u e orientation i n a case i nvolvi n g a type B
a o rtic d issect i o n . N ote h ow clearly the o r i g i n of the subclavi a n (arrow)
is seen to accu rate ly decide if there is a d e q u ate p roxi m a l neck l e n g t h .
B. Ao rtogram fo l l ow i n g d e p l oyment of t h o r a c i c ste nt g raft w i t h
cove rage of the ost i u m of the l eft subclavian a rte ry. C. Posto perative
th ree-d i m e n s i o n a l i m a g i n g d e m o n strat i n g successf u l exc l u s i o n of the
c p roxi m a l entry d i ssection tea r.
1 916 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

m a n euver a l so fac i l itates stra i g hte n i n g out of the tra ns­ balloon (Coda [Cook Medical, B l o o m i n gton, IN, U SA]
verse a rch, w h i c h can be h e l pf u l in m i n i m i z i n g the " b i rd­ o r Tri-Lobe [W. L. G o re, F l a g staff, AZ, U SA]) is adva nced
bea k i n g " effect at the p roxi m a l g raft m a r g i n , where the u p to the p roxi m a l edge of the ste nt g raft and b a l loon
device may not fully o ppose to the " i n n er" a o rtic wa l l . m o l d i n g is performed in a p roxi m a l -to-d ista l seq uence.
B i rd bea k i ng, when p resent, c a n predispose t o prox i m a l B a l loon m o l d i n g should be pe rfo rmed at the p roxi m a l
type I e n d o l e a ks, endog raft co l l a pse, a n d potenti a l a o rt i c a n d d i sta l fixati o n sites, a s we l l as at a reas o f ste nt g raft
occ l u s i o n . ove r l a p in those cases req u i ri n g m u lt i p l e ste nt g rafts.
• Ad d i t i o n a l g raft co m p o n e nts a re added, w h e n n eces- • Agg ressive b a l l o o n i n g can cause component fract u re
sa ry, by exch a n g i n g the fi rst device over the L u n d e rq u i st a n d a o rtic i n j u ry, a n d ca re m ust be taken d u r i n g i nfla­
wire. A m i n i m u m ove r l a p of 5 em between p i eces i s t i o n with consta nt v i s u a l ization a n d knowledge of the
reco m m e nded to e n s u re a d e q u ate a p position a n d m i n i- tension a p p l i ed to the b a l l o o n .
m ize risk of j u n ct i o n a l (type I l l) e n d o l e a k . • B a l loon m o l d i n g is n ot typica l ly req u i red i n cases i nvo lving
aortic d i ssection o r transection, p a rticu l a rly i n cases where
no obvious endoleak is visu a l i zed. B a l loon m o l d i n g may
Balloon Molding
i ncrease risk for iatrog e n i c retrograde type A convers i o n
• B a l loon m o l d i n g is often req u i red in cases i nvolvi n g TAAs. if perfo rmed i n a reg ion o f fri a b l e o r fra g i l e a o rta a n d is
U n der f l u o rosco p i c g u i d a n ce, a n o n co m p l i a n t m o l d i n g genera l ly not recom mended during d i ssection cases.

COMPLETION AORTOGRAM stent g raft l u m e n a n d p o s i t i o n e d at the level of t h e


aortic a rc h .
• After stent g raft d e p l oy m e nt, t h e p i g ta i l catheter is • Ad d i t i o n a l a o rtograms may be pe rfo rmed at t h i s t i m e a s
w i t h d rawn a l o n g t h e outside of t h e d e p l oyed devi ce(s) necess a ry i n order t o e n s u re a d e q u ate stent g raft posi­
over a w i re to b e l ow the level of the stent g raft. T h e tion a n d pate n cy of the s u p ra-aortic a n d ce l i a c a rteries
c a t h e t e r i s t h e n readva nced over a w i r e with i n t h e and to assess for the presence of e n d o l e a ks.

REMOVAL OF SHEATH AND a n d d i sta l vasc u l a r control is obta i n e d i n t h e respective


g r o i n . All wi res and s h eaths a re rem oved . The a rteriot­
ARTERIOTOMY CLOSURE
omy is cl osed tra n sverse ly u s i n g a polypropyl e n e sutu re
• I n cases i nvolvi n g pe rcuta n e o u s access, t h e two p revi­ in either a r u n n i n g cont i n u o u s or i nterru pted fas h i o n .
ously p l aced Percl ose Pro G i i d e devices a re used to c l ose Anteg rade a n d retro g ra d e f l u s h i n g m a n e uvers s h o u l d
the a rteriotomy site(s) (see Pa rt 6, C h a pter 23 for de­ be perfo rmed p r i o r t o co m p l et i o n o f t h e a rteriotomy
t a i ls). If open s u r g i c a l exposure was o bta i n ed, prox i m a l c l o s u re .

LEFT SUBCLAVIAN ARTERY t r e n d towa rd i n creased risk of s p i n a l c o r d isch e m i a w h e n


the l eft subclavian a rtery was covered, s u g g esti n g a po­
REVASCULARIZATION
tent i a l benefit for l eft subclavian a rtery revasc u l a riza­
• E n d ovasc u l a r p roced u res that req u i re cove rage of the tion, but the f i n d i n g was not statistica l ly s i g n ifica nt.4-6
l eft subclavi a n a rte ry h ave the pote n t i a l to i n crease the
risk of spinal cord i nj u ry by co m p ro m i s i n g b l ood flow to
the i p s i l atera l vertebral a rte ry, a n i m portant co l l atera l
pathway for a rte r i a l flow to t h e a nterior s p i n a l a rte ry.
S u bc l a v i a n a rtery revascu l a rization the refore se rves as
a n a d d iti o n a l strategy to decrease the risk of s p i n a l cord
isch e m i a i n sel ect patie nts deemed high risk.
• Tec h n i q ues to revasc u l a rize the l eft subclavian a rtery
i n c l u d e transposition of the subclavian onto the l eft ca­
rotid a rtery o r l eft ca rotid-subclavian bypass g raft i n g
w i t h su bseq uent e m b o l i zation o f the l eft subclavian a r­
tery proxi m a l to the bypass g raft (FIG 5) . These revas­
c u l a rization p roced u res may be pe rfo rmed a s p a rt of a
sta ged repa i r or at the t i m e of TEVAR.
FIG 5 • Left su bclavi a n a rtery transposition is performed by
• The existi n g c l i n ica l evidence to s u p p o rt the efficacy of
l i g at i n g the l eft s u bclavian a rtery p roxi m a l to the verte bral
ro utine l eft subclavian a rtery revasc u l a rization re m a i n s a rtery a n d m ovi n g it ce p h a l a d i n order to perform a n end­
controvers i a l ; t h e r e a re advocates fo r rout i n e revascu­ to-side a n a stomosis between the l eft subclavian a n d l eft
l a rization, sel ective reva sc u l a rization, o r n o revasc u l a r­ c o m m o n ca rotid a rteries. Alternative ly, a Dacron g raft can be
izat i o n . A m eta-a n a lysis of p u b l ished stud ies showed a used as a l eft ca rotid-subclavian bypass.
C h a p t e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R 1 91 7

• I V U S se rves as a u sefu l a dj u n ct i n d i ssect i o n ca ses,


SPECIAL CONSIDERATIONS BASED ON
both in terms of i n it i a l i d e ntificat i o n of true and fa l s e
AORTIC PATHOLOG Y
l u m e n , a s we l l a s a s s i st i n g i n precise positi o n i n g of t h e
Aortic Dissection device.

• The p r i m a ry g o a l of TEVAR for the treatment of d i ssec- Aortic Transection


t i o n is cove rage of the p roxi m a l entry tea r (FIG 6A,B) .
• Tra u m atic a o rtic i n j u ries a re typica l ly l ocated a l o n g the
Stent g raft s i z i n g is based o n the d i a m eter o f the adjacent
inner cu rve of the p roxi m a l desce n d i n g t h o ra c i c a o rta
n o n d i ssected t h o racic a o rta. M i n i m a l o r n o ove rs i z i n g of
the ste nt g raft is reco m m e n d e d .
(FIG 7). G i ve n the p roxi m a l locat i o n , l eft subclavian

a rtery cove rage i s sometimes needed.4
I n acute type B d i ssectio ns, the sept u m is relatively mo­
• I n the a bsence of concom itant hemorrhage o r b ra i n
bile a n d com p l i a nt. Therefore, the d i a m eter of the sma l l
i n j u ry, rout i n e h e p a r i n i s reco m m e n d e d .
true l u m e n i n t h e d i ssected port i o n often ret u r n s to
• Tra u m a patie nts a re freq uently hypovo l e m i c a n d , a s a re­
n o r m a l d i a m eter fo l l owi n g successf u l exc l u s i o n of the
su lt, may have an u n d e rd i ste nded a o rta o n p reope rative
prox i m a l entry tea r.

cross-sect i o n a l i m a g i n g . I n it i a l cross-sect i o n a l i m a g i n g
C h r o n i c d i ssect i o n s have t h icker, less co m p l i a n t septa,
can u n d e rest i m ate t r u e a o rtic m o r p h o l ogy at t h e reg i o n
w h i c h may l i m it expa n s i o n of the true l u m e n desp ite ad­
of the s u b c l a v i a n by as m u c h a s 1 0 % to 2 0 % . I n such set­
e q u ate entry tea r coverage. Ofte n, these patie nts h ave
t i n gs, IVUS may assist in more accu rate ste nt g raft s i z i n g
c h r o n i c false l u m e n a n e u rysm a l d i lation, a n d entry tea r
pe rfo rmed i n vivo.7
a n d fe n estrati o n cove r i n g se rve s i m p l y to decrease fa lse
l u m e n pressu rization and prom ote t h ro m bosis.

A B
FIG 6 • A. CTA reco nstruct i o n d e m o n strat i n g co m p l ex t h o racoa bdom i n a l a o rtic d i ssection with p roxi m a l entry tea r l ocated i n
t h e proxi m a l desce n d i n g thoracic a o rta. B. I n it i a l a o rtogram docu m e n t i n g positi o n o f t h e s u p ra-aortic a rteries. N ote t h e ste nt
g raft h a s been adva nced i nto a p p roxi m ate positi o n but is not yet d e p l oyed .
1 918 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

c
FIG 7 • A. Th ree-d i m e n s i o n a l reco nstructed i m ages s h ow i n g the presence of t ra u matic a o rtic tra nsect i o n at the level of the
l i g a m entum a rteriosum (arrow). B. Aortogram s h ow i n g foca l outpo u c h i n g (arro w) along the inner cu rve of the p roxi m a l
desce n d i n g thoracic a o rta, corre l a t i n g to the t ra u m atic transect i o n observed o n p reoperative i m a g i n g . N ote t h a t the ste nt g raft
has been advanced i nto the proxi m a l desce n d i n g thoracic a o rta but is not yet dep l oyed . C. Aortogram fo l l owi n g t h o racic ste nt
g raft d e p l oyment with successful exc l u s i o n of the transect i o n site.
C h a p t e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R 1 919

PEARLS AND PITFALLS


I n d icat i o n s • TEVAR fo l l ows g e n e ra l reco m m e ndations for e l ective repa i r o f desce n d i n g t h o racic a n d thoracoa b d o m i -
n a l a o rtic a n e u rysms a n d s h o u l d be offered to good a n ato m i c risk patie nts with a n e u rysms > 6 e m .
• Patient select ion s h o u l d t a k e i nto acco u n t t h e n eed f o r reg u l a r i nte rva l c l i n ica l a n d ra d i o l o g i c fo l l ow-u p
i n order t o m o n itor f o r ste nt g raft-re lated co m p l icat i o n s a n d e n d o l e a ks .

Preope rative w o r k u p • H i g h-qua l ity i m a g i n g a n d a b i l ity to confi g u re th ree-d i m e n s i o n a l reco nstructive softwa re a re essenti a l
f o r successf u l p reope rative p l a n n i n g a n d device select i o n .
• Pre- a n d perio perative hyd rat i o n is a centra l p a rt i n the p rotect i o n f r o m contrast- i n d uced n e p h ropathy.
• Pati e nts s h o u l d be stratified accord i n g to base l i n e risk of s p i n a l cord isch e m i a . A prophylact i c l u m ba r
d r a i n s h o u l d b e considered i n those a t h i g h risk.

Patient set u p • A h y b r i d e n d ovascu l a r su ite p rovides o pt i m a l opport u n ity f o r accu rate i m a g i n g a n d ca pa b i l ity t o
perfo rm n ecessa ry o p e n s u r g i ca l exposure o r repa i r o f access-rel ated co m p l i cations.
• Antici pated adju nct procedu res, i n c l u d i n g l eft subclavian a rtery e m b o l ization o r revasc u l a rization, may
req u i re p re p p i n g the l eft neck a n d/o r a r m i nto the s u r g i ca l f i e l d .

T h o r a c i c a n e u rysms • Overs i z i n g of ste nt g rafts by 1 0 % to 20% a n d ba l l oo n m o l d i n g is g e n e ra l ly reco m m e n d ed i n order to


maxim ize proxi m a l a n d d i sta l fixat i o n .
• Proxi m a l a n d d i stal l a n d i n g z o n e s s h o u l d be relatively free o f ste n osis, cal cification, a n d t h r o m b u s t o
maxim ize d u ra b i l ity of t h i s m i n i m a l ly i nvasive tech n o l ogy.

Type B d i ssect i o n • Accu rate i d entificat i o n of true a n d f a l s e l u m e n is essenti a l p r i o r to d e p l oyment of the ste nt g raft.
IV U S may be a usefu l adj u n ct in t h i s sett i n g to confi rm true o r false l u m e n posi t i o n .
• Agg ressive ove rs i z i n g of stent g rafts is not reco m m e n d ed i n patie nts with a o rt i c d issect i o n . B a l loon
molding is g e n e ra l ly rese rved o n ly for t h ose with type I o r Ill e n d o l e a k o n co m p l et i o n a n g iography and
not a g a i n st the reg i o n w h e re t h e re i s a mobile septu m .

Tra u m atic tra n sect i o n • Rout i n e h e p a r i n i s reco m m e n d ed u n l ess contra i n d i cated by conco m ita nt i ntracra n i a l o r s o l i d organ
i n j u ry.
• S i m i l a r to d i ssections, a g g ressive overs i z i n g a n d b a l loon m o l d i n g is n ot routi n e l y performed d u r i n g the
treatment of transections.

