Chapter 57 - Upper extremity vascular exposure Flashcards
Three zones of the upper extremity
1) intrathoracic zone (aortic arch, innominate, subclavian, SVC)
2) thoracic outlet (based of neck to axilla): subclavian, vertebral, axillary
3) arm (axilla to fingers)
Rate of aberrant right subclavian
2%
Course of the aberrant right subclavian
1) arise distal to left subclavian
2) course behind esophagus
Rate of left vert from aortic arch
2-5%
Exposure to get proximal left subclavian control
Anterolateral third interspace thoracotomy
Medium sternotomy good for these arterial controls
1) proximal right subclavian
2) proximal left carotid
3) innominate
limited to 3rd interspace if aorta not needed
Exposure of the proximal arch vessels
1) median sternotomy
2) ligate or preserve left innominate vein
3) protect right recurrent laryngeal and right phrenic
4) tease away fatty tissue and retract overlying veins
more distal exposure
5) extend incision to neck or supraclavicular area
6) partially divide SCM and anterior scalene
Course of the right recurrent laryngeal nerve
loops around right subclavian artery just as it arises from innominate
Course of the right phrenic
passes behind jugular and right innominate vein
anterior to right subclavian artery
anterolateral to innominate artery
Course of the left recurrent laryngeal nerve
loops around aorta in area of ligamentum arteriosum
ascends anterior to arteries
Trapdoor thoracotomy
3rd space sternotomy, supraclavicular incision
3rd space anterolateral thoracotomy
Exposure of the proximal innominate vein
Sternoclavicular rotation
1) first space sternotomy
2) reattach after done
Exposure of the right atrial appendage
1) use as outflow for complex venous occlusive disease
2) limited anterior 3rd interspace thoracotomy
3) enter pericardial sace
4) clamp with satinsky -type clamp
Which SCM head is more easily sacrificed without consequence
Clavicular head
When does the subclavian artery change name to the axillary artery
after crosses over the lateral border of the first rib