Proximal The Retroclavicular John S. Pierandozzi, MD;
Symptomaticoperative techniques, artery
occlusive disease of the proximal portion of the subclavian can be managed by sevthe most commonly eral different used being the carotid-subclavian bypass. We are submitting a new operative approach: the retroclavicular common carotid axillary bypass technique. For the past two years we have favored this technique over the carotid-axillary artery approach for the following reasons: The proximal part of the axillary artery is far more superficial than the subclavian and can be readily exposed through an infraclavicular pectoralis major musclesplitting incision. Also, the length of axillary artery available for anastomosis is considerably longer and less fragile than the subclavian artery. The subclavian artery exposure is a deep one, limited by the unyielding clavicle and confined to a very small area of exposure. On the left side, the thoracic duct can present problems of lymphorrhea if it is inadvertently lacerated. With the division of a few small branches of the axillary artery, it can be elevated to a very superficial position, making the bypass anastomosis much easier to accomplish. The use of the sec¬ ond incision is much less of a technical problem than the dissection necessary to expose the subclavian artery. The longer distance between the common carotid and axillary arteries presents fewer technical disadvantages than the use of an extremely short segment of graft, which is usu¬ ally necessary in the carotid subclavian bypass. The expo¬ sure of the common carotid can be made through a small, medially placed transverse supraclavicular incision with partial division of the sternocleidomastoid muscle. The retroclavicular tunnel can be easily created with blunt dis¬ section, and the space between the clavicle and first rib in the laterally placed tunnel is quite adequate for the pas¬ sage of an 8- to 10-mm Dacron graft. There have been no problems with vascular compression of the graft in any of the shoulder and head maneuvers. Shumacker1 has re¬ cently described a carotid axillary bypass procedure, al¬ though he described passing the graft in a subcutaneous position anterior to the clavicle. There might be some dis¬ advantages to this: the bypass graft is in a more vulnerAccepted
publication July 23, 1974. University of Southern California Medical School and Los Angeles County-University of Southern California Medical Center, Los Angeles, and Presbyterian Intercommunity Hospital, Whittier, Calif. Reprint requests to Department of Surgery, 9200 Colima Rd, Whittier, CA 90605 (Dr. Pierandozzi). for
From the
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Subclavian Common Carotid [unk]nthony
Artery
Occlusion
Axillary Bypass
Ingala, MD; Stanley
Z.
Cowen, MD
Graft-
Axillary Artery Axillary Vein
—
Exposure of carotid and axillary arteries.
able and angulated position. In the retroclavicular tech¬ nique, the graft is in a well protected position. The essentials of the retroclavicular technique (Figure) are as follows: The proximal portion of the common ca¬ rotid artery is exposed first via medially placed transverse supraclavicular incision. Partial or complete division of the sternocleidomastoid muscle is usually necessary, this muscle being reapproximated with the wound closure. The common carotid artery is exposed for an adequate length to allow the use of an intraluminal shunt during the by¬ pass anastomosis. In patients with combined carotid bi¬ furcation and proximal subclavian occlusive lesions, a ver¬ tical incision has been used to expose both the carotid bifurcation and the proximal part of the common carotid artery. (In these cases, the carotid bifurcation endarterec¬ tomy is done first.) Following adequate exposure of the common carotid artery, the proximal part of the axillary artery is exposed through a transverse infraclavicular in¬ cision, the pectoralis major muscle being split parallel to its fibers and the proximal part of the axillary arte¬ ry mobilized medial to the pectoralis minor tendon and muscle. The pectoralis minor tendon may be severed if ad¬ ditional exposure and length of artery are necessary. Divi¬ sion of the small branches of the axillary artery is usually advisable so that the axillary artery can be further ele-
vated into a more superficial position. The retroclavicular tunnel is then created by blunt dissection, beginning in the neck in a plane deep to the deep cervical fascia and an¬ terior to the scalene fat pad and continuing laterally par¬ allel to the neurovascular bundle to approach the proximal portion of the axillary artery retroclavicularly. At this point the clavipectoral fascia can be easily penetrated by a blunt instrument and the tunnel is easily enlarged by fin¬ ger dissection. The common carotid graft anastomosis is then carried out, using an end-of-graft-to-side-of-common-carotid-artery technique. We have used either 8- or 10-mm Dacron grafts or saphenous vein for the bypass. The ends of the grafts are suitably beveled to allow oblique passage of the graft through the retroclavicular tunnel. During the anastomosis we have used an intra¬ luminal common carotid shunt. Following the completion of the common carotid artery graft anastomosis and re¬ moval of the intraluminal shunt, the graft is clamped distal to the anastomosis to allow resumption of blood flow through the common carotid artery. The graft is then passed retroclavicularly through the previously created tunnel, and an end-of-graft-to-side-of-axillary-artery anastomosis is carried out to complete the bypass pro¬ cedure. In our group of six patients, the indications for bypass procedure were primarily ischemie upper extremity symp¬ toms and/or associated subclavian steal syndrome. Two of our patients had associated symptomatic carotid bifurca¬ tion atherosclerotic occlusive lesions requiring simultane¬ ous endarterectomy of the carotid bifurcation. One of our patients had proximal left common carotid artery occlu¬ sive disease with normal patency of the subclavian artery. A carotid axillary bypass procedure was done to restore carotid blood flow. There have been no technical problems with the ret¬ roclavicular common carotid axillary bypass technique. The laterally placed retroclavicular tunnel allows ade¬ quate space between the clavicle and the first rib. All of our Dacron and vein grafts have remained patent, with the longest follow-up being two years. Reference 1. Shumacker HB Jr: Carotid axillary bypass grafts for occlusion of the proximal portion of the subclavian artery. Surg Gynecol Obstet 136:447-448, 1973.