POSTOPERATIVE CARE motic aneurysm ( n = 13 ). 8 Technical success was achieved in


nearly 9 0 % of patients, with an all-cause mortality among
• Patients are typically extubated immediately following the patients treated for aortic aneurysm and aortic dissection of
procedure unless prohibited by concomitant physiologic in­ 20% and 1 0 % , respectively.
sults (e.g., hemodynamic instability, trauma patient) . • No randomized trials comparing TEVAR to open surgery
• Intensive care unit monitoring i s required for patients who have been published to date. However, multiple nonran­
require a lumbar drain for 24 to 48 hours. Immediate and domized comparisons suggest equivalent or better outcomes
frequent neurologic assessments are critical in the early peri­ with TEVAR. In a single-center, retrospective study of
operative period to assess for spinal cord ischemia. Raising over 700 patients who underwent either TEVAR or open
MAP goals are an additional way to minimize risk of cord surgery, mortality was not significantly different at 3 0-day
ischemia. ( 5 . 7 % vs. 8 . 3 % , respectively) or 1 -year ( 1 5 . 6 % vs. 1 5 . 9 % ,
• Durability of TEVAR is reliant on routine imaging to evalu­ respectively) follow-up. 9 Two smaller studies demonstrated
ate for stent graft-specific complications postoperation. a reduction in 3 0-day perioperative mortality with TEVAR
Follow-up chest CT-A and plain x-rays are typically ob­ compared with open surgery ( 1 . 9 % vs. 5 . 7 % ) . 1 0• 1 1
tained at 1, 6, and 12 months and at intervals thereafter.
Consideration should be made between balancing risks for COMPLICATIONS
cumulative lifetime iodinated contrast and radiation expo­
sure versus the necessity for serial graft monitoring. In stable • Stroke continues to be a common complication following
patients, chest x-rays may suffice to confirm device position, TEVAR and is associated with significant in-hospital mor­
with CT scanning reserved for those with migration sug­ tality. Recent clinical series have reported an incidence of
gested by CT or evidence of progressive aortic enlargement stroke after TEVAR to range from 2% to 8 % . 12•13 The un­
or onset of recurrent symptoms such as chest pain. derlying mechanisms contributing to acute ischemic stroke
after TEVAR and the temporal relationship of stroke to the
procedure are not completely understood. However, the
OUTCOMES
constellation of preoperative risk factors, neurologic exami­
• The largest published series, which has reported 1 -year nations, and patterns of brain infarction observed in these
follow-up, included 443 patients treated with TEVAR for patients has led most investigators to conclude that cerebral
a variety of indications, both emergent and elective, as embolization and ischemic events are the primary mecha­
follows: TAA ( n = 249 ) , thoracic aortic dissection ( n = nisms for perioperative stroke in TEVAR.5•13•14 Embolic
1 3 1 ) , traumatic aortic inj ury ( n 5 0 ) , and false anasto-
= events are related to instrumentation of the aortic arch in
1 920 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

patients with severe atheromatous disease, whereas ischemia REFERENCES


is a result of the planned or inadvertent endovascular cover­
1. Dake MD, Miller DC, Semba CP, et al. Transluminal placement of en·
age of supra-aortic vessels.
dovascular stent·grafts for the treatment of descending thoracic aortic
• Spinal cord ischemia and subsequent acute or delayed aneurysms. N Engl ] Med. 1 9 94;3 3 1 : 1 729-1 734.
paraplegia represents the most devastating complication 2. Bavaria JE, Appoo JJ, Makaroun MS, et al. Endovascular stent graft·
of TEVAR. The pathogenesis of spinal cord injury after ing versus open surgical repair of descending thoracic aortic aneu­
TEVAR is likely multifactorial but still poorly understood. rysms in low-risk patients: a multicenter comparative trial. J Thorac
The deployment of thoracic stem grafts results in rapid com­ Cardiovasc Surg. 2007; 1 3 3 : 3 69-3 77.
3. Nienaber CA, Rousseau H, Eggebrecht H, et al. Randomized com­
plete exclusion of varying lengths of segmental collateral
parison of strategies for type B aortic dissection: the INvestigation
vessels without the ability to surgically reimplant or revas­ of STEm Grafts in Aortic Dissection (INSTEAD ) trial. Circulation.
cularize the intercostal arteries. Stent deployment and cath­ 2009; 120:25 1 9-252 8 .
eter manipulation can predispose patients to dislodgement 4. Lee WA, Matsumura J S , Mitchell R S , e t a l . Endovascular repair o f
of thrombotic or atheromatous debris from the aortic wall traumatic aortic injury: clinical practice guidelines o f the Society for
into segmental vessels, with subsequent distal embolization Vascular Surgery. ] Vase Surg. 2 0 1 1 ; 5 3 : 1 8 7-1 92.
5. Buth ], Harris PL, Hobo R, et al. Neurologic complications associated
and occlusion of arteries supplying the spinal cord. More­
with endovascular repair of thoracic aortic pathology: incidence and
over, endovascular coverage of the left subclavian artery risk factors. A study from the European Collaborators on Stem/Graft
may compromise spinal cord perfusion in patients with a Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vase
dominant left vertebral artery, solitary vertebral artery, ca­ Surg. 2007;46 : 1 1 03-1 1 1 0 .
rotid artery disease, or an incomplete circle of Willis. Access 6. Rizvi A Z , Murad M H , Fairman RM, et a l . The effect of left subcla­
site injuries to the iliofemoral vessels may further increase vian artery coverage on morbidity and mortality in patients undergo­
ing endovascular thoracic aortic interventions: a systematic review and
the risk of spinal cord ischemia by compromising collateral
meta-analysis. J Vase Surg. 2009;50 : 1 1 59-1 1 69 .
flow to the anterior spinal artery through the hypogastric
7. Pearce BJ, Jordan W. Using IVUS during EVAR a n d TEVAR: improv­
and pelvic vascular plexus. Lastly, pharmacologic measures ing patient outcomes. Semin Vase Surg. 2009;22 : 1 72-1 80.
aimed at decreasing arterial blood pressure to enhance accu­ 8. Leurs LJ, Bell R, Degrieck Y, et al. Endovascular treatment of tho·
racy of device deployment in cases involving difficult aortic racic aortic diseases: combined experience from the EUROSTAR and
anatomy may lead to hypotension similar to that observed in United Kingdom Thoracic Endograft registries. J Vase Surg. 2004;40:
open surgery. 670-679.
9. Greenberg RK, Lu Q, Roselli EE, et al. Contemporary analysis
• Due to the large sheath sizes required for the delivery of
of descending thoracic and thoracoabdominal aneurysm repair:
thoracic stent grafts, small-diameter, tortuous, or heavily a comparison of endovascular and open techniques. Circulation.
calcified access vessels can predispose to iliofemoral arte­ 2008; 1 1 8 : 8 08-8 17.
rial injury. Postoperative CT-A often documents arterial dis­ 10. Matsumura ]S, Cambria RP, Dake MD, et al. International controlled
sections and injury that can be followed with noninvasive clinical trial of thoracic endovascular aneurysm repair with the Zenith
duplex and managed expectantly until patients have claudi­ TX2 endovascular graft: 1 -year results. J Vase Surg. 2008;4 7(2):
247-257.
cation-like symptoms.
11. Bavaria JE, Appoo ]], Makaroun MS, et al. Endovascular stent graft­
• Endoleaks are a relatively common finding after TEVAR, ing versus open surgical repair of descending thoracic aortic aneu­
affecting nearly 1 5 % of patients in the early or late post­ rysms in low-risk patients: a multicenter comparative trial. J Thorac
operative periods. Type I or III endoleaks typically require Cardiovasc Surg. 2007; 1 3 3 : 3 69-377.
additional stent placement or balloon molding in order to 12. Feezor RJ, Martin TO, Hess PJ, et al. Risk factors for perioperative
improve proximal, distal, or j unctional fixation. Most type stroke during thoracic endovascular aortic repairs (TEVAR) . J Endo·
vase Ther. 2007; 1 4 : 5 6 8-573.
II endoleaks observed on completion angiogram or early fol­
13. Gutsche ]T, Cheung AT, McGarvey ML, et al. Risk factors for periop·
low-up cross-sectional imaging will resolve spontaneously.
erative stroke after thoracic endovascular aortic repair. Ann Thorac
Persistent type II endoleaks, especially those with aneurysm Surg. 2007;84 : 1 1 95-1 200.
sac expansion or failure to adequately seal a proximal entry 14. Fattori R, Nienaber CA, Rousseau H, et al. Results of endovascular
tear or transection, warrant additional intervention. Retro­ repair of the thoracic aorta with the Talent Thoracic stent graft: the
grade flow from intercostal or left subclavian arteries can be Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg.
treated using coil embolization or vascular plug placement. 2006; 1 3 2 : 3 32-3 3 9 .
I

Chapter 14 Exposure and Open Surgical


Management at the Diaphragm
. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - �

Peter H. U. Lee Ra m in E. Beygui

DEFINITION PATIENT HISTORY AND PHYSICAL

• Thoracoabdominal aneurysms and complicated descending FINDINGS


aortic dissections are the two most likely reasons for requir­ • Most patients who are referred for surgery for a thoracoab­
ing surgical exposure of the diaphragm in vascular surgery. dominal aneurysm present with no symptoms. However, when
The need to expose the aorta both above and below the they do have signs and/or symptoms, they may present with
diaphragm requires an extended incision spanning the left pain in the chest, abdomen, or lower back; a mass in the abdo­
thorax to the abdomen, the length and exact location of men, which may be pulsatile, or rigid abdomen; and evidence of
which depends on the location of the targeted aortic pathol­ atheroembolism distally. The aforementioned symptoms, with
ogy. Often, the diaphragm must be divided, necessitating an signs of hypovolemic shock, may indicate a ruptured aneurysm.
awareness of the regional anatomy as well as various surgi­ • Uncomplicated descending aortic dissections are generally
cal management considerations. managed medically. However, if the dissection is compli­
cated, such as when it is associated with significant symp­
DIFFERENTIAL DIAGNOSIS toms or leads to visceral or distal malperfusion, rapid
• Thoracoabdominal aneurysm: The Crawford classifica­ surgical intervention is warranted.
• A more complete discussion regarding indications for interven­
tion categorizes thoracoabdominal aneurysms accord­
ing to the extent of the aneurysm and is the most widely tion in aortic dissections and thoracoabdominal aortic aneu­
used 1 ( FIG 1 ) . The classification is as follows : type I, from rysm can be found in a number of relevant reference textbooks.
the left subclavian artery to j ust above the renal arteries;
IMAGING AND OTHER DIAGNOSTIC STUDIES
type II, from the left subclavian artery to the infrarenal
aorta; type III, from the mid-descending thoracic aorta • Imaging is used to determine the proximal and distal extent
to below the renal arteries; type IV, from the diaphrag­ of repair required. It impacts the type of exposure required
matic aorta to the iliac bifurcation; and type V (modified (i.e., thoracotomy vs. laparotomy vs. thoracoabdominal
classification by Safi et aJ.2 ) : from the mid-descending incision) as well as the level of incision.
thoracic aorta. • If the exposure is for the repair of thoracoabdominal aortic
• Descending (type B) aortic dissection: Two classifications pathology, all patients require adequate preoperative imag­
systems are commonly used to describe the extent of aortic ing, ideally consisting of a computed tomography aortography
dissections ( FIG 2 ) . Stanford type A dissections involve the (CTA) with or without 3-D reconstruction. Magnetic resonance
ascending aorta with or without involving the descending aortography (MRA) may also provide the necessary informa­
aorta, whereas type B dissections only involve the descend­ tion, but this generally requires more time, is more expensive,
ing aorta beyond the left subclavian artery. The DeBakey and requires more extensive postprocessing. However, MRA
classification includes type I, which involves both the is the study of choice when CTA is contraindicated or unsafe,
ascending and descending aortas; type II, which involves such as in patients with a contrast allergy or renal insufficiency.
only the ascending aorta; and type III, which involves only Catheter-based invasive aortography has generally been sup­
the descending aorta. planted by CTA and MRA as the primary preoperative imaging

II Ill V
I v

FIG 1 • Mod ified Crawford c l a ssificati o n .


192 1
1 922 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

• Assess the need for spinal cord protection, including the use
of lumbar drainage of cerebrospinal fluid ( CSF), distal aortic
perfusion, epidural cooling, and distal aortic perfusion.
• Given the expected amount of blood loss, a Cell Saver and
rapid infuser should be available.
• Double lumen endotracheal tube should be used for single­
lung ventilation of the right lung. Bronchial blockers are not
reliable adjuncts for this purpose.

Positioning

• Initially, place the patient supine on a deflated beanbag (FIG 3).


Roll the left chest upward and toward the right and place a
shoulder roll under the right axilla and a bump under the left
scapula while also gently pulling and securing the right arm over
to the right side. Ideally, the upper back should be rotated about
60 degrees to the table with the pelvis remaining flat, such that
the trunk is twisted to the right. Position the patient with the
break located halfway between the left costal margin and the left
iliac crest. Jackknife the table and then inflate the beanbag. Be
sure to support and secure the arms ( "airplane" splint for the left
DeBakey II Ill arm) and pad all pressure points on the body and extremities.
• Prep the left chest with the following boundaries: the axilla
Stanford A B
superiorly, the spine posteriorly, and the sternum and abdo­
FIG 2 • Stanfo rd/DeBa key cl assificat i o n . men beyond the right of midline anteriorly. Keep the groins
in the field for surgical access to the femoral vessels for pos­
sible cannulation if necessary.
modality o f choice, as i t i s more cumbersome and does not pro­
vide a complete assessment of the aneurysm, including throm­
bus volume and adjacent anatomic structures.
• If the surgery is elective, as in the case of an incidentally
found aneurysm, extensive preoperative evaluations are nec­
essary to minimize postoperative morbidity and mortality.
• Thorough evaluations of the cardiac, pulmonary, and renal sys­
tems are necessary, especially because these systems are most
commonly affected when there are complications. Depending
on the risk factors and prior history, further testing may be re­
quired and patients should be referred to appropriate specialists
for proper evaluation. A good neurologic evaluation is also war­
ranted, particularly if the patient has a prior history or symp­
toms suggestive of a lower extremity weakness or spinal injury.

SURGICAL MANAGEMENT

Preoperative Planning

• Determine the possible need for adj uncts such as cardiopul­


monary bypass and neurophysiologic monitoring. In some
instances, pulmonary artery catheters may be warranted for
monitoring cardiovascular hemodynamics. FIG 3 • Positi o n i n g .

• The p roxi m a l extent of the path o l ogy a n d the a ntici­


PLANNING THE INCISION
pated location of the p roxi m a l clamp determ i n e t h e l evel
• T h i s c h a pt e r d e a l s w i t h d i sta l t h o r a c i c a o rt i c p a t h o l ­ of the t h o ra c i c port i o n of the i n c i s i o n .
ogy req u i r i n g e x p o s u r e of t h e d i a p h ra g m w h e re a s i m ­ • If the p roxi m a l c l a m p is to be p l aced between the
p l e t h o ra coto m y i n c i s i o n wo u l d n ot b e a d e q u at e . S u c h a o rtic a rch a n d j u st beyond the l eft s u bclavian a rte ry,
m o re l i m ited p a t h o l o g i e s a re d e s c r i b e d e l se w h e r e . the ch est is e ntered through the 4th or 5th i ntercos­
tal spaces (e . g . , Crawford types I l l and V a n e u rysms) .
C h a p t e r 1 4 EXPO S U R E A N D O P E N S U R G I CAL MANAG E M E N T AT T H E D I A P H RA G M 1 923

• If t h e p rox i m a l c l a m p is to be p l aced j u st a b ove or at


the d i a p h ra g m , the 8th or 9th i nterspace s h o u l d be
ente red (e . g . , Crawford type IV a n e u rysms).
• Consider the possi b l e use of p a ra l l e l or " d o u b l e " t h o ra­
coto my i n cisions if expos u re of both the proxi m a l a n d
d ista l extent o f the thoracic a o rta i s needed. I n t h i s case, External
Serratus
the s k i n i n c i s i o n i s p l aced between the l evels of the two oblique
anterior
i nterspaces a ntici pated to be e ntered . muscle
muscle
• The l e n gt h a n d locat i o n of a b d o m i n a l i n c i s i o n is deter­ I nternal
m i ned by d i sta l extent of the a o rtic pathol ogy. oblique Costal
• A mod ified t h o racoa bdom i n a l i n c i s i o n that does n ot muscle margin
exte n d to m i d l i n e is a d e q u ate if l i m ited exposu re of
the a b d o m i n a l a o rta to the level of the ce l i ac a rtery
is req u i red.
• Exte n d the i n c i s i o n to the m i d l i n e for exposure of
the viscera l a o rt a .
• The i n c i s i o n s h o u l d be exte nded down the a b d o m i ­
n a l m i d l i n e f o r m o re extensive exposu re of the i n ­
fra re n a l a bdom i n a l a o rta (types I I , I l l, a n d IV) to t h e
a o rtic b ifu rcation o r com m o n i l i a c a rteries (FIG 4).

FIG 4 • Thoracoabd o m i n a l i n c i s i o n .

