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How I Do It: Aortic Arch DebranchingExposures, Tunnels and Techniques

4/14/2016

Warren Gasper MDAssistant Professor of SurgeryUCSF Vascular Surgery

No disclosures

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Into the arch

� Zone 2

• Occlude the left subclavian artery

� Zone 1

• Occlude the left carotid and left subclavian arteries

� Zone 0

• Occlude the innominate, left carotid and left subclavian arteries

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J Endovasc Ther 2002;9:suppl 2; II98–105

Zone 2 – preserve the left subclavian

� Left carotid to left subclavian bypass

• Short, prosthetic bypass from common carotid to subclavian

• Need to ligate/occlude the subclavian proximal to the vertebral

• Preferred if there is LIMA-coronary bypass, no need to interrupt LIMA flow

� Left subclavian to carotid transposition

• No bypass conduit, proximal subclavian artery is oversewn

• Can be difficult to get proximal to the vertebral and internal mammary

Assess the origin of the vertebral artery to ensure it is preserved

Preoperative carotid duplex – treat occlusive disease concomitantly

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Carotid-subclavian bypass

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� Supraclavicular incision

� Divide the platysma

� Divide the clavicular head of the SCM if needed

� Divide the omohyoid

Rutherford Atlas of Vascular Surgery 1993

Carotid-subclavian bypass

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� Supraclavicular incision

� Divide the platysma

� Divide the clavicular head of the SCM if needed

� Divide the omohyoid

� Ligate the external jugular if needed

Valentine Vascular Exposures 2003

� Mobilize the inferior and medial edges of the scalene fat pad and retract superolateral

� Divide the thoracic duct if needed

� Identify the phrenic nerve running anterior to the anterior scalene muscle

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Carotid-subclavian bypass

Valentine Vascular Exposures 2003

� Mobilize the inferior and medial edges of the scalene fat pad and retract superolateral

� Divide the thoracic duct if needed

� Identify the phrenic nerve

� Divide the anterior scalene (bovie, bipolar, scissors)

8 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16

Carotid-subclavian bypass

Rutherford Atlas of Vascular Surgery 1993

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� Proximal and distal control of the subclavian artery

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Carotid-subclavian bypass

Rutherford Atlas of Vascular Surgery 1993

� Divide the SCM or retract it medially

� Expose the lateral edge of the internal jugular and retract medially

� Expose the left common carotid artery while protecting the vagus nerve

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Carotid-subclavian bypass

Rutherford Atlas of Vascular Surgery 1993

� Prosthetic graft

• 6 or 8mm PTFE or Dacron

� Sew the graft end-to-side to the subclavian artery first

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Carotid-subclavian bypass

Ouriel Atlas of Vascular Surgery 1998

� Pass above or below the phrenic nerve

� Pass below the internal jugular vein

� Use 5mm aortic punch (optional) and sew end-to-side

� Ligate the subclavianproximal to vertebral or use an endovascular plug

� Close the platysma and skin over a JP drain

12 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16

Carotid-subclavian bypass

Ouriel Atlas of Vascular Surgery 1998

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Zone 1: Preserve the left carotid and left subclavian arteries

Right carotid – left carotid – left subclavian bypass

= 4 anastomoses

Alternative: Right carotid – left subclavian – right carotid bypass

= 3 anastomoses

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Perspect Vasc Surg Endovas Ther 2012;24(4) 184–192

Carotid-carotid-subclavian bypass tips� Expose right common carotid with a longitudinal incision and the left common

carotid and subclavian through a supraclavicular incision

� Be aware of the vagus nerves

• In an unlucky situation, injury to both nerves can cause bilateral vocal cord paralysis and airway compromise

� Bypass technique:

• 6 or 8mm PTFE or Dacron

• Right common carotid – Left subclavian – Left common carotid

� Tunnel choices

� Ligate/occlude the proximal left subclavian and left common carotid arteries

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Tunnels

Retropharyngeal

Anterior

Valentine Vascular Exposures 2003

Rarely used option: subclavian-subclavian bypass

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Ouriel Atlas of Vascular Surgery 1998

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Rarely used option: subclavian-subclavian bypass

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Ouriel Atlas of Vascular Surgery 1998

Rarely used option #2: axillo-axillary bypass

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Ouriel Atlas of Vascular Surgery 1998

Rarely used option #2: axillo-axillary bypass

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Ouriel Atlas of Vascular Surgery 1998

Conclusions

� Debranching procedures have high success and long-term patency rates

�Watch for anatomic variations and carotid artery disease

� Right carotid-left subclavian-left carotid bypass will save an anastomosis

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