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174
Fig. 15.5 Image
demonstrating exposure of
the anterior scalene muscle
with phrenic nerve running
over it
M. R. Weaver
Fig. 15.6 Image
demonstrating the
subclavian artery after
division of the anterior
scalene muscle
Having obtained arterial control proximal and distal to the aneurysm working
from both incisions, the aneurysm is freed from the neighboring neurovascular structures and any arterial branches are ligated and divided. Having the aneurysm
Pectoralis major
Pectoralis minor
15 Subclavian Artery Aneurysm
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Brachial plexus
Clavicle
Axillary artery
Axillary vein
Fig. 15.7 Sagittal image demonstrating course to the axillary artery with splitting of the bers of
the pectoralis major muscle and division of the pectoralis minor muscle near its insertion to the
coracoid process
175
Fig. 15.8 Image
demonstrating interposition
graft from the subclavian
artery to the axillary artery
passing anatomically
between the clavicle and
rst rib for repair of
aneurysm
completely free, the patient can be systemically heparinized with the arteries
clamped, the aneurysm resected, and arterial reconstruction performed with interposition vein graft (Fig.15.8). With one’s nger placed within the thoracic outlet the
arm can be moved in multiple stress positions to make sure that no residual compression remains. If compression remains resection of the rst rib may
need to be performed in addition to the cervical rib.
Potential complications include nerve injury to the brachial plexus or phrenic
nerve and lymphatic injuries, specically on the left side, an injury to the thoracic
duct. There is a low threshold for reexploration of any signicant or persistent
lymph leak.
Chapter 16
Axillary andBrachial Aneurysms
FarahHanifAliMohammad
Surgical Anatomy
Axillary Artery
The axillary artery has three parts based on pectoralis minor. The rst part is superior and medial to the pectoralis minor and begins as continuation of the subclavian
artery at the lateral edge of the rst rib. Here it gives off its rst branch named the
superior thoracic artery. The second portion lies underneath the pectoralis minor
and gives off thoracoacromial and lateral thoracic artery. Third portion lies lateral to
the pectoralis minor and gives off subscapular, anterior, and posterior humeral circumex artery. It continues on to become brachial artery at the lower margin of teres
major. The axillary vein runs along its entire course medially. The brachial plexus
runs posterior to the rst and then interlaces the second and third part.
Brachial Artery
The axillary artery continues on to become the brachial artery past the inferior border of teres major. The brachial artery passes between the biceps and triceps muscles. In the antecubital fossa, it divides into the radial, interosseous, and ulnar
arteries to supply the soft tissues of the forearm. The median nerve runs along the
artery crossing from relatively lateral to medial position as it goes distally. Its rst
F. H. A. Mohammad (*)
Henry Ford Hospital, Detroit, MI, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. S. Hans et al. (eds.), Primary and Repeat Arterial Reconstructions,
https://doi.org/10.1007/978-3-031-13897-3_16
177
178
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F. H. A. Mohammad
major branch called the deep brachial artery runs posteriorly and serves as a major
collateral in the setting of brachial injury. Two brachial veins closely run along the
artery in the brachial sheath.
Axillary andBrachial Artery Aneurysms
Axillary and brachial artery aneurysms are uncommon and account for less than 1%
of peripheral artery aneurysms. True aneurysms may be congenital, degenerative, or
inammatory in nature. Chronic repetitive trauma of the axillary artery can also
cause aneurysmal degeneration. This phenomenon is seen in patients who are
chronically dependent on crutches. Axillary aneurysms have also been reported in
baseball pitchers. They can also arise from rst rib compression in thoracic outlet
syndrome. Pseudoaneurysms can occur after penetrating and blunt trauma. They
can also be iatrogenic in nature. Brachial artery is frequently used as an access during cardiac catheterizations and arterial lines. Mycotic brachial artery pseudoaneurysms have also been reported in patients with history of IV drug abuse.
All symptomatic true or pseudoaneurysms should be repaired. Most common
presentation is distal embolization leading to digital ischemia. They may also present with neurologic symptoms associated with brachial plexus (axillary) or median
nerve (brachial artery) compression. Pseudoaneurysms may also present in the setting of infection, in which case ligation may be well tolerable due to signicant
collaterals. Asymptomatic true aneurysms should be repaired if >2 cm.