• S p l it the exte r n a l a b d o m i n a l o b l i q u e m uscle i n the d i rec­


THE INITIAL INCISION AND EXPOSURE
t i o n of its fi bers.
• M a rk w h e re t h e i n ci s i o n is to be m a d e i n c l u d i n g f i n d i n g • Divide t h e u n d erlyi n g i nternal o b l i q u e a n d t ra n sversus
the a p p ro p r i ate i nterspace a n d the extent o f the a b d o m ­ a b d o m i n u s m u scles between the cost a l m a r g i n and lat­
i n a l i n c i s i o n a s described e a r l i e r. e ra l edge of the rectus sheath.
• Sta rt with the t h o racic i n c i s i o n ove r the a p p ropriate • Divide l eft rectus m uscle .
i nterspace and then exte nd it across the costa l m a rg i n . • The t h o racic i n c i s i o n s h o u l d p rovi de a d e q u ate exposu re
Depe n d i n g o n t h e deg ree o f t h e a b d o m i n a l exposu re re­ posteriorly and s h o u l d be exte nded to the e rector s p i n a e
q u i red, exte nd this i n c i s i o n o b l i q u ely to the m i d l i n e of fasc i a .
the a b d o m e n . The m i d l i n e i n c i s i o n can t h e n be extended • Expose the i ntercosta l m u scles by i nc i s i n g t h r o u g h the
to the l evel of the symphysis p u b is, if n ecessa ry. su bcuta neous tissues a n d the exte r n a l o b l i q u e fasc i a .
• The a b d o m i n a l i n c i s i o n is carried t h r o u g h the su bcutane­
ous tissu es, the exte r n a l a b d o m i n a l o b l i q u e a p o n e u rosis,
and t h e a nterior rectus sheath.

ABDOMINAL EXPOSURE Sepa rate the perito n e u m f r o m the l atera l a n d


poste r i o r a b d o m i n a l wa l l s as we l l as from t h e
• Deve l o p the a b d o m i n a l port i o n of the i n c i s i o n before d ia p h ra g m superio rly.
entry i nto the l eft p l e u r a l cavity • Tra nsperito n e a l : T h i s a p proach provides better expo­
• The a o rta may be exposed by an extra perito n e a l or trans­ s u re for visce r a l a rtery revascu l a rization when req u i red,
perito n e a l a p proa c h . espec i a l l y when bypass i s req u i red to t h e right ren a l
• Extra perito n ea l : T h i s a p p roach is i d e a l for repa i r i n g a rte ry.
t h o racoa bdom i n a l a n e u rysms, especia l ly t h ose i n - • Ad d i t i o n a l deta i l s of these a p p roaches can be fo u n d e lse­
volvi n g the u p p e r a b d o m i n a l a o rta (FIG S) . w h e re and a re beyo n d the scope of t h i s cha pter.
Deve l o p the p l a n e between the tra n sversa l i s
fasc i a a n d the pariet a l perito n e u m .
1 924 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG S • Abdom i n a l a o rtic exposu re via extra perito n e a l


a p p roach.

• Ad d it i o n a l exposure can be o bta i n ed from " n otch i n g "


THORACIC EXPOSURE
a n adjacent r i b . T h i s is acco m p l ished b y exc i s i n g a 2-cm
• Deve l o p a p l a n e su perfi c i a l to the r i bs a n d i ntercosta l seg ment of t h e rib poste r i o r l y
m uscles. • If t w o i nterspaces a re b e i n g entered, deve l o p a n ad­
• H o l d venti lation to the l eft l u n g a n d a l low it to co l l a pse. e q u ate plane a nterior to the ribs. The s k i n a n d ove r l y i n g
• E nter the l eft ch est by open i n g the i ntercost a l space m uscles ca n be retracted to acco m m odate b o t h thoracic
a l o n g the s u p e r i o r edge of the lower r i b, m a k i n g s u re i nterspace exposures.
not to i n j u re the l u ngs. • Use a self-reta i n i n g retractor to m a i nta i n exposu re .
• To maxi m i ze t h e exposu re, it may be n ecessa ry to per­ • Be awa re that there ca n be extensive adhesions with i n
form a s u b p e r i oste a l resect i o n of t h e r i b a bove o r t h e p l e u ra that m a y pred ispose t o l u n g i n j u ry. U s u a l ly,
below the i nterspace entered, depen d i n g o n t h e target these ad hesions can be m o b i l ized b l u ntly if t h i n but may
l ocat i o n . need bovie ca ute ry o r scissors if m o re su bsta nti a l .

EXPOSURE AND DIVISION OF THE


DIAPHRAGM
• Release a n y ad hesions that may be p rese nt, m o b i l ize the
lung by dividing the i nfe r i o r p u l m o n a ry l i g a m e nt, and
retract the lung ce p h a l a d to expose t h e d i a p h r a g m .
• N ext, j o i n the l eft t h o racic cavity a n d the retro perito­
n e u m o r a b d o m e n by d ivid i n g the d i a p h ra g m .
• The diaphragm can be i ncised partia l ly or completely (FIG 6).
• Part i a l i n c i s i o n : I ncise the m uscu l a r portion of the d i ­
a p h ra g m a n d p rese rve the centra l te n d i n o u s port i o n .
T h i s a p p roach m i n i m izes respi ratory co m p l ications.
• Co m p l ete d i v i s i o n : T h i s a p p roach p rovides the best
exposu re of the a o rta. T h i s exte nds the i n c i s i o n from
the d ivided costa l m a r g i n to the a o rtic h i atus. Divi­
s i o n ca n be acco m p l ished either rad i a l l y o r c i rcu mfer­
enti a l ly. B e s u re to leave a p p roxi m ately 2 to 3 em of FIG 6 • Division o f t h e d i a p h ra g m .
d i a p h ra g m from the i ntern a l costa l m a rg i n to a i d i n
t h e l ater c l o s u re o f d ia p h ra g m . T h e c i rcu mferenti a l
a p p roach a lso theo retica l l y m i n i m izes d i s r u pt i o n of
the p h re n i c n e rve a n d is g e n e ra l ly p refe rred .
C h a p t e r 1 4 EXPO S U R E A N D O P E N S U R G I CAL MANAG E M E N T AT T H E D I A P H RA G M 1 92 5

• P l a ce ch est tu bes .
CLOSURE
• Rea p p roxi m ate the i nterspace with m u lt i p l e s i m p l e o r
• After co m p l et i o n of the core s u r g i ca l p roced u re, close fig u re-of-e i g h t heavy (no. 1 ) n o n a bsorba b l e suture.
the d i a p h ra g m . • C l ose t h e incision i n l ayers, i n c l u d i n g the m u scle with
• Ta ke patient o u t o f fl exed position a n d c l ose t h e d i a­ ru n n i n g Vicryl as we l l as the deep dermal layer. Close the
p h r a g m with heavy ru n n i n g suture. skin with su bcutic u l a r sutu res o r sta ples.

PEARLS AND PITFALLS


I n d icat i o n s • Preo perative CTA or M RA is m a n d atory to dete r m i n e the suita b i l ity of the a o rtic pathol ogy for
s u r g i ca l repa i r.
P l a cement of i n c i s i o n • The p l acement of the i n ci s i o n s h o u l d be ca refu l ly considered preoperatively based o n i m a g i n g
a n d the exte nt o f the pathol ogy. A s i n g l e thoractomy i n c i s i o n can b e p l aced even if two i ntercos­
tal spaces need to be entered . To m i n i m ize morbid ity, beg i n with a s m a l l e r i n c i s i o n because it can
a l ways be exte nded w h e n n ecessa ry.
I nj u ry to p h r e n i c • A c i rc u m fe renti a l d ivision of the d i a p h ra g m can p rovi de the best exposure w h i l e a l so m i n i m i z i n g
the risk o f i n j u ry to the p h re n i c n e rve.
C l o s u re • When carryi n g out a c i rcu mfrent i a l d ivision of the d i a p h ra g m , leave 2 to 3 em of d i a p h r a g m
f r o m the i ntern a l costa l m a rg i n for t h e repa i r of the d i a p h ra g m when closi n g .

POSTOPERATIVE CARE COMPLICATIONS


• Monitor in the surgical intensive care unit as necessary for • Bleeding; take back
the extent of the aortic reconstruction required. • Phrenic nerve palsy or paralysis
• Remove chest tubes when drainage is adequately low. • Diaphragmatic hernia
• Continuous spinal cord protection and neurologic monitor­ • Pulmonary complications, respiratory failure
ing immediately postoperatively; continue CSF drainage for • Wound complications
-3 days. • Paralysis; spinal cord ischemic inj ury, associated with thora­
• Follow-up imaging with CTA to establish a baseline coabdominal aortic surgery
• Standard postoperative incision and wound care • Stroke/transient ischemic attack (TIA), associated with tho­
racoabdominal aortic surgery
OUTCOMES • Multiorgan failure, associated with thoracoabdominal aor­
• It is proposed that pulmonary dysfunction associated with tic surgery
• Death, associated with thoracoabdominal aortic surgery
thoracoabdominal aortic surgery is to a large part associated
with diaphragmatic dysfunction. Stickley and Giglia3 recom­
mend a new technique using a gastrointestinal stapler to di­ REFERENCES
vide the diaphragm. This technique is proposed to be "rapid,
1. Crawford ES, Crawford JL, Safi HJ, et a!. Thoracoabdominal aortic
hemostatic, and aids with reapproximation at the completion
aneurysms: preoperative and intraoperative factors determining imme­
of the case" and that "this method of diaphragm division is diate and long-term results of operations in 605 patients. J Vase Surg.
quicker and less traumatic and has the potential to decrease 1 9 8 6 ; 3 ( 3 ) : 3 8 9-404.
the incidence of postoperative pulmonary dysfunction. " 2. Safi HJ, Winnerkvist A, Miller CC III, et a!. Effect of extended cross­
• Huynh et al.4 conclude that renal failure, spinal cord deficit, clamp time during thoracoabdominal aortic aneurysm repair. Ann
and pulmonary complication were the major determinants Thorac Surg. 1 9 9 8 ;66(4): 1204-1209.
3 . Stickley SM, Giglia JS. Novel use of a gastrointestinal stapler for dia­
of length of stay (LOS) in patients for thoracoabdominal
phragm division during thoracoabdominal aortic exposure. Ann Vase
aortic aneurysm (TAAA) repair. Their study has shown that
Surg. 2 0 1 3 ;2 7 ( 5 ) : 6 8 9-69 1 . doi: 1 0 . 1 0 1 6/j . avsg.20 1 2. 1 1 .005.
the preservation of diaphragmatic function and the use of 4. Huynh TT, Miller CC III, Estrera AL, et a!. Determinants of hospital
the adj unct distal aortic perfusion and CSF drainage may length of stay after thoracoabdominal aortic aneurysm repair. J Vase
reduce hospital LOS. Surg. 2002;35 ( 4 ) : 648-653.
-

Chapter 15 Retroperitoneal Aortic


Exposure
r
r

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - · - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - �

Ma tth e w Mel/
t

IMAGING AND OTHER DIAGNOSTIC responses (hives, rash) may be successfully tempered by pre­
STUDIES medication with steroids and antihistamines, depending on the
relative indication for contrast administration and the patient's
General Considerations overall medical condition. Adverse effects of intravenous or

intraarterial contrast administration on creatinine clearance
Retroperitoneal aortic exposure may be desirable for a
may be partially ameliorated by preprocedural oral or in­
variety of vascular conditions, including abdominal aortic
travenous hydration and administration of N-acetylcysteine
aneurysms, aortoiliac occlusive disease, and mesenteric or
(Mucomyst) . Although sometimes considered a reasonable
left renal artery occlusive disease.

alternative under these circumstances, gadolinium-based con­
Retroperitoneal exposure may be preferred for patients with
trast administration for magnetic resonance arteriographic in­
a hostile abdomen from previous intraabdominal infection,
dications is also contraindicated in patients with a creatinine
surgery, or radiation.

clearance less than 60 mL per minute. When contrast admin­
Compared with transabdominal aortic exposure, retroperi­
istration is absolutely out of the question, CT images acquired
toneal exposure may be associated with shorter postopera­
without contrast may provide adequate anatomic imaging to
tive ileus, decreased pulmonary complications, decreased
proceed with surgery, with the caveat that anomalies such as
pain, and lower incidence of late complications including
a retroaortic left renal vein may be present and unrecognized
small bowel obstruction or aortoenteric fistulae. 1

until exposed at surgery.
Retroperitoneal aortic exposure can be converted, when
necessary, to thoracoabdominal exposure with excellent
visualization of the superior mesenteric artery (SMA), left SURGICAL MANAGEMENT
renal artery, celiac axis, and descending thoracic aorta.2 Instrumentation
• Examination of intraabdominal contents is possible through
a retroperitoneal approach by simply opening a peritoneal • In addition to standard vascular instrumentation, additional
window as necessary. equipment may aid in exposure of the aorta and its visceral
branches from the retroperitoneal approach:
Preoperative Imaging Beanbag and airplane for positioning
A fully articulated operative table, capable of flex and
• Prior to aortic reconstruction, detailed anatomic imaging reflex at the level of the umbilicus
derived from modern, multirow detector computed tomo­ Self-retaining, table-mounted retractor (e.g., Bookwalter,
graphic arteriography ( CTA) will greatly facilitate surgical Omni, or other)
planning. Image acquisition should extend from the normal Finochietto chest retractor
proximal aorta to the common femoral artery bifurcations Nos. 3, 4, and 5 Fogarty occlusion balloons
bilaterally. Runoff imaging may also aid decision making Cold renal perfusion
depending on clinical circumstances. Arterial cannulas for renal perfusion
• Data derived from submillimeter imaging slices may be read­
ily reformatted into multiplanar and 3-D reconstructions,
Positioning
with excellent resolution of the peripheral mesenteric and
renal vasculature. • The patient is placed supine on a beanbag and all lines and
• Noncontrast images should also be obtained to help assess tubes are placed. For exposure of the infrarenal aorta and
the degree of mural calcification present in diseased proxi­ iliac arteries, the left shoulder is lifted and protected with the
mal aorta. Recognition of extensive mural calcification may beanbag and padding. The left arm can be abducted or ro­
modify the location chosen for clamp placement, or prohibit tated to the patient's right with a padded airplane retractor
safe clamping entirely in diseased segments. for support. The table break and the kidney bar are used to
• CTA may require larger contrast dose than that required for open up the retroperitoneal space between the 1 2th rib and
catheter-based contrast aortography. Contrast volumes re­ the iliac crest as the incision is developed. For this reason,
quired for CTA may be reduced significantly by modifying it is essential that the patient be positioned with the umbi­
the field of view or imaging parameters required for the pro­ licus on the table break. An oblique incision is made from
cedure. Consultation with the responsible radiologist will below the umbilicus to the tip of the 1 1th rib. With this loca­
ensure optimal imaging of the necessary arterial anatomy tion, the incision can be extended into the 1 Oth intercostal
with minimal contrast and radiation exposure. space and the chest entered if additional proximal exposure
• Contrast-based aortography, either CT or catheter-based, may is required ( FIG 1 ) . When additional iliac artery or pelvic ex­
be contraindicated for patients with reduced creatinine clear­ posure is anticipated, the incision should be initiated distal
ance or an anaphylactic reaction to contrast. Milder allergic to the umbilicus. Either way, in patients with considerable

1926
C h a p t e r 1 5 RETROPERITONEAL AORT I C EXPOS U R E 1 92 7

abdominal girth and redundant pannus, landmarks should


be confirmed to ensure that the incision is not placed too far
distally on the abdomen, as j uxtarenal aortic control can be
extremely difficult when the incision is placed too far distally
on the abdomen.
• For thoracoabdominal exposure, the patient is placed in the
right lateral decubitus position using a beanbag and axillary
role for support. The left arm is protected with adequate
padding and an airplane-type retractor. It is important to
secure the left arm such that the scapula rolls anteriorly,
providing exposure of the posterior lateral chest. The inci­
sion will be made overlying the 8th intercostal space and
extended toward the umbilicus.
, ,
I
I
I
I

FIG 1 • Patient position fo r t h o racoabd o m i n a l exposure with


i n c i s i o n i n the 8th i ntercosta l space (dotted l i ne). Positi o n i n g is
s u p p o rted with a bea n b a g and r i g h t axi l l a ry ro l l .