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Symptomaticoperative techniques, artery
occlusive disease of the proximal portion of the subclavian can be managed by sevthe most commonly eral different used being the carotid-subclavian bypass. We are submitting a new operative approach: the retroclavicular common carotid axillary bypass technique. For the past two years we have favored this technique over the carotid-axillary artery approach for the following reasons: The proximal part of the axillary artery is far more superficial than the subclavian and can be readily exposed through an infraclavicular pectoralis major musclesplitting incision. Also, the length of axillary artery available for anastomosis is considerably longer and less fragile than the subclavian artery. The subclavian artery exposure is a deep one, limited by the unyielding clavicle and confined to a very small area of exposure. On the left side, the thoracic duct can present problems of lymphorrhea if it is inadvertently lacerated. With the division of a few small branches of the axillary artery, it can be elevated to a very superficial position, making the bypass anastomosis much easier to accomplish. The use of the sec¬ ond incision is much less of a technical problem than the dissection necessary to expose the subclavian artery. The longer distance between the common carotid and axillary arteries presents fewer technical disadvantages than the use of an extremely short segment of graft, which is usu¬ ally necessary in the carotid subclavian bypass. The expo¬ sure of the common carotid can be made through a small, medially placed transverse supraclavicular incision with partial division of the sternocleidomastoid muscle. The retroclavicular tunnel can be easily created with blunt dis¬ section, and the space between the clavicle and first rib in the laterally placed tunnel is quite adequate for the pas¬ sage of an 8- to 10-mm Dacron graft. There have been no problems with vascular compression of the graft in any of the shoulder and head maneuvers. Shumacker1 has re¬ cently described a carotid axillary bypass procedure, al¬ though he described passing the graft in a subcutaneous position anterior to the clavicle. There might be some dis¬ advantages to this: the bypass graft is in a more vulnerAccepted
publication July 23, 1974. University of Southern California Medical School and Los Angeles County-University of Southern California Medical Center, Los Angeles, and Presbyterian Intercommunity Hospital, Whittier, Calif. Reprint requests to Department of Surgery, 9200 Colima Rd, Whittier, CA 90605 (Dr. Pierandozzi). for
From the
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/19/2015
Subclavian Common Carotid [unk]nthony
Artery
Occlusion
Axillary Bypass
Ingala, MD; Stanley
Z.
Cowen, MD
Graft-
Axillary Artery Axillary Vein
—
Exposure of carotid and axillary arteries.
able and angulated position. In the retroclavicular tech¬ nique, the graft is in a well protected position. The essentials of the retroclavicular technique (Figure) are as follows: The proximal portion of the common ca¬ rotid artery is exposed first via medially placed transverse supraclavicular incision. Partial or complete division of the sternocleidomastoid muscle is usually necessary, this muscle being reapproximated with the wound closure. The common carotid artery is exposed for an adequate length to allow the use of an intraluminal shunt during the by¬ pass anastomosis. In patients with combined carotid bi¬ furcation and proximal subclavian occlusive lesions, a ver¬ tical incision has been used to expose both the carotid bifurcation and the proximal part of the common carotid artery. (In these cases, the carotid bifurcation endarterec¬ tomy is done first.) Following adequate exposure of the common carotid artery, the proximal part of the axillary artery is exposed through a transverse infraclavicular in¬ cision, the pectoralis major muscle being split parallel to its fibers and the proximal part of the axillary arte¬ ry mobilized medial to the pectoralis minor tendon and muscle. The pectoralis minor tendon may be severed if ad¬ ditional exposure and length of artery are necessary. Divi¬ sion of the small branches of the axillary artery is usually advisable so that the axillary artery can be further ele-
vated into a more superficial position. The retroclavicular tunnel is then created by blunt dissection, beginning in the neck in a plane deep to the deep cervical fascia and an¬ terior to the scalene fat pad and continuing laterally par¬ allel to the neurovascular bundle to approach the proximal portion of the axillary artery retroclavicularly. At this point the clavipectoral fascia can be easily penetrated by a blunt instrument and the tunnel is easily enlarged by fin¬ ger dissection. The common carotid graft anastomosis is then carried out, using an end-of-graft-to-side-of-common-carotid-artery technique. We have used either 8- or 10-mm Dacron grafts or saphenous vein for the bypass. The ends of the grafts are suitably beveled to allow oblique passage of the graft through the retroclavicular tunnel. During the anastomosis we have used an intra¬ luminal common carotid shunt. Following the completion of the common carotid artery graft anastomosis and re¬ moval of the intraluminal shunt, the graft is clamped distal to the anastomosis to allow resumption of blood flow through the common carotid artery. The graft is then passed retroclavicularly through the previously created tunnel, and an end-of-graft-to-side-of-axillary-artery anastomosis is carried out to complete the bypass pro¬ cedure. In our group of six patients, the indications for bypass procedure were primarily ischemie upper extremity symp¬ toms and/or associated subclavian steal syndrome. Two of our patients had associated symptomatic carotid bifurca¬ tion atherosclerotic occlusive lesions requiring simultane¬ ous endarterectomy of the carotid bifurcation. One of our patients had proximal left common carotid artery occlu¬ sive disease with normal patency of the subclavian artery. A carotid axillary bypass procedure was done to restore carotid blood flow. There have been no technical problems with the ret¬ roclavicular common carotid axillary bypass technique. The laterally placed retroclavicular tunnel allows ade¬ quate space between the clavicle and the first rib. All of our Dacron and vein grafts have remained patent, with the longest follow-up being two years. Reference 1. Shumacker HB Jr: Carotid axillary bypass grafts for occlusion of the proximal portion of the subclavian artery. Surg Gynecol Obstet 136:447-448, 1973.
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