Vascular Trauma Flashcards
Zone 1 of the neck
Base of the neck below the cricoid cartilage
Zone 2 of the neck
Cricoid cartilage to the angle of the mandible
Zone 3 of the neck
Angle of the mandible to the base of the skull
Approach to zone 1 injuries of the neck
Incision along the SCM, sometimes requiring extension to the thorax via a median sternotomy
Operative approach to zone 2 of the neck
Incision along the SCM. If bilateral, consider a collar incision
Graft options for internal carotid artery injuries (4)
- Saphenous vein (usually a good size match but takes awhile to harvest)
- External carotid artery interposition
- External carotid artery transposition
- PTFE (avoid if concomitant esophageal injury)
All patients with ICA injuries must be on aspirin for life.
Vertebral artery anatomic zones (4)
V-1: origin of vertebral artery from subclavian to TP of C6
V-2: interosseous portion between C6 and C2
V-3: C2 to base of skull
V-4: base of skull to confluence of L and R vertebral arteries which forms the basilar artery
Control of bleeding from vertebral artery: endovascular/embolization or open?
Embolization preferred as access to interosseous portions and above is very difficult and even clamping at origin from subclavian will not control due to backbleeding from Circle of Willis.
Exposure of RIGHT subclavian artery injuries distal to takeoff of vertebral
Right supraclavicular incision (sternoclavicular junction extending the length of the clavicle)
Exposure of RIGHT subclavian artery injuries proximal to takeoff of vertebral
Median sternotomy, may be combined with supraclavicular incision
Exposure of LEFT subclavian artery injuries distal to takeoff of vertebral
Difficult exposure due to posterior takeoff of L subclavian from aortic arch.
High anterolateral thoracotomy through the third intercostal interspace
Exposure of LEFT subclavian artery injuries proximal to takeoff of vertebral
Left supraclavicular incision (sternoclavicular junction extending the length of the clavicle, one fingersbreadth above clavicle with clavicular resection).
When doing clavicle resection via supraclavicular incision for subclavian artery injury, what nerve must be identified and preserved?
Phrenic nerve running lateral to medial on anterior scalene muscle. Isolate with vessel loop and transect anterior scalene as low as possible.
If a left supraclavicular incision for subclavian artery is attempted and exposure is inadequate, what are other options?
High anterolateral thoracotomy through third intercostal space.
If this remains inadequate, the two incisions may be connected via a median sternotomy in order to complete the trapdoor. This incision has high morbidity.
If patient is in extremis and subclavian artery injury repair is not feasible, should ligation be proximal or distal to the vertebral?
Proximal as this allows for retrograde flow to the extremity via the vertebral and collateral circulation to the shoulder.