• The i n c i s i o n is carried t h r o u g h the exte r n a l o b l i q ue, n ey. D e p loyi n g t h e retracto r system e a r l i e r w i l l i nterfere
i ntern a l o b l i q ue, and tra n sversus a b d o m i n i s m uscles. The with the d i ssect i o n n ecessa ry to access the a p p ro p r i ate
retroperito n e a l space is then entered l atera l ly near the retroco l i c space. F o l l o w i n g p l a c e m e n t of the i n it i a l pad­
tip of the 1 1 th rib by identifyi n g the cha racte ristic yel­ ded retractor blade along t h e m ed i a l m a rg i n of t h e
l ow p reperito n e a l fat. The retroperito n e a l space is then w o u n d , ci rcu mfere n t i a l retract i o n i s secu red by p l a ce­
deve loped from l atera l to m ed i a l using a sponge stick ment of a d d i t i o n a l b l a d es, typica l ly o p posite each oth e r
o r h a n d s for blunt d issect i o n . Ante r i o rly, the perito n e u m to p revent u n d u e t e n s i o n o n t h e retract i o n system, with
t e n d s to be m o r e ad h e rent at the level o f the rectus seq uenti a l replacement with deeper b l a d e s and a d d i ­
sheath; ca re s h o u l d be taken to avo i d enteri n g the peri­ t i o n a l retract i o n u n t i l t h e e n t i re p e r i a o rt i c retro pe rito­
tonea l cavity i n t h i s a re a . The psoas fascia i s encou ntered neum i s exposed .
as the d issect i o n is deve loped posteriorly in the cou rse of • The a o rta a n d i l i a c a rteries a re then d i ssected free of
t h i s d i ssection, w h i c h leads d i rectly to t h e l eft i l iac vesse l s su rrou n d i n g tissue. C i rcu mferenti a l a o rtic control is a n
a n d u reter. D i ssect i o n is conti n u e d p roxi m a l ly a nterior to essenti a l safety element o f a l l a o rtic procedu res, a n d care
the u reter; the u reter is either l eft in situ to l i m it i n j u ry s h o u l d be taken to gently and patiently create a space
or gently retracted m ed i a l ly with s i l astic s l i n g s as the ret­ betwee n the i nfe r i o r ve n a cava (IVC), a o rta, and verte­
roperito n e a l space is deve l o ped. bra l bodies poste riorly to pass an u m b i l ical tape a r o u n d
• S u pe r i o rly, the kid ney is identified as the d issect i o n i s the a o rta with a rig ht-a n g l e c l a m p . C i rcu mferenti a l c o n ­
cont i n ued a nterior to G e rota's fasci a-a potenti a l space trol of the co m m o n i l iac a rteri es, o n the o t h e r h a n d , is
exists between desce n d i n g co l o n and G e rota's fascia in not n ecessary i n all circumstances. S uffi cient m ed i a l a n d
the retro perito n e u m , which is p rog ressive ly deve loped in l atera l d issect i o n to a l low f o r p l acement o f a Wyl i e hy­
a ce p h a l a d d i rect i o n from the psoas m uscle, adjacent to pogastric c l a m p a r o u n d the co m m o n i l iac a rtery w i l l usu­
t h e a o rta. O n ce the re n a l ve i n is visu a l i zed i n this spa ce, a l ly suffice. Avo i d a n ce of atte m pts at c i rcu mfere n t i a l i l i ac
the superior m a r g i n of the d issect i o n is co m p l ete. If control will reduce the risk of r i g h t i l i a c ve i n i n j u ry. When
su prare n a l a o rtic control a n d exposu re is req u i red, t h i s c i rcumferenti a l control is req u i red, patience is n eces­
same d i ssect i o n p l a n e s h o u l d be deve l oped poster i o r to sa ry to g ra d u a l l y sepa rate the r i g h t co m m o n i l i a c a rtery
the k i d n ey, e l evat i n g the kid ney a n d u reters a l o n g with from the d i sta l IVC a n d l eft common i l iac ve i n . When a
the perito n e a l contents and retract i n g all to t h e right to ve n o u s i n j u ry is encou ntered d u r i n g t h i s m a n e u ver, d ivi­
expose the s u bd i a p h ra g matic visce ral a o rta. s i o n of the co m m o n i l i ac a rte ry may be n ecessary to g a i n
• Se lf-reta i n i n g retracto r syste m s a re best d e p l oyed ei­ a d e q u ate exposu re f o r contro l . Alternative ly, a n occ l u ­
t h e r afte r t h e psoas m u scle i s i d e ntified o r fo l l owi n g s i o n ba l l oo n may be i ntrod uced f r o m the right c o m m o n
exposure o f t h e re n a l ve i n o r e l evat i o n of t h e l eft k i d - fe m o ra l o r exte r n a l i l i ac ve i n s w i l l t a m p o n a d e the ve n o u s
1 928 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

b l eed i n g u n t i l sufficient expos u re is g a i ned to repa i r


t h e wo u n d . F i n a l ly, a cove red se lf-expa n d i n g endog raft
may a lso be d e p l oyed over a w i re to g a i n contro l . Ag a i n,
readj ustment of the retractor syste m with each consecu­
tive sta g e of exposure w i l l o pt i m ize o perative effi ciency.
Freq uently, to opti m i ze d ista l exposu re, the p roxi m a l re­
tractor b l a d es need to be tempora r i l y rel axed a n d vice
versa.
• T h i s exposu re provides a d e q u ate exposu re to the i nfrare­
nal a o rta (and i nfe r i o r mesenteric a rtery if re i m p l a ntat ion
is a ntici pated), r i g ht a n d l eft co m m o n a n d l eft exte r n a l
i l i ac a rteries. The r i g ht exte r n a l i l iac a rtery is n ot we l l
visua l i zed from t h i s a p p roach, a l t h o u g h tu n n e l i n g t o the
right fem o r a l a rtery is read i l y a c h i eved for a o rtofe m o r a l
bypass g raft i n g when n ecessa ry. Ca re s h o u l d be t a k e n
to deve l o p the t u n n e l i m med iately a nterior to t h e i l i a c
a rteries to a v o i d i nj u ry to the r i g h t u rete r o r tra p p i n g the
u reter betwee n the g raft limb a n d adjacent a rte ry. When
right exte r n a l i l i a c a rtery exposure i s req u i red d u ri n g a
l eft retrope riton e a l exposu re, a cou nteri ncision may a lso
be p l aced in the r i g h t lower q u a d ra nt, a lt h o u g h patient
positi o n i n g a n d retractor syste m p l a cement may l i m it the
potenti a l use of t h i s m a n e uver.
• For p roced u res req u i ri n g m o re proxi m a l , viscera l a o rt i c FIG 2 • The d i a p h ra g m is i n cised c i rcu mferenti a l ly (d otted
exposu re, the latiss i m u s dorsi i s identified a n d d i ssected l i ne) to p rotect the p h re n i c n e rve a n d t h e reby preserve
from su rrou n d i n g s u p e rfi c i a l and deep tissues and re­ d i a p h ra g matic f u n ct i o n . A o n e-to two cent i m eter cuff of
tracted l atera l ly. The 8th i ntercosta l space is opened pos­ d i a p h ra g m is l eft attached to the ch est was to a i d e in closure.
teriorly to the parasp i n a l m uscles and a nteriorly to the
costa l m a r g i n , w h i c h is d ivided. As the retroperitoneal
space is deve loped, the perito n e u m is b l u ntly sepa rated • D i ssect i o n of t h e p l a n e poste r i o r t h e G e rota's fascia
from the i nfe r i o r su rface of the d i a p h r a g m . The d i a­ a l l ows for expos u re of t h e l eft renal a rte ry, which i s
phragm is d ivided i n a ci rcumferenti a l m a n n e r 1 to 2 em a n i m p o rt a n t l a n d m a r k i n f u rt h e r d i ssect i o n of t h e vis­
from its atta c h m e nts to the ch est wa l l to avo i d i n j u ry to cera l a o rt a . O n ce t h e o r i g i n of t h e l eft renal a rtery i s
the p h r e n i c n e rve (FIG 2) . The m e d i a n a rcuate l i g a ment i d e ntified a n d t h e m e d i a n a rcuate l i g a m e n t h a s b e e n
is i d e ntified a n d d ivided. Prox i m a l a o rtic control can n ow d iv i d e d , t h e v i scera l a o rta a n d o r i g i n s of t h e c e l i a c a x i s
be obta i n e d u n d e r d i rect vision, a g a i n fo l l ow i n g strate­ a n d S M A ca n be i s o l ated with s h a r p d i ssect i o n . W i t h
g i c p l a cement of self-reta i n i n g retractor b l a des, t a k i n g t h e l eft k i d n ey rotated a nt e r i o r ly, t h e S M A c a n be
ca re to identify a n d a v o i d i n j u ry to the eso p h a g us. exposed over a d i st a n ce of a p p ro x i m a t e l y 5 em (FIG 3) .

FIG 3 • Exposu re o f the viscera l a o rta


with the l eft k i d n ey l i fted to expose the
l eft renal a rtery a n d the entire poste r i o r-
latera l a o rta. N ote that the l eft re n a l ve i n
ro l ls off t h e a o rta.
C h a p t e r 1 5 RETROPERITONEAL AORT I C EXPOS U R E 1 929

A d d i ti o n a l exposu re c a n be o bta i n e d by rotat i n g t h e


k i d n ey poste r i o r to expose t h e S M A a s it cou rses b e h i n d
t h e p a n c reas (FIG 4).
• Fol lowing vascu l a r repa i r, the retro perito n e a l space
s h o u l d be i n spected fo r hem ostasis. The u reter s h o u l d be
i n s pected, and any suspected i n j u ry o r leak ca n be i n ves­
tig ated with i ntrave n o u s methyl e n e b l u e . If needed, the
perito n e u m can be opened for i nspect i o n of a b d o m i n a l
contents.
• Remov i n g t h e ta b l e break or lowe r i n g the k i d n ey bar
if used will a i d i n a p p roxi m a t i n g tissue l ayers without
tension.
• If d ivided, the d i a p h ra g m can be rea p p roxim ated with
a cont i n u o u s ru n n i n g a bsorba b l e suture. The suture can
be secu red at t h e a nterior costa l m a r g i n and w i l l h e l p
a p p roxi m ate these structu res a s we l l .
• If t h e t h o rax was entered, a l a rge-bore ch est tube i s
p l aced dependently a n d secured w i t h U stitches.
• A l a rg e B l a ke or Jackson-Pratt d r a i n can be p l aced in the
retroperito n e a l space to avo id early posto perative f l u i d
co l l ections.
• The m uscu l a r l ayers a re cl osed with cont i n u o u s a bsorb­
able sutu res and the s u bcuta neous tissue and skin c l osed FIG 4 • Exposu re of the viscera l a o rta with the l eft k i d n ey

with sta n d a rd tec h n i q ues. l eft in situ. T h i s a p p roach a l l ows for a d d i t i o n a l exposu re of
the p roxi m a l s u p e r i o r mesente ric a rtery.

PEARLS AND PITFALLS


• Choosi n g the m ost a p p ro p r i ate p roced u re for a n y g iven patient with m esenteric or re n a l a rtery occ l u sive d i sease is dependent o n
a m u ltitude of factors, especia l ly w i t h the w i despread ava i l a b i l ity of percuta neous i nterventions. Open surgical p roced u res c o n ­
t i n u e to rem a i n a n exce l lent a ltern ative f o r patie nts with m u ltivessel d i sease, with coexist i n g a o rto i l i ac occ l u sive o r a n e u rysm a l
d i sease, a n d with d isease too extensive t o b e adeq uately treated with wi re-based tec h n i q ues. When select i n g from t h e va riety of
open p roced u res, patient comorbid ity, body h a b itus a n d its i m pact on a d e q u ate exposu re, q u a l ity of the i nflow a n d outflow ves­
sels, a n d a b i l ity to safely c l a m p vessels s h o u l d a l l be taken i nto co n s i d e rat i o n . Havi n g a work i n g knowledge of a l l a lternatives is
i m porta nt, as occa s i o n a l ly, i ntraoperative fi n d i ngs d i ctate a deviation from the preoperative p l a n .
• I ntraoperative m a n a g e m e n t is s i m i l a r to t h a t f o r other abdom i n a l vascu l a r p roced u res. When the d issect i o n i s co m p l ete, patie nts
a re g iven h e p a r i n at a dose of 1 00 u n its/kg prior to c l a m p i n g vessels, a c h i evi n g a ta rget activated clott i n g t i m e (ACT) of 200 to
250 secon d s . For cases where renal perfus i o n is i nterrupted, 0 . 2 5 to 0.5 g/kg of m a n n itol is g iven p r i o r to cross-c l a m p i n g . As soon
as poss i b l e, the k i d n ey i s perfused with 300 to 400 m l of sa l i n e cooled to 4"C. T h i s may be d o n e at the ren a l a rtery ost i u m i m me­
d i ately after a renal e n d a rte recto my, o r d i rectly i nto t h e renal a rtery at the level of the d i stal a n a stomosis. Renal a rtery ca n n u l as,
w h i c h come in a variety of si zes, a re used for perfu s i o n . U s i n g a size that m ost closely matches the d i a meter of the ren a l vessel
assu res that the perfusate w i l l g o i nto the k i d n ey and not s p i l l onto the operative f i e l d .
• When revasc u l a rization is co m p l ete, h e p a r i n is reversed w i t h p rota m i n e w h i l e checking for h e m ostasis. The patency of revascu­
l a rization may be checked with i ntraoperative d u p lex i m a g i n g . Confi rmation of a n a d e q u ate e n d p o i nt is especi a l ly i m porta nt
w h e n e n d a rterectomy h a s been perfo rmed, as i n t i m a l f l a ps may p resent a s a d e l ayed vessel occ l u s i o n a n d end-organ l oss.