Pseudoaneurysms from iatrogenic injury may be amenable to ultrasound-guided
thrombin injection. If the neck is wide or there are pressure-induced skin changes
from the aneurysm, it will need an open repair. Most commonly management
includes simple primary repair, resection with end-to-end anastomosis, patch angioplasty, and interposition bypass.
Operative Steps for Axillary Artery Aneurysms
The patient is positioned supine with the ipsilateral arm abducted to 90 degrees. The
rst and second portions of the axillary artery are best exposed with an infraclavicular incision approximately 2cm below the clavicle. The incision is made from midclavicle to anterior surface of deltoid, approximately 7–8cm in length. Subcutaneous
soft tissue and clavipectoral fascia are divided. The pectoralis major muscle bers
are either retracted or split (Fig.16.1). The axillary sheath lies in the fatty areolar
tissue underneath the fascia. The artery lies just deep and slightly cephalad to the
vein. The vein should be carefully dissected and retracted caudally. The nerves lie
behind the rst portion of the axillary artery at this level; thus, clamps should be
placed carefully. Pectoralis minor muscle may need to be divided for exposure for
Brachial plexus
us
16 Axillary andBrachial Aneurysms
179
Fig. 16.1 Infraclavicular
exposure of axillary artery.
Division of Pectoralis
minor tendon at its
insertion
Fig. 16.2 Distal axillary
and proximal brachial
artery exposure
Brach. artery
Pect.
minor
Ax. artery
Ax. vein
Medial cord of
Ax. vein
Ax. artery
Pect. minor
Lateral cord of
brachial plex
the second portion of the axillary artery. The pectoral nerves should be identied
and protected if the pectoralis minor is resected near the coracoid process. Ligation
and division of the thoracoacromial artery help in exposure. The cords of the brachial plexus run anterior and around the artery in this region; thus, careful dissection
is required. If more lateral or if the third portion needs exposure, the incision would
have to be extended on to the deltopectoral groove (Fig.16.2). The pectoralis major
may be resected near its insertion if necessary. The cephalic vein is dissected along
its medial border and retracted laterally along with deltoid muscle. Here the clavipectoral fascia is divided along the inferior border of the coracobrachialis muscle up
to the coracoid process. The neurovascular bundle lies in the areolar tissue underneath the fascia. The median nerve is the most supercial portion in the sheath. The
nerve can be carefully retracted cephalad. The vein and ulnar nerve lie medial the
180
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F. H. A. Mohammad
artery in this segment. Once the artery is exposed and encircled, decision is made
for the repair. Aneurysm repair usually involves resection and interposition bypass.
Autogenous vein grafts preferably lower extremity veins (great saphenous veins are
better) can be chosen. Prosthetic reconstruction may be utilized if there are no adequate vein conduits. The conduit can be tunneled anatomically if aneurysm is focal
and within exposure or tunneled subcutaneously if proximal and distal incisions are
made in a skip fashion. In rare cases if the aneurysm is due to thoracic outlet syndrome, then appropriate thoracic outlet decompression will need to be performed.
In the setting of a pseudoaneurysm, intraoperative assessment of the vessel may be
needed to potentially resect the pseudo and repair the artery primarily or with vein
patch angioplasty.
Pearls
Understanding the relation to the artery to the surrounding structures is key to avoiding technical complications. The vein lies medial to the artery and may be adherent
and should be carefully mobilized especially due to the surrounding inammation.
The brachial plexus and pectoral nerves lie behind the rst part but then wrap the
second portion and continue on to form the median nerve lying supercial to the
third portion of the axillary artery. Careful meticulous dissection is necessary to
avoid any nerve or venous injuries.
Operative Steps for Brachial Artery Aneurysm
The patient is placed supine with the arm abducted to 90° over an arm board. The
entire arm from the axilla to the hand is prepped and draped. This helps with checking perfusion at the conclusion of the procedure. To expose the brachial artery in the
arm, an axial incision is made on the medial aspect of the arm between the biceps
and triceps muscles (Fig.16.3). Care should be taken to avoid the supercial basilic
vein running medially in the lower portion of the arm. The biceps muscle is retracted
anteriorly, and the deep fascia over its medial border is incised. This exposes the
neurovascular bundle. The most supercial structure is the median nerve and should
be carefully mobilized and retracted. The artery lies underneath the nerve surrounded
Fig. 16.3 Type of
incisions ( transverse and
S-shaped) for exposure of
the brachial artery at the
elbow
ysm
16 Axillary andBrachial Aneurysms
181
by two brachial veins. The deep brachial artery should be identied and protected
while exposing the proximal brachial artery. Other branches including the superior
and inferior ulnar collateral arteries may need to be controlled in the mid or distal
exposure. Interconnecting veins over the artery can be carefully ligated. Surgeon
should be aware of the possibility of high bifurcation if two large branches are seen.
