No disclosures Warren Gasper MD Assistant Professor of Surgery - - PowerPoint PPT Presentation

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 1

How I Do It: Aortic Arch Debranching Exposures, Tunnels and Techniques

4/14/2016

Warren Gasper MD Assistant Professor of Surgery UCSF Vascular Surgery

No disclosures

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

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

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

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

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 2

Carotid-subclavian bypass

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Supraclavicular incision Divide the platysma Divide the clavicular head

• f the SCM if needed

Divide the omohyoid

Rutherford Atlas of Vascular Surgery 1993

Carotid-subclavian bypass

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

Supraclavicular incision Divide the platysma Divide the clavicular head

• f 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

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

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

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 3

Proximal and distal control

• f the subclavian artery

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

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

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

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

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

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 subclavian proximal to vertebral or use an endovascular plug Close the platysma and skin

• ver 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

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

14 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 15 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16

Tunnels

Retropharyngeal Anterior

Valentine Vascular Exposures 2003

Rarely used option: subclavian-subclavian bypass

16 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 Ouriel Atlas of Vascular Surgery 1998

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 5

Rarely used option: subclavian-subclavian bypass

17 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 Ouriel Atlas of Vascular Surgery 1998

Rarely used option #2: axillo-axillary bypass

18 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 Ouriel Atlas of Vascular Surgery 1998

Rarely used option #2: axillo-axillary bypass

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

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