POSTOPERATIVE CARE ischemia. During this time, urine output is not reflective of
the patient's overall volume status, and crystalloid should
• In addition to the standard postoperative strategies for be given at rates sufficient to maintain central filling pres­
patients undergoing aortic surgery, including serial hema­ sures. Also, serum creatinine should be serially measured.
tocrit and hemoglobin, electrolytes, creatinine, and lactic It is common for the serum creatinine to increase slightly
acid, it is important to monitor renal and intestinal func­ in the first 1 or 2 postoperative days, but increases of more
tion. Patients undergoing renal revascularization commonly than 20% or 3 0 % warrant further investigation, especially
have an obligatory diuresis for the first 12 hours after sur­ if associated with oliguria. Sudden changes in renal function
gery. This phenomenon may be due to residual effects of that are unexplained or unresponsive to corrective measures
operative mannitol as well as a response to transient renal warrant duplex imaging to determine renal perfusion.
1 930 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

• Patients after mesenteric revascularization often develop the anastomosis. Additionally, the anastomotic site should
hyperactive peristalsis, sometimes while the incision is still be chosen in a similar coronal plane to prevent kinking once
open. Under these circumstances, serial examination for the end organs assume their natural position.
bowel sounds in the first 24 hours can provide clues to the
continued patency of the revascularization. Serial lactate Injury during Endarterectomy
levels are also checked. Although immediate postoperative
• Identifying the appropriate endarterectomy plane is usually
lactate levels are elevated, they should return to normal as
the patient is warmed and resuscitated. Coagulation param­ straightforward in the aorta, renal arteries, and SMA. The
eters may also be elevated initially in response to blood loss celiac artery can be challenging, as it may be thin-walled,
and transient hepatic ischemia. These parameters should be and plaque removal may injure the arterial wall. Limited
monitored and corrected for active bleeding; normal values injuries can be repaired with interrupted 4-0 or 5-0 Prolene
sutures supported with Teflon pledgers, but larger injuries or
are usually present by the first postoperative day.
those with severely attenuated vessel walls may not be suc­
cessfully repaired with this technique. If the integrity of the
COMPLICATIONS artery is in doubt, it may be safer to transect it and perform a
General Considerations
bypass from the aorta to the transected celiac artery using an
8 -mm or 1 0-mm graft. The celiac artery stump can be over­
• As with all aortic surgery, potential complications after vis­ sewn with pledgeted 3-0 Prolene suture placed into healthy
ceral artery revascularization include myocardial infarction, aorta. Unacceptable endpoints after renal endarterectomy
respiratory failure, and postoperative bleeding. Addition­ are best treated with conversion to a bypass.
ally, renal failure is always a potential complication during
visceral revascularization, although its incidence is low.3-5 Inadequate Distal Endarterectomy Endpoint
Potential causes of renal failure include generalized hypo­
• Plaque extending to the infrapancreatic SMA may be dif­
perfusion from cardiac dysfunction or hypovolemia, pro­
longed intraoperative ischemia, or thrombosis of the repair. ficult to entirely remove with standard thoracoabdominal
Progressive or unexpected renal failure should initiate a exposure. Intraoperative duplex can confirm an adequate
prompt workup including duplex imaging of the kidneys endpoint, and if there is any uncertainty, the abdominal cav­
to identify potentially treatable causes. Thrombosis with ity can be entered and the SMA exposed by dividing the liga­
absence of flow to the kidney is generally irreversible unless ment of Treitz. This maneuver will provide exposure of the
identified immediately. SMA as it emerges from behind the pancreas, usually at a
• Intestinal ischemia is the major concern after mesenteric place distal to the diseased segment. Inspection by palpation
revascularization. Signs and symptoms may include severe or with duplex ultrasound can evaluate the repair. Incomplete
abdominal pain, continued acidosis, and hematochezia. endarterectomy or intimal flaps can be managed through an
Ischemia may be secondary to vessel or graft thrombosis arteriotomy at this location. A reasonably sized SMA can be
or may result from distal embolization during or follow­ transected and the retained plaque removed; reapproxima­
ing the repair. Patients with evidence of peritonitis should tion with interrupted sutures will secure the intima distal to
be promptly reexplored, and those treated initially for acute the endarterectomy. Exposing the endpoint in a smaller ves­
mesenteric ischemia should have a planned second look at sel is most safely performed with a lateral arteriotomy and
12 to 24 hours if there was any question of intestinal viabil­ subsequent patch angioplasty closure to prevent narrowing.
• Problematic endarterectomy endpoints in the celiac artery
ity at the time of the original operation. Arterial duplex may
confirm the viability of the repair but cannot rule out embo­ or renal arteries may be best managed with placement of a
lization as a cause for postoperative intestinal ischemia. At bypass graft. Conversion to bypass will require enough ex­
exploration, nonviable intestine can be resected, and issues posure of the target vessel to allow for revascularization dis­
with the revascularization can be addressed. tal to the diseased segment. Either end-to-end or end-to-side
reconstruction is acceptable and should be performed, mak­
Graft or Vessel Twisting or Kinking ing certain that the intima is secured with the suture line.

• When performing a bypass to the SMA, it is important to re­


REFERENCES
tract the mesentery in a caudal direction to adequately assess
graft length. Inadequate positioning will result in excessive 1. Leather RP, Shah DM, Kaufman JL, et al. Comparative analysis of
graft length and potential kinking and thrombosis once the retroperitoneal and transperitoneal aortic replacement for aneurysm.
Surg Gyneeol Obstet. 9 8 9; 1 6 8 ( 5 ) : 3 8 7-39 3 .
peritoneal contents are reduced to the abdomen and the inci­
2. Mell MW, Acher CW, Hoch J R , et a l . Outcomes after endarterectomy
sion is closed. Additionally, for retrograde bypass, the graft for chronic mesenteric ischemia. ] Vase Surg. 2008;48 ( 5 ) : 1 1 32-1 1 3 8 .
should be placed with enough slack to allow the distal end­ 3. Kasirajan K , O'Hara PJ, Gray BH, e t al. Chronic mesenteric ischemia:
point to be in-line with the SMA with caudal retraction of open surgery versus percutaneous angioplasty and scenting. J Vase
the intestines. This positioning will prevent both kinking Surg. 200 1 ; 33 ( 1 ) :63-7 1 .

of the graft and tenting and narrowing of the anastomosis. 4. Rapp JH, Reilly LM, Qvarfordt PG, e t a l . Durability of endarterectomy
and antegrade grafts in the treatment of chronic visceral ischemia.
Bypass to the renal arteries should similarly be constructed
J Vase Surg. 1 9 8 6 ; 3 ( 5 ) : 799-806.
with appropriate graft length as it will lay in the retroperi­ 5. Wei bull H, Bergqvist D, Bergentz SE, et al. Percutaneous transluminal
toneum after retraction is released. For cases of arterial renal angioplasty versus surgical reconstruction of atherosclerotic renal
reimplantation, it is important to maintain orientation of artery stenosis: a prospective randomized study. J Vase Surg. 1 9 9 3 ;
the target vessel to prevent twisting during construction of 1 8 (5 ) : 84 1-850; discussion 850-842.
- I

Chapter 16 Hybrid Revascul arization


Strategies for Visceral/Renal
Arteries
. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - �

Benja m in W Sta rn es

DEFINITION IMAGING AND OTHER DIAGNOSTIC


• The term " hybrid" in vascular surgery traditionally refers to STUDIES
the use of both traditional open surgical and endovascular • Contrast-enhanced, axial thin-slice computed tomography
techniques for remedy of the vascular condition ( FIG 1 ) . arteriography ( CTA) is the current standard for imaging
• Two hybrid approaches are described i n this chapter. paravisceral aneurysms. Detailed information can be gath­
Complete visceral debranching and endovascular tube ered regarding the precise origin of the celiac, superior mes­
graft repair enteric artery (SMA), and renal arteries ( FIG 2 ) .
Partial visceral debranching and physician-modified fenes­ • Other important findings o n CTA should be a s follows:
trated endovascular repair Size and quality of access vessels for delivery of endovas­
cular devices ( > 7 mm)
DIFFERENTIAL DIAGNOSIS Location of left renal vein
• Paravisceral aortic aneurysms may develop due to the fol- Aberrant anatomy (e.g., replaced right hepatic artery)
lowing conditions: Quality of gastroduodenal artery for possible celiac artery
Degenerative aneurysm ligation or sacrifice
Aortic dissection Renal cortical thickness
Mycotic aneurysm
SURGICAL MANAGEMENT
Paraanastomotic j uxtarenal aneurysm
Connective tissue disorders (Marfan's syndrome) • Indications for repair include aortic aneurysms of more than
Beh<;et syndrome 5 . 5 em, symptoms, or evidence of rapid expansion ( > 0 . 5 em
per 6 months) .
PATIENT lll STORY AND PHYSICAL FINDINGS
Preoperative Planning
• The maj ority of patients are asymptomatic and the diagnosis
is made with imaging done for other reasons. Some patients • As formal open repair would often include a bicavitary incision
will complain of mild to moderate abdominal and low back (chest and abdomen, as in a formal thoracoabdominal repair),
pain. Severe and unrelenting pain should raise the index of the standard preoperative assessment should focus on the pa­
suspicion for a mycotic process which, if confirmed, would tient's fitness to undergo major vascular surgery. This includes
make hybrid approaches prohibitive. assessment of heart, lung, and kidney function and reserve.

FIG 1 • " Hybrid repa i r " refers to the use of both


trad iti o n a l open s u r g i ca l and e n d ovascu l a r tech n i q u es
to m a n a g e the same p ro b l e m . S M A, superior m esenteric
a rtery. A. I ntraoperative p h oto. B. Post operative CTA
after co m p l eted repa i r.

193 1
1 932 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 2 • CTA axial i m ages d e p i ct i n g (A) a 7 .4-cm paraan asto motic


j uxta rena l a o rtic a n e u rysm a n d (B) a hea lthy a o rtic seg ment in
the reg i o n of the SMA.

I
Positioning I
I
• I
Proper and precise positioning should be as follows ( FIG 3 ) :
I
Patient supine o n standard operating room table o r imaging I
I
table ...
I
Hair properly clipped over entire abdomen and both
r "'
groins I
Both arms tucked ( option to have right arm at 90 degrees I
I
if planning brachial access) I
I
Foley under one leg and padded I
I

FIG 3 • Depict i o n of positi o n i n g a n d i ntended i n c i s i o n in the


m i d l i ne.

COMPLETE VISCERAL DEBRANCHING AND • The t h i rd a n d fo u rt h port i o n s of the d u o d e n u m a re mo­


b i l ized to the right fo l l owi n g d ivision of the l i g a m ent of
ENDOVASCULAR TUBE GRAFT REPAIR­
Tre itz, expos i n g the a nterior su rface of t h e a o rta. The in­
STAGE 1 ferior m esenteric ve i n is l i g ated and d ivided a s we l l and
the d i ssect i o n conti n u e d along the prox i m a l a o rta u n t i l
First Step-Exposure
the l eft renal ve i n is clearly identified (FIG S) .
• Sta n d a rd m i d l i ne l a pa rotomy a n d positi o n i n g of retractor • Widely m o b i l ize t h e l eft r e n a l ve i n s h a r p l y a n d e n c i rc l e
system w i t h a m o i st u m b i l i cal tape. The self-reta i n i n g re n a l ve i n
• U po n e ntry i nto the a bdomen, the fa l ciform l i g a m ent is retractor b l a d e is used t o retract t h e l eft re n a l vei n ce p h ­
d ivided between c l a m ps a n d l i g ated . The tria n g u l a r l i ga- a l a d a s necess a ry to fac i l itate f u rther exposure.
me nts a bove the l iver a re d ivided to fac i l itate a d e q u ate • The origin of the re n a l a rteries is identified by ca refu l
exposu re/retract i o n w h i l e m i n i m i z i n g risk of hepatic cap­ posterol atera l d i ssection a ro u n d the aorta, j ust cep h a l a d
s u l a r i n j u ry, a ntici pati n g syste m i c a nticoa g u l at i o n l ater in o f the overlyi n g re n a l vei n . Exposure o n the r i g ht is com­
the p roced u re . p l i cated somewhat by the overlyi n g i nfe rior ve n a cava/
• A nasogastric tube is positi oned in the sto mach to provide l eft ren a l ve i n confl uence. At l east 2 em of re n a l a rtery
temporary deco m p ress i o n . The common hepatic a rtery s h o u l d be exposed b i l atera l ly. E n c i rcle the ren a l a rteries
is identified fo l l owi n g d ivision of the gastrohepatic l iga­ with s i l astic vessel loops. O n the l eft, finger d issect b l u ntly
ment a n d traced back to origin of celiac a rtery. Once iden­ along the aorta i n a cep h a l a d fas h i o n to com p l ete the ret­
tifi ed, the ta rget a rtery is e n c i rcled with a si lastic vessel ropa ncreati c t u n n e l for the ce l i a c l i m b of the bypass g raft.
loop. Space is created a l o n g the l eft side of the a o rta with • The SMA is i d e ntified n ext by pa l pation with i n the base
b l u nt/fi nger d i ssection, beg i n n i n g at the level of the ce l i a c of the sma l l bowe l mesente ry, d i rectly a nterior to the
a rtery, to create the retrograde bypass t u n n e l posterior t o pancreas. D o p p l e r u ltrasonography may assist identifi­
the pancreas (FIG 4). cation when the pu lse is fa i nt. O n ce id entified, a 3-cm
• The colon a n d omentum a re l ifted i n a ce p h a l a d d i rec­ seg ment of SMA is isol ated as p roxi m a l as possi ble to the
tion, the s m a l l bowel swept to the patie nt's right a n d root of the m esentery. B eg i n n i n g with the m i d d l e co l i c
packed i n m o i st towe ls. Self-reta i n i n g retractors (Om n i a rte ry, m u lt i p l e mesenteric a rteries q u ickly branch from
o r Bookwalter) s h o u l d b e positioned a t t h i s j u n ct u re to the S M A as it e m e rges from the pancreas, u n dersco r i n g
m a i nta i n exposu re, with ca re taken to a p propriately pad the n e e d for proxi m a l identification a n d isolat i o n . T h e
the retractor b l ades as n ecessa ry. S M A is contro l led w i t h vessel loops.
C h a pt e r 1 6 H Y B R I D REVAS C U LARIZAT I O N STRATEG I ES FOR V I S C E RAL/RENAL ARTE R I E S 1 933

FIG 4 • D rawi n g of exposu re of the ce l i ac


a rtery t h r o u g h the lesser sac. N ote the b l u nt
f i n g e r d issect i o n a l o n g the l eft side of the
a o rta a n d b e h i n d the pancreas.

• T h e n ext step is t o prepare t h e d o n o r a rtery f o r hybrid by­ a rtery exposu re may be a c h i eved via m e d i a l-visce ral rota­
pass. The specific a rtery-m ost com m o n l y the com m o n or tion, deve l o p i n g the entire retro perito n e a l p l a n e o n the
exte r n a l i l iac a rteri es-s h o u l d be sel ected from the p re­ l eft. The l atte r a p p roach provides the added ben efit of
ope rative i m a g i n g study. The retroperito n e u m is opened exc l u s i o n of the g raft from the viscera a n d abdom i n a l
d i rectly over the sel ected d o n o r a rte ry, w h i c h is exposed contents o n c e the viscera a re retu rned to t h e i r orig i n a l
w h i l e p rotect i n g the adjacent u reter. Alternatively, d o n o r posit i o n . T h i s m a neuver a d d s s i g n ificantly m o re t i m e to

�---- Left renal vein

_..-L---'--- I nferior
mesenteric
vein

-"'�-..,--..:.;"-..,�--.:,..=-7--- I nferior
mesenteric
artery

FIG S • D rawi n g of exposu re of t h e l eft


re n a l ve i n a n d a nterior su rface of the a o rtic
a n e u rysm . Dashed line d e p i cts i ntended
incision line to avo i d n ervi e r i g e ntes.
1 934 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

the case, h oweve r, a n d contri b utes to i ncreased b l ood


loss. G raft cove rage can a l so be obta i n ed without deve l ­
o p i n g the e n t i re retroperito n e a l p l a ne, e i t h e r via d i rect
t u n n e l i n g a l o n g the p refe rred cou rse of the g raft or cre­
ation of an omental tongue affixed d i rectly to the g raft .

Second Step-Anticoagulation

• System i c a nticoa g u lation is achieved with a bolus i njec­


tion of u nfractionated heparin, 50 u n its/kg . M o n itori n g
activated clott i n g t i m e is a usefu l method of m a i nta i n i ng
adequate a nticoa g u lation d u ri n g the p roced ure.

