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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3643_Библиотеки_им_академика_М_И_Перельмана.pdf
83
CCA
ECA
ICA
IJV
SupThy
PAROTID
XII
DP-SH
ICA
ECA
CCA
DP-SH
XII
IJV
*
THYROID
*
c
d
Fig. 4.4 (continued)
4 Surgical Approaches for Cerebrovascular Revascularization
84
e
f
Fig. 4.4 (continued)
H. Muresian
85
g
h
Fig. 4.4 (continued)
4 Surgical Approaches for Cerebrovascular Revascularization
86
CCA
ECA
ICA
i
j
Fig. 4.4 (continued)
H. Muresian
87
ECA
ICA
CCA
IJV
CAROTID
SINUS
NERVE
XII
k
l
Fig. 4.4 (continued)
4 Surgical Approaches for Cerebrovascular Revascularization
88
ECA
ICA
CCA
IJV
ANSA
m
n
Fig. 4.4 (continued)
H. Muresian
89
CCA
ECA
ICA
Ling
Facial
Max
AscPhar
ECA
ICA
CCA
IJV
AscPhar
a
b
Fig. 4.5 The ascending pharyngeal artery. Panel ( a ): angiographic
demonstration of a well-developed ascending pharyngeal (AscPhar)
artery, paralleling the ICA. The AscPhar offers anastomoses with the
intracranial ICA in cases with severe stenosis of the latter. If the
AscPhar originates in the very proximal segment of the ICA (at the
bulb), it may maintain the patency of the ICA even in cases with highest
degree stenoses. During surgery, a larger AscPhar must be isolated and
temporarily clamped to avoid troublesome back bleeding. Panel ( b ):
intraoperative aspect of the right carotid bifurcation and a larger
AscPhar artery
4 Surgical Approaches for Cerebrovascular Revascularization
90
CLAVICLE
1-1.5 cm
Fig. 4.6 Surgical exposure of
the vertebral artery. The V0 and
V1 segments of the VA can be
approached either by a
supraclavicular horizontal
incision or by a longitudinal
incision, anterior to the SCM and
starting at the level of the
sternoclavicular joint. In both
situations, the concomitant
exposure of the CCA is possible.
With the supraclavicular
approach, the SCA can be also
accessed. Access to the V2
segment of the VA is possible
through the longitudinal incision
(see also text for further details)
H. Muresian
91
CCA
SCA
IJV
ASM
ASM
BP
IJV
CCA
ASM
SCA
Ph
BP
a
b
Fig. 4.7 Supraclavicular approach. Intraoperative view. Panel ( a ): the
clavicular head of the SCM is cut, allowing the exposure of the CCA
and IJV. The latter is retracted toward anterior and medial; thus,
bypasses or reimplantations into the CCA will be in a retro-jugular
position. The vagus nerve must also be identifi ed and preserved. The
SCA is best exposed after cutting the anterior scalene muscle (ASM)
this maneuver facilitating the approach. Laterally, the brachial plexus
(BP) limits the exposure of the SCA. Dissection may proceed inferiorly
over both the CCA and SCA, to the level of the bifurcation of the brachiocephalic trunk (only on the right side). Panel ( b ): with more exten-
sive retraction, the phrenic nerve is identifi ed and protected (Ph). All
the branches of the SCA can be identifi e d
4 Surgical Approaches for Cerebrovascular Revascularization
92
CCA
ICA
ECA
OH
SCM
IJV
CCA
VA
OH
IJV
C
6
a
b
Fig. 4.8 Anterior cervical approach to the VA. Concomitant expo-
sure of the SCA, CCA, and bifurcation can be obtained through this
incision. Panel ( a ): dissection starts as with a regular approach to the
carotid bifurcation and more proximal CCA. Note the omohyoid
muscle (OH) still contained in the pretracheal (visceral) layer of the
cervical fascia. Panel ( b ): the OH was retracted inferiorly and dissec-
tion proceeded between the CCA and IJV. The vagus nerve is
retracted together with the IJV laterally. The VA is identifi ed in the
solid angle between the anterior scalene and the longus colli muscles
(the two converging at the level of the anterior tubercle of C
6
). The
VA is usually covered by the vertebral vein. On an intermediate
plane, the inferior thyroid artery crosses the VA anteriorly and the
CCA posteriorly, from lateral to medial. The inferior thyroid artery
may be divided for surgical access, if necessary. Numerous sympathetic fi bers encompass this portion of the VA and these must be preserved as much as possible. Dissection proceeds toward the origin of
the VA from the SCA. If necessary, the transverse vertebral canal can
be opened with a rongeur
H. Muresian