Anatomic Exposures in Vascular Surgery: Tips & Tricks

Erica L. Mitchell MD, MEd SE, FACS, DFSVSProfessor & Chief, Vascular and Endovascular SurgeryUniversity of Tennessee Health & Science University

Regional One Health, Elvis Presley Trauma Center

Disclosures

None

R. James Valentine & Gary G. Wind 4th edition Anatomic Exposures in Vascular Surgery images

Exposure of the Extracranial Carotid Artery

Exposure of the Cervical Carotid Artery

Tips & Tricks

• DUS to identify carotid bifurcation• Curve incision superiorly to avoid

marginal mandibular branch of the facial nerve

Exposure of the Cervical Carotid Artery

Tips & Tricks

• Facial vein and LN typically lie over the bifurcation

• Accessory n crosses superiorly and into SCM

Exposure of the Cervical Carotid Artery

Tips & Tricks

• Vagus n can be injured with retraction

Exposure of the Cervical Carotid Artery

Tips & Tricks

• Avoid cautery cephalad to the carotid bifurcation

• Hypoglossal n

Exposure of the Cervical Carotid Artery

Tips & Tricks

• Ligate the occipital artery/vein to “untether” the Hypoglossal n

• Divide the posterior belly of the digastric muscle

• Styloid process

Exposure of the Cervical Carotid Artery

Tips & Tricks

• Glossopharyngeal n• Between ICA & IJ deep to styloid process

and attached muscles

Exposure for TCAR

Tips & Tricks

• DUS space between heads of sternocleidomastoid muscle

• Longitudinal or transverse incision

Exposure for TCAR

Tips & Tricks

• Avoid retraction injury to Vagus n

Exposure of the Cervical Vertebral Artery

• V1: Proximal segment• Subclavian origin to transverse process C6

• V2: Interosseous segment• C6 to C2

• V3: Third segment • C2 transverse process to skull base

• V4: Intracranial segment• Atlantooccipital membrane to Basilar artery

Exposure of the Cervical Vertebral Artery: V1

Tips & Tricks

• Transect clavicular SCM low• Vagus n• Sympathetic chain

• Posterolateral of carotid sheath

Exposure of the Cervical Vertebral Artery: V1

Tips & Tricks

• Transect Omohyoid low• Ligate all thoracic ductal vessels

Exposure of the Cervical Vertebral Artery: V1

Tips & Tricks

• Mobilize scalene fat pad medial to laterally

• Phrenic n

Exposure of the Cervical Vertebral Artery: V1

Tips & Tricks

• Divide Inferior Thyroid artery and Vertebral vein

• Divide or retract Anterior scalene muscle laterally

Exposure of the Extrathoracic Subclavian Artery

Tips & Tricks

• Distal exposure of the Subclavian a

Exposure of the Extrathoracic Subclavian Artery

Tips & Tricks

• Exposure improved with transection of the Anterior scalene m

Exposure of the Extrathoracic Subclavian Artery

Tips & Tricks

• This is deeper than you think

Carotid – Subclavian Bypass

Tips & Tricks

• Short graft• Tunnel behind the IJ

Carotid – Subclavian Transposition

Tips & Tricks

• Control the Subclavian a before you ligate it

Carotid – Subclavian Transposition

Tips & Tricks

• Transpose behind the IJ

Exposure of the Axillary Artery

Axillary artery is defined by the lateral margin of the first rib proximally and the lateral edge of the teres major muscle distally

Exposure of the Axillary Artery

Branches of the Axillary Artery

• First segment has one branch• Second segment has two branches• Third segment has three branches

Exposure of the Axillary Artery

Nerves of the Axilla• The brachial plexus surround the

axillary artery within the axillary sheath

Exposure of the Axillary Artery

Tips & Tricks

• Focus on 1st section of the artery• The more lateral the dissection, the

greater the risk of nerve injury

Exposure of the Axillary Artery

Tips & Tricks

• Abduct the arm 90°

Exposure of the Axillary Artery

Tips & Tricks

• Make the incision parallel to the artery, not the clavicle

• Spread vs transect pectoralis major fibers

Exposure of the Axillary Artery

Tips & Tricks

• Vessels lie under the Clavipectoral fascia

Exposure of the Axillary Artery

Tips & Tricks

• Retract vein inferiorly

Axillary to Femoral Artery Bypass

Tips & Tricks

• To avoid graft disruption• Align end-side anastomosis non-

perpendicular• Beveled anastomosis

Axillary to Femoral Artery Bypass

Tips & Tricks

• To avoid graft disruption• Anastomosis 1st portion• Route graft parallel to artery • Tunnel under Pectoralis major• Allow sufficient laxity in axillary portion