Third Step-Multivisceral Bypass

• Trifu rcated g rafts exist for the pu rpose of fa c i l itati n g


m u ltivessel hybrid revasc u l a r ization, b u t the u s e o f these
a re l i m ited by the tende n cy of the m i d d l e l i m b to occ l u d e
w h e n "squeezed " betwee n the outside l i m bs d u r i n g g raft
rout i n g a n d a bdom i n a l closure. In m ost circumstan ces, a
sta n d a rd 1 2 x 7 bifu rcated, co l l a g e n - i m preg n ated kn it­
ted po lyester g raft provides exce l lent condu its for b i l at­
e ra l renal revasc u l a rization, with a sepa rate 8-mm l i m b
c o n n ected t o t h e ce l i a c a n d S M A . Exa m ples o f bypass
g raft confi g u rations a re s h own in FIGS 6 and 7.
• The prox i m a l ( i l i ac/i nfl ow) a n a stomosis is co m p l eted fi rst FIG 7 • Aortob i i l i ac a n d su bseq uent d e b ra n c h i n g for a

with ru n n i n g 4-0 or 5-0 polypropy l e n e suture. patient with a sol itary l eft kid ney a n d i nfra renal a n e u rysm .
• The n ext a nasto mosis to be completed should be o n e an­
tici pated to be the tec h n ica l ly m ost d iffi cu lt, g iven expo­
s u re and g raft routi n g issues. M ost co m m o n ly, this is the p u l led t o l e n gth a n d a n a stomosed end-to-e nd with 5-0
right re n a l a rte ry. This is d ivided fo l l owing p l a cement of polypropylene suture. The l i m b and a rtery a re flushed j u st
a l a rg e c l i p at the orig i n . The a p p ropriate g raft l i m b is prior to co m p l etion of the g raft, after which the c l a m ps
are released to reperfuse the kid ney. Following t h i s se­
q u e nce, warm re n a l isch e m i a t i m e is g e n e ra l ly l ess t h a n
1 2 m i n utes. The stu m p o f the r i g ht re n a l a rtery is then
suture l i g ated; avo i d c l i p d islodgement. Note: Excessive
tract i o n o n the confl uence of the l eft re n a l ve i n and vena
cava may cause cava l i n j u ry and massive hemorrhage d u r­
i n g preparation a n d co m p letion of the right re n a l a rtery
a nastomosis. Retractor posit i o n i n g needs to acco u nt for
potentia l ve nous i n j u ry d u r i n g exposure and s i g n ificantly
relaxed fo l l owi n g comp leti o n of the a n asto mosis.
• The left ren a l anastomosis is com p l eted in nearly identica l
fashion, m i n u s m a ny of the exposure l i m itations present
o n the rig ht.
• The S M A g raft is ca refu l ly sized to length so that it fol­
l ows a " ( " -sha ped confi g u ration without k i n k i n g . I nflow
can be obta i n e d either from the m a n y bodies of the g raft
or either of the co m p l eted r e n a l l i m bs . The S M A-g raft
a n asto mosis is co m p l eted e n d-to-s ide with i nterru pted
o r ru n n i n g 5-0 polypropylene suture. The e n d-to-s ide
a rteri otomy l e n gt h is 1 . 5 to 2 t i m e s the width of the
bypass g raft ( 1 2 to 16 m m ) . Alternatively, end-to-e nd
a n asto motic co nfi g u ration may reduce the l i ke l i h ood of
g raft k i n k i n g depen d i n g o n final confi g u rati o n . Fol l ow­
i n g com p l et i o n of the a n asto m osis, the proxi m a l SMA is
l i g ated with a l a rg e c l i p o r c i rcu mference suture. Ag a i n ,
FIG 6 • D rawi n g of a fou r-vesse l debra n ch i n g based off of isc h e m i a t i m e s h o u l d be u n d e r 1 0 to 1 2 m i n utes.
the l eft co m m o n i l i a c a rte ry. N ote that the l eft renal ve i n was • Typical ly, fo l l owi n g S M A a n d ren a l g raft co m p letion, repo­
d ivided in t h i s case, a n d su bseq uently repai red, for bette r siti o n i n g of the retraction system is n ecessa ry to reobta i n
exposure of the r e n a l a rteries. a n d opt i m ize celiac a rtery expos u re . Prior t o reexposi n g
C h a pt e r 1 6 H Y B R I D REVAS C U LARIZAT I O N STRATEG I ES FOR V I S C E RAL/RENAL ARTE R I E S 1 93 5

the celi ac, a vascu l a r c l a m p is repassed through t h e ret­ is tied to the u m b i l ical tape, w h i c h is then p u l led cepha­
ropancreatic t u n n e l l eft of the a o rta. This position is then lad beh i n d the p a ncreas a n d i nto position for either end­
m a i nta i n ed u n t i l the tra nsverse colon a n d mesoco l o n to-end o r end-to-side a n astomosis. Care a g a i n needs to
a re reduced to t h e i r usual locati o n . T h i s reexposes the be taken to o pt i m ize limb rout i n g a n d length to m i n i m ize
" l ooped " ce l i a c a n d co m m o n h e patic a rteries previously risk for k i n k i n g .
isol ated i n the Jesser s a c . T h e c l a m p t i p exit i n g the retro- • After coverage of rem a i n i n g exposed g raft l i m bs with
h e patic tunnel is identified, a n d a m o i st u m b i l ical tape is omentum o r parieta l perito n e u m as a p p ropriate, sta n d a rd
p u l led through the tunnel. Following t h i s, the ce l i a c l i m b abdom i n a l closure is performed.

COMPLETE VISCERAL DEBRANCHING AND 0.035-in stiff (e . g . , L u n d e rq u i st®, C o o k M e d i c a l , B l oom­


i n gton, I N) w i re t h rou g h t h e a bdom i n a l a n d thoracic
ENDOVASCULAR TUBE GRAFT REPAIR­
a o rta. O pt i m a l f i n a l w i re positi o n i n g i s at/j u st d i sta l to
STAGE 2 the l eft subclavian a rtery orifice.

First Step-Percutaneous Access


Third Step-Intravascular Ultrasound
• F o l l o w i n g the "debranch i n g " p roced u re descri bed i n
• An 8.2-Fr Visions® catheter (Volcano Therapeutics, I rv i n e,
sta g e 1 , e n d ovascu l a r a n e u rysm repa i r (EVAR) m a y be
pe rfo rmed either at the same sett i n g o r with i n seve ra l CA) is used to confirm a p p ropriate p roxi m a l a n d d ista l
weeks of the i n it i a l p roced u re . The risk of potential a n ­ l a n d i n g zones for endovascu l a r g raft placement. The opti­
e u rysm r u pt u re associ ated w i t h a sta ged a p p roach needs mal g raft size a n d config u ration is dete r m i ned by a n a lysis
to be b a l a n ced with the a d d i t i o n a l operative risk i n h e r­ of CTA i m ages reformatted and visu a l i zed o n a dedicated
ent i n t h e l o n g e r a n esthetic t i m e req u i red to co m p l ete 3-D i m a g e workstation (Aq uariusNet®, Te raRecon, I nc,
both sta ges in one sitt i n g . For the EVAR p roced u re itself, S a n M ateo, CA) . G raft d i a m eter s h o u l d be ove rsized by
sta n d a rd percuta neous access to an a p p ro p r i ately sized 1 0 % to 1 5 % for t h i s a p p l icat i o n .
• D u r i n g adva ncement of the device, the orig i n of the
access vessel is obta i n e d using S e l d i n g e r tech n i q u e and
a w i re adva nced i nto the a o rta under f l u o rosco p i c g u id­ debra n c h i n g g raft ca n a l so be visua l i zed either t h rou g h
a n ce. I n o u r p racti ce, t h i s i s m ost co m m o n ly o bta i n e d f l u o rosco p i c confi rmation o f a meta l l ic c l i p p l aced d u r i n g
percuta neous ly, u s i n g u ltraso u n d g u i d a n ce a n d preplace­ the debra n c h i n g p roced u re o r u n d e r i ntravasc u l a r u ltra­
ment of polypropy l e n e suture p r i o r to d i lation of the sound (JVUS) rea l-t i m e g u i d a nce. Using IVUS, the posi­
access sites (a lso known a s the " p reclose" Perc l ose® tech­ tion of the IVUS catheter is m a rked o n the f l u o roscopic
n i q u e (Abbott Vascu l a r I n c, Redwood C ity, CA) . 1 An 1 1 -F r m o n itor when the cath ete r itself reco g n i zes the orifice
sta n d a rd s h eath is p l aced i nto the com m o n fe moral a r­ of the debranched g raft. Alternative ly, a contrast powe r
tery a n d fl ushed with hepa r i n ized sa l i n e . W i re adva nce­ i nject i o n can be performed t h ro u g h an a p p ro p r i ately po­
ment from the fe moral a rtery to the a o rtic a rch m u st be sitioned a rte r i o g ra p h i c catheter with 30 m l of contrast
visu a l i zed ra d i o g ra p h ica l ly t h roug hout its cou rse, as the i nj ected at 1 5 ml per seco n d to confirm the proxi m a l a n d
w i re may p referenti a l ly enter the debra n c h i n g g raft a n d d i sta l l a n d i n g zones.
c a u s e end-organ i nj u ry o r hemorrhage without rea l -t i m e
position m o n ito r i n g a n d g u i d a nce. Fourth Step-Endograft Deployment

• The e n d ovascu l a r g raft is d e p l oyed fo l l ow i n g device­


Second Step-Stiff Wire Exchange
specific i nstruct i o n s for use ( J F U ), cove r i n g the native
• After w i re advancement to the transverse a o rtic a rch, o r i g i n s of the viscera l vesse l s a n d exc l u d i n g the a o rtic a n ­
sta n d a rd w i re exc h a n g e tec h n i q u e is used to position a e u rysm . The fem o ra l a rteriotomy i s t h e n closed.

PARTIAL VISCERAL DEBRANCHING AND inju ry, a nticipating syste m i c a nticoagu lation later i n the
proced u re.
PHYSICIAN-MODIFIED ENDOVASCULAR • A nasogastric tube is positioned i n the stomach to provide
REPAIR-STAGE 1 temporary decompression. The com mon hepatic a rtery is
identified fol lowi n g d ivision of the gastrohepatic l i g a ment
First Step-Exposure
and traced back to origin of celiac a rtery. Once identified,
• Sta n d a rd m i d l i ne l a p a rotomy a n d positi o n i n g of retractor the target artery is encircled with a sil astic vessel loop. Space
syste m . is created along the left side of the aorta with blu nt/finger
• U po n entry i nto the a bdomen, the fa lciform l i g a ment is dissection, beg i n n i n g at the leve l of the celiac a rtery, to cre­
d ivided between c l a m ps a n d ligated . The tria n g u l a r l iga­ ate the retrograde bypass tunnel posterior to the pa ncreas.
ments above the l iver a re d ivided to fac i l itate adequate ex­ • The colon and omentum a re l i fted in a cep h a l a d d i rec­
posu re/retraction w h i l e m i n i m izing risk of hepatic caps u l a r tion, the s m a l l bowel swept to the patie nt's r i g ht a n d
1 93 6 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

packed i n moist towe ls. Self-reta i n i n g retractors (O m n i loss. G raft cove rage c a n a l so be obta i n ed without deve l ­
o r Bookwalter) s h o u l d b e positioned a t t h i s j u n ct u re to o p i n g the e n t i re retroperitoneal p l a ne, e i t h e r via d i rect
m a i nta i n exposu re, with care taken to a p p ropriately pad t u n n e l i n g a l o n g the p referred cou rse of the g raft or cre­
the retractor b l ades as necessa ry. ation of a n omental tongue affixed d i rectly to the g raft .
• The t h i rd a n d fo u rt h portions of the d u o d e n u m a re mo­
b i l ized to the r i g h t fo l l owi n g d ivision of the l i g a m ent of Second Step-Anticoagulation
Tre itz, expos i n g the a nte r i o r s u rface of t h e a o rta. The in­
• System i c a nticoagu lation is achieved with a bolus i njec­
ferior m esenteric ve i n is l i g ated a n d d ivided a s we l l and
tion of u nfractionated heparin, 50 u n its/kg . M o n itoring
the d i ssect i o n cont i n ued along the prox i m a l a o rta until
activated clott i n g t i m e is a usefu l method of m a i nta i n i n g
t h e l eft re n a l ve i n is clearly identifi e d .
adequate a nticoa g u lation d u r i n g the p roced u re.
• Widely m o b i l ize the l eft r e n a l ve i n s h a r p l y a n d e n c i rcle
with a m o i st u m b i l i ca l tape. The self-reta i n i n g re n a l ve i n
Third Step-Multivisceral Bypass
retractor b l a d e is used t o retract t h e l eft re n a l ve i n ce p h ­
a l a d a s necess a ry to fac i l itate f u rther exposure. • Trifu rcated g rafts exist for the pu rpose of fac i l itati n g
• The orig i n of the ren a l a rteries is identified by ca refu l pos­ m u ltivessel hybrid reva sc u l a r ization, b u t the u s e o f these
terol atera l d i ssection a ro u n d the a o rta, j u st ce p h a l a d of a re l i m ited by the tende n cy of the m i d d l e l i m b to occ l u d e
the overlyi n g re n a l vei n . Exposu re on the right is com p l i ­ w h e n squ eezed betwee n the outside l i m bs d u ri n g g raft
cated somewhat b y the overlying i nferior v e n a cava/l eft rout i n g a n d a bdom i n a l closure. In m ost circumstances, a
re n a l vei n confluence. At least 2 em of ren a l a rtery s h o u l d sta n d a rd 1 2 x 7 bifu rcated, co l l agen-i m p re g n ated kn it­
be exposed b i l atera l l y. E n c i rcle the re n a l a rteries w i t h si­ ted polyester g raft provides exce l l ent co n d u its for b i lat­
l astic vessel loops. O n the l eft, f i n g e r d i ssect b l u ntly along e ra l renal revasc u l a r i zation, with a sepa rate 8-mm l i m b
the a o rta i n a cep h a l a d fash ion to com p l ete the retro pan­ c o n n ected t o t h e ce l i a c a n d S M A . Exa m ples o f bypass
creatic t u n n e l for the ce l i ac limb of the bypass g raft. g raft confi g u rations a re s h own in FIGS 6 and 7.
• The SMA is i d e ntified n ext by pa l pation with i n the base • The prox i m a l (i l i ac/i nfl ow) a n a stomosis is co m p l eted fi rst
of the sma l l bowe l mesente ry, d i rectly a nterior to the with ru n n i n g 4-0 or 5-0 polypropy l e n e suture.
pancreas. D o p p l e r u ltrasonography may assist i d e ntifi­ • The n ext a n asto mosis to be completed s h o u l d be o n e a n ­
cat i o n when the pu lse is fa int. Once i d entifi ed, a 3-cm tici pated to be the tec h n i c a l l y m ost d iffi cu lt, g iven expo­
seg ment of S M A is isol ated as p rox i m a l as possi ble to the s u re and g raft routi n g issues. M ost co m m o n ly, this is the
root of the mesentery. B eg i n n i n g with the middle co l i c right re n a l a rte ry. This is d ivided fo l l owi n g p l a cement of
a rte ry, m u lt i p l e mesenteric a rteries q u ickly branch from a l a rg e c l i p at the orig i n . The a p p ropriate g raft l i m b is
the S M A as it e m e rges from the pancreas, u n dersco r i n g p u l led to length a n d a n asto mosed end-to-end with 5-0
the n e e d f o r proxi m a l identification a n d isolat i o n . T h e polypropylene suture. The l i m b a n d a rtery a re fl ushed j u st
S M A is contro l led w i t h vessel loops. prior to c o m p letion of the g raft, after w h i c h the c l a m ps
• The n ext ste p is to p re p a re the d o n o r a rtery fo r hybrid by­ a re released to reperfuse the k i d n ey. F o l l o w i n g t h i s se­
pass. The specific a rtery-most com m o n ly the co m m o n or q u e n ce, warm ren a l isch e m i a t i m e is genera l ly less t h a n
exte r n a l i l iac a rteries-s h o u l d be sel ected from the p re­ 1 2 m i n utes. The stu m p of the r i g ht ren a l a rtery is then
operative i m a g i n g study. The retro perito n e u m is opened suture l i g ated; avoid clip d islodgement. N ote: Excessive
d i rectly over the sel ected d o n o r a rte ry, w h i c h i s exposed traction o n the confl uence of the l eft ren a l vei n and vena
w h i l e p rotect i n g the adjacent u reter. Alternatively, d o n o r cava may cause cava l i nj u ry a n d massive hemorrhage d u r­
a rtery exposu re may be a c h i eved via m e d i a l-visceral rota­ i n g preparation a n d comp letion of the r i g ht ren a l a rtery
tion, deve l o p i n g the entire retroperito n e a l p l a n e o n the a n astomosis. Retractor positi o n i n g needs to account for
l eft. The l atte r a p p roach provides the added benefit of potential venous i n j u ry d u r i n g exposure and s i g n ifica ntly
exc l u s i o n of the g raft from the viscera a n d abdom i n a l rel axed fo l l owi n g co m p l etion of the a n astomosis.
contents once the viscera a re returned to t h e i r orig i n a l • The renal a n a sto m osis is co m p l eted i n nearly identical
posit i o n . This m a n euver adds s i g n ificantly more time to fash ion, minus m a n y of the exposu re l i m itat i o n s p resent
the case, h oweve r, and cont r i b utes to i ncreased b l ood o n the r i g ht.