At the antecubital fossa, usually a transverse incision just inferior to the antecubital crease may be sufcient (Fig.16.4). However, if the aneurysm is large or more
extensive exposure is needed, then an S-shaped incision is more suitable. The superior longitudinal portion is made along the medial border of the biceps muscle, and
horizontal portion runs along the crease, and inferior portion extends laterally onto
the forearm. As the incision is deepened, the basilic vein again may be encountered
on the medial portion. The antecubital nerve should be protected if possible. The
bicipital aponeurosis is seen in the center of the wound at the fascial level. Once this
Fig. 16.4 Exposure of left
brachial artery, radial and
ulnar artery
Brachial art. aneur
Biceps
Ulnar nerve
Median nerve
Radial nerve
Brachioradialis
Flexor pollicis long.
Flexor carpi ulnaris
Flexor dig. profundus
Radial art.
Ulnar art.
182
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F. H. A. Mohammad
is divided, the artery can be seen in between two deep brachial veins. Depending on
the location and extent of the brachial aneurysm, the artery may be exposed.
Aneurysm repair usually involves resection and interposition bypass. Autogenous
vein grafts preferably lower extremity veins (great saphenous veins are better) can
be harvested. Prosthetic reconstruction may be utilized if there are no adequate vein
conduits. The conduit can be tunneled anatomically. In the setting of a pseudoaneurysm, intraoperative assessment of the vessel may be needed to potentially resect
the sac and repair the artery primarily or with vein patch angioplasty. If the concern
is that the aneurysm is due to an infection and reconstruction is not possible, then
the artery may be ligated as long as the deep brachial branch is preserved.
Pearls
Understanding the relation to the artery to the surrounding structures is key to avoiding technical complications. Median nerve is supercial and crosses the artery from
lateral to medial position. Injury to the nerve can be devastating. Careful meticulous
dissection is necessary to avoid any nerve or venous injuries.
Part II
Open Arterial Reconstructions for Arterial
Occlusive Disease
Chapter 17
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Carotid Endarterectomy
SachinderSinghHans
Surgical Anatomy
Common Carotid andInternal andExternal Carotid Arteries
The common carotid arteries (CCA) are variable in length and their anatomic origin. The right CCA originates at the bifurcation of the brachiocephalic trunk posterior to the right sternoclavicular joint and continues cephalad in the neck. The left
CCA arises from the highest portion of the arch of the aorta to the left and posterior
to the brachiocephalic trunk and can be divided into the intrathoracic portion and a
cervical portion.
The cervical portion of each CCA passes obliquely cephalad and slightly laterally to the upper border of the thyroid cartilage where it divides into the external and
internal carotid arteries. The CCA with the internal jugular vein and vagus nerve are
contained in the carotid sheath, the vein coursing lateral to the artery and the vagus
nerve lying between the artery and the vein posteriorly; however, in its inferior portion, the vagus nerve tends to cource anteriorly and medial (Fig.17.1). The upper
border of the thyroid cartilage (carotid bifurcation) is usually at the level of the
fourth cervical vertebral body. The carotid bifurcation is variable, and bifurcation
can be as low as the level of cervical fth or even cervical sixth vertebral body or
high at the level of cervical third vertebral body. At the point of division of the CCA,
internal carotid artery (ICA) is slightly dilated into carotid sinus. The adventitial
layer of the ICA is thicker in the carotid sinus and contains numerous sensory bers
arising from glossopharyngeal nerve. These nerve bers respond to changes in the
S. S. Hans (*)
Vascular and Endovascular Services, Henry Ford Macomb Hospital,
Clinton Twp, MI, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. S. Hans et al. (eds.), Primary and Repeat Arterial Reconstructions,
https://doi.org/10.1007/978-3-031-13897-3_17
185
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