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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3643_Библиотеки_им_академика_М_И_Перельмана.pdf
93
Fig. 4.9 Exposure of the cervical SCA through supraclavicular inci-
sion. The incision starts at the level of the sternoclavicular joint and
proceeds laterally to the clavicular midpoint (division of the external
jugular vein is not necessary). The pretracheal (visceral) layer of the
cervical fascia is cut, the OH muscle is retracted toward superior, and
the scalene fat pad is excised partially or retracted (caution to ligate
the suprascapular vessels and lymph channels). The anterior scalene
muscle is identifi ed, together with the phrenic nerve (the latter courses
over the anterior surface of the muscle from lateral and superior to
medial and inferior – although variations may be encountered). When
needed, the scalene muscle is divided (we do this maneuver routinely). Staying close to the SCA will prevent inadvertent entry into
the pleura. Through the same incision, access to the CCA and VA is
also possible
4 Surgical Approaches for Cerebrovascular Revascularization
94
Fig. 4.10 Exposure of the
cervical SCA through
longitudinal incision. This
incision allows a comfortable and
concomitant exposure of the VA,
CCA, carotid bifurcation, and
SCA. In the image presented, the
anterior scalene muscle was
divided
H. Muresian
95
Fig. 4.11 Exposure of the axillary artery.
When the distal SCA cannot be approached
or when of scarce quality, the axillary artery
(Ax) offers a sound alternative. Figure
4.11
offers an example of a CCA-to-Ax artery
bypass. Panel ( a ): the Ax is approached by
a subclavicular incision and prepared. Tex
Ax is lateral to the axillary vein AxV. The
fascicles of the brachial plexus encompass
the artery except its anterior aspect. Usually,
the Ax is prepared at the level of origin of
the thoracoacromial artery (crossed by the
pectoral ansa). Panel ( b ): the CCA is
approached by a supraclavicular incision
(again, posterior to the IJV). Panel ( c ): the
CCA-to-Ax bypass. The vascular graft in
tunneled under the clavicle
4 Surgical Approaches for Cerebrovascular Revascularization
96
Fig. 4.12 Simultaneous supra- and infraclavicular approach. Even in
emergency cases (e.g., trauma), there is no need for dividing the clavicle, as a good approach is offered by the two incisions. Any tunnel
under the clavicle must be performed over the artery or just lateral to it,
in order to protect the subclavian vein
Fig. 4.13 Exposure of the fi rst
rib. In cases with thoracic outlet
syndrome, excision of the fi rst rib
(or additional cervical rib) can be
performed through a
supraclavicular incision. The
SCA and BP are dissected and
protected. The anterior scalene
muscle can be safely divided.
The middle scalene muscle can
be also divided with caution to
the long thoracic nerve (C
5
–C 7 )
as it perforates the latter muscle
H. Muresian
97
SCM
BCT
CCA
Fig. 4.14 Exposure of the brachiocephalic trunk. Upper sternotomy.
The BCT cannot be safely isolated only through a cervical incision, and
partial upper sternotomy is required, especially if clamping of its origin
(or adjacent aorta) is needed. The sternal incision can be united with the
right supraclavicular incision or not. The sternum is cut to the level of the
manubrium and partially retracted. The right laryngeal recurrent, the
vagus, the sympathetic ansa, and the phrenic nerve must all be protected.
A graft anastomosed on the BCT can be easily tunnelzed to cervical level
ECA
ICA
IJV
X
CCA
SCA
Fig. 4.15 Exposure of the
brachiocephalic trunk. Cervical
approach. A supraclavicular
transverse or anterior
longitudinal cervical incision will
allow access to the BCT and its
bifurcation (less to its origin from
the aorta). The nerves mentioned
above must be thoroughly
protected. The CCA, VA, and
SCA are approached
comfortably. Should the more
distal SCA be exposed, this will
require medial traction of the IJV
4 Surgical Approaches for Cerebrovascular Revascularization
98
ECA
ICA
IJV
CCA
Xs
XII
DP-SH
ECA
Styl
CCA
IJV
XII
a
b
Fig. 4.16 Exposure of the distal internal carotid artery. Panel ( a ): pre-
auricular extension of the cervical incision (the latter may be either submandibular or longitudinal). Isolation of the carotid bifurcation and
adjacent cranial nerves. The posterior belly of the digastric muscle and
stylohyoid are either divided or retracted (in the case presented, the muscles are divided). By entering the retromandibular space, the distal ICA
is exposed. Note the kinking of the ICA. Hypoglossal nerve = XII. Superior
laryngeal nerve = Xs. Panel ( b ): further dissection of the distal ICA up to
the level of the carotid foramen. The styloid process (Styl) was isolated
after dividing the origin of the styloid muscles. If necessary, the styloid
process can be excised. The petrous temporal bone can be easily palpated and the ICA is exposed up to the carotid foramen
H. Muresian
99
Fig. 4.17 Exposure of the distal vertebral artery V3. Panel ( a ): the
incision for the V3 segment of the VA will pass just under the tip of
the mastoid process, surpassing the process by approximately 2 cm.
The anterior part of the incision is reclined toward the thyroid cartilage; this allows the concomitant exposure of the carotid bifurcation.
Panel ( b ): the incision is deepened after dividing (partially or totally)
the origin of the SCM and after identifying the accessory nerve (XI).
Note that, in the case illustrated, the XI nerve is in pre-jugular
position. Dividing the prevertebral muscles, the anterior ramus of the
cervical nerve C
2
is visible, marking the loop of the VA between the
C
2
and C 1 vertebrae. Usually, approximately 1.5 cm of the VA can be
thus exposed. Bleeding from adjacent plexiform venous channels can
be sometimes troublesome. Panel ( c ): bypass completed. A saphenous
graft was inserted from the carotid bifurcation to the V3. Alternatively,
branches of the ECA can be directly anastomosed to the V3 segment
of the VA
X
CCA
IJV
ICA
XI
XII
V3
C
2
ECA
a
b
4 Surgical Approaches for Cerebrovascular Revascularization
100
GRAFT
c
Fig. 4.17 (continued)
H. Muresian
101
Fig. 4.18 Approach to ascending aorta through median sternotomy.
Panel ( a ): patient prepared for median sternotomy (and additional cer-
vical incisions for exposure of the carotid and subclavian arteries).
Panel ( b ): the ascending aorta can be also isolated without opening the
pericardium; however, a safer approach and control are offered by
opening the pericardial cavity. The aorta is explored and palpated
before clamping. A lateral clamp can be applied after the anesthesia
team controls blood pressure and rhythm. Panel ( c ): a bifurcated
prosthesis is anastomosed on the ascending aorta. In this particular
case, the patient underwent an ascending aorta-to-bicarotid bypass.
Note the lateral position of the graft, not immediately underneath the
sternum. Panel ( d ): another patient in whom the ascending aorta is the
donor vessel. In this case, a quadrifurcated graft (with two additional
branches inserted “ad hoc”) was anastomosed on the aorta: the patient
underwent an ascending aorta-to-bilateral carotid and bilateral subclavian artery bypass
a
b
4 Surgical Approaches for Cerebrovascular Revascularization
102
c
d
Fig. 4.18 (continued)
H. Muresian