PARTIAL VISCERAL DEBRANCHING AND o n a ded icated ste r i l e table in t h e operat i n g room and
m a rked with t h e relat ive l ocat i o n s ( l e n gth from p roxi­
PH YSICIAN-MODIFIED ENDOVASCULAR
mal e n d and c l ockface measurements) of the ce l i a c a n d
REPAIR-STAGE 22 S M A fen estrati o n s a s p revi ously d ete r m i ned via Ter­
a Reco n ® workstation a n a lysis. M i n o r adj u st m e nts a re
First Step-Creation o f a Fenestrated Graft for the
a l l owed to m i n i m i ze strut ove r l a p of p l a n ned fen estra­
Celiac and Superior Mesenteric Artery
tion l ocat i o n s . Fen estrat i o n s in the po lyester e n d o g raft
• The a p p ro p r i ate e n d ovascu l a r device is chosen accord i n g fa b r i c a re created with a d isposa b l e ophth a l m i c ca utery
t o sta n d a rd I F U s i z i n g g u i d e l i nes, typ i ca l ly i ncorporat i n g to m i n i m i ze fray i n g . The fen estrations a re o u t l i ned
1 0 % to 1 5 % oversi z i n g . The ste r i l e g raft is u n s heathed a n d rei nfo rced with 1 5- m m g o l d A m p l atz Gooseneck®
C h a pt e r 1 6 H Y B R I D REVAS C U LARIZAT I O N STRATEG I ES FOR V I S C E RAL/RENAL ARTE R I E S 1 93 7

FIG 8 • Photog raph o f a t h o racic endog raft w i t h two


fenestrations created for the ce l i ac (struts p rese nt) a n d S M A
(strut free), p r i o r to resheat h i n g a n d d e p l oyment.

s n a res (ev3 E n d ovasc u l a r, I n c, Plymouth, M N) . These a re


h a n d sewn i nto p l ace u s i n g 4-0 Prolene sutu re in a d o u ­
b l e r o w ci rcumferent i a l l y (FIG 8) . D i a m eter-red u c i n g t i e s
w e r e t h e n u s e d to constra i n t h e device a l o n g i t s poste­
rior border (op posite the SMA and o r ce l i a c fen estrati o n
at 6 o'clock) by rerouti n g t h e exist i n g p roxi m a l t r i g g e r
w i re t h r o u g h a n d t h r o u g h t h e g raft mate r i a l at t h e m i d ­
FIG 9 • N ote the d o u b l e densities dep icti n g the o r i g i n s of
port i o n of each of t h e top t w o Z ste nts. The constra i n i n g
the c e l i a c a n d S M A on t h i s f l u s h a o rtog ra m .
ties a re t h e n t i e d down i nto p l a ce over t h e t r i g g e r w i re .
The enti re g raft is t h e n wetted with h e p a r i n ized sa l i n e
a n d t h e n reloaded i nto t h e exist i n g sheath . 7 - F r Raa be® s h eaths (Cook M e d i c a l , B l o o m i n g t o n , I N )
a re adva nced toget h e r t h r o u g h t h e 1 8- F r s h e a t h . Work­
Second Step-Percutaneous Access ing t h ro u g h t h ese s h eaths, t h e SMA and ce l i a c vesse l s
• Sta n d a rd percuta n e o u s access to an a p p ro p r i ately s i zed a re s e l ected t h r o u g h t h e fen estrat i o n s u s i n g sta n d a rd
access vesse l i s obta i n ed u s i n g S e l d i n g e r tech n i q u e . The catheter a n d g u i d e w i re tec h n i q u es, with t h e s h e a t h s
i n it i a l g u i d e w i re i s adva n ced i nto the a o rta u n d e r fluo­ u l t i m ately adva nced i nto t h e ta rget vesse l s over stiff
w i res.
rosco p i c g u i d a n ce . I n o u r p racti ce, this i s m ost co m m o n ly
• After sheath adva ncement a n d confirmation of target
o bta i n ed percuta n e o u s ly, u s i n g u ltraso u n d g u i d a n ce
vesse l acqu isition, the m a i n body is d iste nded flush with
a n d p r e p l a c e m e n t of polypropy l e n e sutu re p r i o r to d i ­
the su rrou n d i n g a o rta with a m o u l d i n g ba l l oo n (e . g . ,
l a t i o n of t h e access s ites ( a l s o k n own a s t h e " p reclose"
Coda®, C o o k M e d i c a l , B l o o m i ngton, I N ) . T h i s i nflation
Percl ose® tech n i q u e (A bbott Vasc u l a r I n c, Redwood
represents the final o p po rtu n ity to d iste n d the endo­
C ity, CA) . 1 A n 1 1 - F r sta n d a rd s h eath i s p l aced i nto the
g raft i n the reg i o n of the viscera l ste nts. Late ra l posit i o n ­
co m m o n fe m o r a l a rtery and f l u s h e d with h e p a r i n ized
i n g of the i m a g e i n t e n s i f i e r g u ides ste nt p l acement i nto
sa l i n e . W i re advancement from t h e fe m o r a l a rtery to
the SMA and ce l i ac a rteries (typica l ly 8- to 9-mm stents;
t h e a o rt i c a rc h m u st be v i s u a l ized rad i o g ra p h i ca l ly
t h ro u g h o ut its cou rse, as t h e w i re may p refe re n ti a l l y
FIG 1 0) . FIG 11 s h ows fo l l ow-u p computed tomography
(CT) i m a g i n g of a patient 1 yea r after successf u l treat­
enter t h e d e b ra n c h i n g g raft a n d cause e n d - o rg a n re n a l
ment with t h i s tec h n i q u e .
i n j u ry, r u pt u re o f G e rota's fa scia, a n d retro perito n e a l
h e m o r r h a g e w i t h o u t rea l -t i m e p o s i t i o n m o n ito r i n g a n d
Sixth Step-Access Site Closure
g u i d a n ce.
• The access sites a re closed with the p revi ously p l aced
Third Step-Stiff Wire Exchange sutu res.
• A sta n d a rd 4- or 5-Fr catheter is used to pe rfo rm a w i re
exc h a n g e to a stiff 0.035-in L u n d e rq u i st® w i re (Cook
Medical, B l o o m i ngton, IN). The w i re is positioned so that
its tip is j ust d i stal to the l eft subclavian a rtery.

Fourth Step-Marking of the Target Vessels and


Graft Deployment

• A contrast power i njection can be pe rfo rmed with 1 0 mL of


contrast i njected at 25 mL per second to m a rk the precise
orig ins of the ce l iac and SMA (FIG 9). The mod ified g raft is
positioned over the target vessels, oriented, and dep loyed .

Fifth Step-Cannulation of the Target Vessels

• An 1 8- F r s h eath is a d va n ced from t h e contra latera l FIG 1 0 • Latera l i m a g e d e p i ct i n g p l acement of a covered


g ro i n a n d i nto the d i sta l g raft over a stiff w i re . Two b a l l o o n-expa n d a b l e ste nt i nto the S M A prior to d e p l oyment.
1 938 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 1 1 • A.B. F o l l ow-up CT i m ages of a


patient successfu l ly treated with p a rti a l
viscera l debra n c h i n g a n d physi c i a n -mod ified
e n d ovascu l a r fen estrated repa i r.

PEARLS AND PITFALLS


C h o i ce of operati n g room • Use sta n d a rd O R ta b l es f o r open s u r g i c a l p roced u res a n d i m a g i n g ta b l es f o r i m a g e- g u i ded o r
(OR) ta b l e h y b r i d p roced u res. Adva nced p l a n n i n g is essenti a l to o pt i m i ze outco m e . N ever sacrifice exposu re !
Exposu re of co m m o n i l i a c • I d e ntify a n d p rotect the u rete r.
a rtery
P l a cement of wi res after • Pass g u idewi res u n d e r cont i n u o u s f l u o rosco p i c g u i d a nce fo l l ow i n g d e b ra n c h i n g . An adva n c i n g
d e b ra n c h i n g p roced u re a o rtic w i re may p refe renti a l l y e n t e r a n d trave rse the debra n c h i n g g raft, c a u s i n g end-org a n i n j u ry,
d i so r i e ntation, a n d possi b l e endog raft m a l d e p l oyment if n ot recog n i ze d .
Ti m i n g of ste nt g raft • A lways seat the endog raft with ba l l oo n i nflation p r i o r to p l acement of viscera l bridg i n g ste nts.
ba l l oo n m o u l d i n g d u r i n g I n st r u m e ntat i o n o r d iste ntion of the fen estrated endog raft fo l l owi n g branch vesse l ste n t i n g may
fe n estrated EVAR compromise ste nt positi o n i ng, i nteg rity, and paten cy.

POSTOPERATIVE CARE COMPLICATIONS


• Open aortic debranching procedures are not benign; almost • Access-related complications
all patients will require intensive care postprocedure. Spi­ • Hemorrhage requiring transfusion
nal drainage is used selectively for aortic coverage extending • Paraplegia
more than 10 em cephalad to the celiac artery. Postoperative • Stroke
anuria or persistent acidosis/rising lactate require immediate • Renal failure
investigation to prove branch vessel patency. • Death

OUTCOMES REFERENCES
• Contemporary hybrid debranching procedures for complex 1. Starnes BW, Andersen CA, Ronsivalle JA, et al. Totally percutaneous
abdominal aortic aneurysmal disease are associated with a aortic aneurysm repair: experience and prudence. J Vase Surg.
1 3 % operative mortality rate, 2 % permanent paraplegia 2006;43 (2) :270-276.
rate, and 1 % stroke rate.3 2. Starnes BW, Quiroga E. Hybrid-fenestrated aortic aneurysm repair: a
novel technique for treating patients with para-anastomotic juxtarenal
• Hybrid approaches offer the advantage of versatility, avoid­
aneurysms. Ann Vase Surg. 2 0 1 0;24( 8 ) : 1 1 50-1 1 5 3 .
ance of extensive operative exposures, and potentially offer 3 . Starnes BW, Tran NT, McDonald J M . Hybrid approaches to
a broader range of therapies to a patient population that repair of complex aortic aneurysmal disease. Surg Clin North Am.
would not otherwise be considered for aortic surgical repair. 2007;8 7(5 ) : 1 0 8 7-1098, ix.
- I

Chapter 17 Snorkel/Chimney and Periscope


Visceral Revascul arization
during Compl ex Endovascul ar
Aneurysm Repair
1
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ·

Jason T. Lee Ronald L. Dalm a n

DEFINITION treatment. Careful attention during the history and physi­


cal examination to cardiac and renal comorbidities aids in
• Although routine endovascular aneurysm repair (EVAR) has risk-stratifying the patient for potential repair of their JAA.
gained widespread acceptance as the procedure of choice for Because most patients are asymptomatic and aneurysms are
patients with suitable aortic neck anatomy, the optimal ap­ repaired to prevent future rupture, some reasonable quality
proach to the j uxtarenal aortic aneurysm (JAA), often with of life must be present for the patient to enjoy the survival
challenging anatomy at the visceral neck, remains contro­ advantage.
versial. 1 Although open repair is an effective and durable
option for patients with JAA, particularly in centers of excel­ IMAGING AND OTHER DIAGNOSTIC
lence for low physiologic risk patients,2 endovascular tech­
STUDIES
niques including fenestrated and branched EVAR (FBE) have
emerged as effective, potentially less invasive alternatives.3 • High-quality computed tomography angiography ( CT-A) on
• In the United States, however, lack of widespread availabil­ a modern 64-slice scanner able to produce at least 2-mm-thin
ity of FBE has allowed other techniques to emerge, and in cuts is a requirement for treatment with snorkel techniques.
this chapter, we describe the increasingly popular " snorkel " These imaging algorithms allow the creation of virtual mod­
or " chimney" technique, defined as a parallel stent graft ad­ els of the aneurysm for the surgeon to better appreciate the
j acent to the endograft main body to maintain perfusion to relationship of branches and potential areas of technical
renal and visceral branches during EVAR and placed from a challenge ( FIG 1 ) . Patients with compromised kidney func­
cranial direction, and the "periscope" technique, where the tion who cannot undertake iodinated contrast are poor can­
parallel stent graft is placed from the caudal direction. didates for snorkel procedures, as noncontrast scans fail to
• First described by Greenberg and associates,4 the snorkel elucidate thrombus volume, branch artery patency, and lumi­
strategy can be employed either as a bailout from accidental nal diameter in the preoperative planning that is paramount
coverage of vital side branches during deployments requir­ to success.
ing close approximation of the main body to the branch ar­ • Access to a three-dimensional ( 3 -D ) workstation/program
tery in question, or the intentional cranial relocation of the and familiarity with reconstruction software by the implant­
EVAR seal zone for JAAs.5-8 ing surgeon for manipulation of the images and creating cen­
terline pathways should be mandatory to most accurately
DIFFERENTIAL DIAGNOSIS plan device orientation, selection, and sizing ( FIG 2) .
• Because the snorkel technique usually involves access of
• The challenge for the vascular specialist in treating JAAs the brachial artery for delivery of the parallel visceral stent
revolves around an increasing number of choices for inter­ grafts, visualization of the arch and proximal subclavian is
vention, including traditional suprarenal repair, hybrid type
debranching procedures, fenestrated and branched devices
in clinical trials or certain centers, and snorkel/chimney/
periscope techniques. The choice is most often based on pa­
tient physiologic parameters, physician experience with the
multitude of techniques, and a very individualized approach
to complex aortic anatomy.

PATIENT HISTORY AND PHYSICAL


FINDINGS
• Most patients present electively and essentially without
symptoms for consideration of repair of their JAA, as it
is most often discovered during radiographic workup for
vague abdominal discomfort, back pain, or as part of a
screening program. A pulsatile, nontender abdominal mass
can be elicited on careful abdominal exam. Any signs of per­
sistent abdominal or back pain or hemodynamic instabil­
ity or compromise should suggest the possibility of an acute FIG 1 • 3-D reco nstruct i o n of j uxta renal a n e u rysm with i nfra­
aortic pathology and prompt more urgent workup and renal neck l e n gt h of 5 m m .

1939
1 940 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

SURGICAL MANAGEMENT

Preoperative Planning

• All patients considered for snorkel/chimney or periscope tech­


niques should have undergone an extensive informed consent
discussion related to off-label use of endograft components for
treatment of their complex aneurysm. Alternatives often dis­
cussed include open surgery with suprarenal clamping, hybrid
de branching, referral to a center with access to fenestrated or
branched devices, or no surgery at all. Once the decision is
made to proceed with the snorkel strategy, we prefer a two­
surgeon approach with one performing the femoral access
portion and one the brachial access portion. Both surgeons
FIG 2 • Te raRecon workstation view h i g h l i g ht i n g a b i l ity to should have reviewed on the 3-D workstation the anatomy,
m a n i p u l ate i m ages in m u lt i p l e user-defi ned p l a nes. the endovascular plan, and the sequence for deployment.
• Access to a hybrid endovascular suite is highly recommended,
although not mandatory, for successful completion of these pro­
most conveniently obtained by including the chest in the cedures. Fixed imaging provides improved accuracy, reliability,
standard CT-A of the abdomen and pelvis. The presence of a and reproducibility of the anatomy throughout the sequence
challenging type III arch, where the subclavian inserts below of the snorkel procedure. Knowledgeable operating room and
the inner curve of the aortic arch, makes the procedure more cath-angio staff should be assigned to these cases and available
challenging and many times prohibitive due to concerns endografts and wires/catheters as well as backups should all be
about arch manipulation, cerebral emboli, and deliverability arranged ahead of time to provide the safest working environ­
of stent grafts ( FIG 3 ) . If the patient has already undergone ment for the patient as well as the operative team.
an adequate CT-A abdomen and pelvis and one wishes to • Choosing the main body endograft, its configuration, and
avoid the additional contrast load of repeating the study, a size has been described by numerous authors who all report
noncontrast chest computed tomography ( CT) can be per­ excellent results overall with a wide variety of devices and
formed to visualize the arch but then should be combined formulas. 9 In general, we often " oversized" to about 2 5 % to
with arterial duplex and waveforms of the upper extremities 3 0 % instead of the typical 1 5 % to 2 0 % for standard EVAR
to ensure patency of the axillosubclavian arterial system. to account for the additional fabric infolding to accommo­
• For patients with chronic kidney disease, high-grade renal date the snorkel stent ( s ) .
stenosis, atretic kidneys, or multiple visceral and renal ves­ • Given the amount of dye often used as well as renal artery
sels involved in the endovascular plan for snorkeling, nu­ manipulation during the most complex of snorkel cases,
clear medicine split renal function tests can help determine if we prefer to admit the patient the evening before or several
it is reasonable to sacrifice one of the renal arteries. This can hours prior to surgery for additional intravenous hydration
be done in order to simplify the snorkel strategy and keep when possible.
the number of cranially oriented stent grafts to two, which • General anesthesia is preferred, with consideration for pre­
may have an influence on overall morbidity and mortality operative lumbar drainage based on risk of spinal cord ische­
from the procedure. 1 •7•8 mia. Arterial monitoring, when necessary, is achieved via the
right arm. Adequate venous access can consist of either large­
bore peripheral intravenous lines (IVs) or a central line. There
is usually not a need for autotransfusion or cell saver setups
unless an iliac or axillary conduit is planned where there is
more potential for early blood loss during the procedure.

Positioning

• The hybrid room can be set up as either "head" position ( FIG 4)


or "right side, table rotated" depending on the type of imaging
equipment. With the right arm tucked, the left arm is prepped
circumferentially and placed on an armboard at about 75 to
90 degrees while the chest and abdomen down to the groins
are prepped. Surgeon A, who will stand at the patient's right
hip, has control of the C-arm and imaging functions and is
in charge of obtaining femoral access and delivery of devices
from the groins. Surgeon B stands above the outstretched left
FIG 3 • Type I l l a o rtic a rch with o r i g i n of subclavian a rtery b e i n g arm, with an additional sterile table extending off the left hand
l ower t h a n i n n e r cu rve of a o rtic a r c h . The a b i l ity to adva n ce a to allow for wires and catheters to remain sterile and available
snorkel s h eath from the l eft a r m is seve rely comprom ised i n t h i s for arm access during the procedure. The monitor is placed
confi g u ration a n d g e n e ra l ly n ot reco m m e n d ed if a ltern ative at a slight angle toward the foot of the bed to allow both sur­
repa i r methods a re ava i l a b l e . geons to visualize, or a slave monitor can be employed.
C h a p t e r 1 7 S N O R K E L/CH I M N EY A N D P E R I SCOPE EVAR 1 941

FIG 4 • E n d ovasc u l a r su ite set u p for


s n o rkel/ch i m ney EVAR with l eft arm
p repped and outstretched, C-a rm at
rig ht-si d ed/ta b l e rotated posit i o n to
a l l ow for latera l i m a g i n g, and m o n itors
at foot of bed. S u rgeon A sta nds at
patient's right h i p and controls C-a r m .
S u rgeon B sta nds a b ove patie nt's l eft
a r m to d e l iver wi res a n d catheters
from side table.

• For the s i m p l est of all snorkel cases, when j u st o n e renal


SNORKEUCHIMNE Y ENDOVASCULAR
a rtery n eeds stenting, a l ower brach i a l i n ci s i o n can be
ANEURYSM REPAIR
m a d e to a l low i nsert i o n of a single 7-Fr sheath (FIG SC) .
Arm Access
Renal/Visceral Cannulation and Sheath
• A 5-cm tra nsverse i n c i s i o n s l i g htly b e l ow t h e l eft axi l l a
Advancement
over t h e p a l p a b l e brach i a l p u lse affo rds seve ra l centi­
m eters of l o n g i tu d i n a l expos ure of t h e h i g h brach i a l • A 5-Fr m i cropu ncture access is o bta i n e d u n d e r d i rect
a rtery (FIG SA) . Stay i n g p roxi m a l to t h e d e e p brach i a l visua l i zation i nto the brach i a l a rte ry. A B e ntson w i re is
a rtery takeoff a l l ows a l a rg e e n o u g h ca l i be r o f bra­ advanced, u n d e r f l u o rosco p i c g u i d a n ce, m ost often i nto
c h i a l a rtery for typ i c a l d e l ivery of two 7-Fr sheaths for the ascend i n g a o rta. The use of an O m n iflush catheter
a d o u b l e re n a l snorkel p roced u re . At l e a st 7 to 8 em and g l idewire (either a 260-cm Rosen o r A m p l atz [Cook
of h e a lthy bra c h i a l a rtery s h o u l d be d i ssected free a n d Medical, B l oom i n gton, I N ] ) co m b i nation, to d i rect the
s l u n g w i t h vessel l o o p s to a l low accu rate p u n ct u re o f w i re toward the viscera l a o rta, a l l ows a w i re exc h a n g e
t h e vesse l . The t w o p u n ctu res s h o u l d be p l a ced at least fo r a stiffe r p l atfo r m . Ove r t h i s stiffer p l atfo rm, two
2 em a p a rt, a n d n ot n ext to each other, to fa c i l itate later 7-Fr 90-cm P i n n a c l e Desti nation sheaths (Te r u m o M e d i ­
s i m p l e r, i n d iv i d u a l p r i m a ry c l o s u r e . cal, Some rset, NJ) a re positioned n e a r the visce ral target
• For cases w h e n l a rg e r d e l ivery s h e a t h s may n e e d to b e branches to fa c i l itate ca n n u lation attem pts (FIG 6A) .
i n se rted o r i n cases w h e re potent i a l l y u p to th ree o r • T h ro u g h t h e 7 - F r sheaths, t h e targeted re n a l a n d vis­
fo u r snorkel stents n eed d e l ive ry, then a n i nfra c l avicu­ cera l branches a re ca n n u l ated using 260-cm-l ength hy­
lar incision a n d exposu re of the axi l l a ry a rtery for pos­ d r o p h i l i c g u idewi res and a 1 2 5-cm J B 1 catheter (Cook
s i b l e 1 0- m m Dacron c o n d u i t p l acement is reco m m ended M e d i c a l , B l o o m i ngton, I N) . An a n g i o g ra p h i c run ca n be
(FIG SB) . When t h i s is p l a n ned, a 20-Fr o r 22-Fr s h eath pe rfo rmed from a flush catheter a d v a n ced from fe m ­
can be i nserted to get around the a rch and then th ree o r a l access to a i d i n re n a l ca n n u l a t i o n (FIG 68) . T h o r­
6-Fr o r 7-Fr sheaths can be used to ca n n u l ate the visce ral o u g h k n o w l e d g e of t h e preope rative a n atomy, d e r ived
vesse ls. from refo rmatt i n g from the 3-D workstati o n fa c i l itates

FIG S • A. Skin i n c i s i o n via a h i g h brach i a l i n c i s i o n


n e a r the axi l l a exposes the p rox i m a l b rach i a l a rte ry,
often g i v i n g a d e q u ate size for d o u b l e pu nctu re.
B. I nfracl avicu l a r i n c i s i o n to expose the axi l l a ry a rtery
n ecessa ry w h e n t h ree or fo u r sno rkel/c h i m ney sheaths
needed. A 1 0- m m o r 1 2- m m Dacron conduit can be
sewn i nto the axi l l a ry a rtery i n t h i s posit i o n . C. S m a l l
i n c i s i o n over p a l p a b l e brach i a l a rtery n e a r a ntecubital
crease ca n be used w h e n o n ly single s n o rkel/c h i m ney
sheath n ecessa ry.
1 942 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 6 • A. Two 7 - F r Te r u m o sheaths p l aced from


a r m access down desce n d i n g t h o racic aorta ready
to be positioned near vi scera l a o rtic reg i o n . B. R i g h t
ren a l a rtery ca n n u l ated w i t h g l idew i re a n d J B 1
catheter. O m n if l u s h catheter from below reve a l s i n
a n a n g iogram t h e position o f t h e l eft renal a rtery to
be ca n n u lated n ext.

t h i s p o rt i o n of t h e p roced u re, g u i d i n g opti m a l a n g u l a ­ devices (Abbott Va sc u l a r, Sa nta C l a ra, CA) orie nted at
t i o n o f t h e C-a r m . 10 o'clock and 2 o'clock posit i o n s 1 0
• O n ce ca n n u l ated, the sheaths a re adva n ced coaxi a l ly • The m a i n body endog raft ca n then be del ivered up the
i nto the ta rget a rtery orifice. When n ecessa ry, or i n cases chosen fe moral side to the pa ravisceral a o rta at the same
w h e re t h e re is a s l i g ht turn to the h o rizonta l rath e r t i m e as the i CAST (Atri u m Medical, H u dson, NJ) o r Via­
t h a n downward a n g led, the soft hydro p h i l i c g u idewire bahn (Gore Medical, Flagstaff, AZ) stents a re adva n ced
needs to be exc h a n g e d for a 260-cm J-t i p Rosen w i re through the snorkel sheaths out to the ta rget re n a l a rter­
(Cook Medical, B l o o m i n gton, I N) or A m p l atz S u p e rstiff ies (FIG 7A} . The typical length of the i CAST is 59 m m ,
(1 -cm t i p) to fa c i l itate s h eath advancement i nto the ta r- w i t h the d i a m eter si zed a p p ropriately to sea l i n the ta rget
g et renal a rte ry. Confi rmation a n g iog raphy, t h r o u g h the ren a l a rte ry, m ost often 5, 6, o r 7 m m . For Viaba h n stents,
sheath, i s performed to e n s u re patency of t h e renal a r­ s i m i l a r d i a m eters a re used in 50- o r 1 00- m m l e n gths as
teri es, ca n n u lation of the m a i n renal a rte ry, a n d avo i d ­ a p p ro p riate. To p reve nt th eoretica l com p ress i o n of the
a nce of a c c i d e n t a l s i d e branch ca n n u lati o n . Viaba h n stent by the main body of the endog raft, the
Viaba h n can be reinforced from the inside with a ba re­
m eta l, b a l l oon-expa n d a b l e stent a l o n g the a reas of over­
Positioning o f Main Body Endograft and Snorkel
lap with the m a i n body. The positi o n i n g of the snorkel
Stent Grafts
stent req u i res that at least 10 m m of fixation i nto the
• Sta n d a rd fe m o ra l access for EVAR is e m p l oyed for s n o r­ ren a l a rtery be p resent a n d that the p roxi m a l exte nt of
kel tech n i q u e . T h i s is we l l descri bed i n other cha pters. the g raft is a bove the fa bric of the main body endog raft.
B r i efly, a s m a l l transverse i ncision, below the i n g u i n a l • In a latera l p roj ect i o n a n g i o g ra phy, the superior mes­
l i g a m e nt, ca n be used to expose the c o m m o n femo- enteric a rtery (SMA) is visua l i zed (wh e n perfo r m i n g the
ra l a rtery to the b ifu rcat i o n for del ivery of endog raft typica l d o u b l e renal s n o rkel) a n d the main body fa bric
components. The percuta neous a p p roach i n vo lves the edge p l aced i m m ed iately below the origin of the S M A
" p reclose" tech n i q u e a n d e m p l oys two Perclose ProG i i d e (FIG 7B) .

FIG 7 • A. I n t h e a nterior-posterior view,


both snorkel iCAST stents in position from arm
a p p roach a l o n g with m a i n body endog raft being
put i nto position. B. Lateral view a n g iogram
shows ta keoff of SMA (red arrow) a n d positi o n i n g
o f the m a i n body endog raft fa bric e d g e (white
arrow) immediately below SMA.
C h a p t e r 1 7 S N O R K E L/CH I M N EY A N D P E R I SCOPE EVAR 1 943

FIG 8 • A. M a i n body endog raft d e p l oyed in a ntero poste r i o r (AP) view with snorkel stents in posit i o n . B. After ca n n u lation
of contra l atera l gate a n d adva ncement of p roxi m a l m o l d i n g balloon i nto a o rtic stent, the two snorkel stents a re f u l l y i nflated .
C. The m o l d i n g b a l l o o n is then maxi m a l ly infl ated to p rofi l e a n d to m i n i m ize g utters. D. The m o l d i n g b a l loon is co m p l etely
defl ated prior to snorkel ste nt ba l l oo n defl ati o n .

• At t h i s poi nt, f i n a l s m a l l adj u stme nts can be m a d e as the re n a l snorkel bal loons a re deflated to a l l ow perfu­
we l l a s further a n g i o g r a p h y to e n s u re that t h e s n o rkel sion of the k i d n eys.
stents a re i n good posit i o n . To avo i d the issue of the
i CAST ste nt b e i n g u n sta b l e off its b a l loon, we often Completion of Distal Components
l eave t h e 7-Fr sheaths i n p l ace to p rotect them until f i n a l
• Prior to losi n g w i re a ccess to the re n a l vesse ls, a p roxi­
d e p l oyment.
mal a o rtog ram is pe rfo rmed to look for a l a rg e type I
e n d o l e a k or poor perfus i o n of either targeted k i d n ey. If
Sequence of Stent Graft Deployment and Balloon this is satisfactory, the d i st a l compon ents of the e n d o­
Molding g raft can be adva n ced a n d d e p l oyed i n the u s u a l fas h i o n .
• Repa i r of the access sites, p a rticu l a r l y the brach i a l site,
• The m a i n body endog raft is d e p l oyed at the ta rget l oca·
req u i res ca refu l i nterru pted 6-0 o r 7-0 P ro l e n e sutu res,
tion with its fa bric edge being i m med iately below the
and a d e q u ate h a n d and foot perfus i o n is verified prior
S M A edge (FIG SA) . Depe n d i n g o n the endog raft system
to co m p letion of t h e case.
used, d e p l oyment p roceeds down to the contra latera l
• Postope rative CTA d e m o n strates the typ i c a l a p pearance
gate open i n g . From the contra l atera l fe m o r a l access,
of the snorkel stents adjacent to the m a i n body e n d o­
ca n n u l at i o n of the gate is confirmed and a noncom p l i ·
g raft with m i n i m a l g utters (FIG 9A), a n d the 3-D reco n­
a n t m o l d i n g ba l l oo n (32- o r 40- m m C o d a b a l loon; Cook