Exposure of the Brachial Artery

Relationship of artery, nerves, and biceps

Exposure of the Brachial Artery

Tips & Tricks

• Abduct arm 90°

Exposure of the Brachial Artery

Tips & Tricks

• For brachial/axillary sheath hematomas incise investing brachial sheath

Exposure of the Brachial Artery

Tips & Tricks

• High brachial bifurcations ~8-10% & in upper 1/3 of arm

• Median & ulnar nerves adjacent

Exposure of the Brachial Bifurcation

Tips & Tricks

• Avoid longitudinal incisions across the antecubital crease

• Risk of flexion contractures

• Transverse or S-shaped antecubital incision

Exposure of the Brachial Bifurcation

Tips & Tricks

• Medial antebrachial cutaneous nerve• Basilic vein transpositions

Exposure of the Brachial Bifurcation

Tips & Tricks

• Bifurcation exposed by retracting pronator teres and flexor muscle mass

Exposure of the Brachial Bifurcation

Tips & Tricks

• Ulnar artery dives between the heads of the flexor digitorum superficialis

Exposure of the Mid-forearm Radial Artery

Tips & Tricks

• Landmark for incision• Midpoint antecubital crease to styloid

process of the radius• Groove of medial edge of brachioradialis

muscle

Exposure of the Mid-forearm Radial Artery

Tips & Tricks

• Medial edge of brachioradialis muscle

Radial Artery Harvesting

Tips & Tricks

• Confirm Ulnar dominance• Retract brachioradialis & pronator

teres apart• Preserve recurrent radial artery

branch (proximally) & superficial palmar artery (distally)

Exposure of the Mid-forearm Ulnar Artery

Tips & Tricks

• Incision is radial to the Flexor Carpi Ulnaris

• Preserve palmar branch of the Ulnar n• Superficial to the antebrachial fascia

Arterial Circulation to the Hand

Tips & Tricks

• Terminate in superficial and deep palmar arches

• Incomplete superficial and deep palmar arches are common

• One arch patent in most individuals

Arterial Circulation to the Hand

Tips & Tricks

• Superficial palmar arch• More variable than deep arch • Most commonly incomplete

Forearm Fasciotomy

Upper Extremity Compartment Syndrome

• Fracture of the distal radius (adults)• Supracondylar fractures (children)

3 primary compartments• Volar: Flexor, superficial, & deep• Lateral: mobile wad—brachioradialis,

extensor carpi radialis longus, & brevis• Dorsal: extensor, superficial, & deep

Forearm Fasciotomy

Tips & Tricks

• Deep Volar Compartment• Most commonly affected in forearm

compartment syndromes• Flexor digitorum profundus, flexor pollicis

longus, & pronator quadratus• Anterior interosseous artery

Forearm Fasciotomy

Tips & Tricks

• Release of Deep Volar Compartment essential

Forearm Fasciotomy

Tips & Tricks

• Single incision can be used to decompress the lateral and volar compartments

• Release of Deep Volar Compartment essential

Forearm Fasciotomy

Exposure of the Supraceliac Aorta

Tips & Tricks

• NGT to palpate esophagus• Deep abdominal retractor set

Transabdominal Exposure of the Supraceliac Aorta

Tips & Tricks

• Divide left triangular ligament liver• Only cut through avascular plane

• Hepatic veins and vena cava at the dome of the liver

• Retract left lobe superiorly and laterally with a long sturdy retractor

Transabdominal Exposure of the Supraceliac Aorta

Tips & Tricks

• Open gastrohepatic omentum to expose right crus of the diaphragm.

Transabdominal Exposure of the Supraceliac Aorta

Tips & Tricks

• Mobilize the right crus to expose the aorta

Transabdominal Exposure of the Supraceliac Aorta

Tips & Tricks

• Finger dissect along each side of the aorta

• Do not circumferentially dissect around the aorta

Transabdominal Exposure of the Celiac Artery

Tips & Tricks

• The median arcuate ligament can be very adherent to the CA

• MALS

Transabdominal Exposure of the Celiac Artery

Tips & Tricks

• The celiac ganglion must be cleared to fully expose the celiac trunk

Transabdominal Exposure of the Superior Mesenteric Artery

Tips & Tricks

• Proximal SMA is under the pancreas and IMV/Splenic vein confluence

Transabdominal Exposure of the Superior Mesenteric Artery

Tips & Tricks

• The SMA/V lie over the 3rd portion of the duodenum and uncinate process of the pancreas

• It is not necessary to mobilize the ligament of Treitz

Transabdominal Exposure of the Superior Mesenteric Artery

Tips & Tricks

• Retract transverse colon cephalad• Leave ligament of Treitz as is• Retract small bowel to the right• Score mesentery in oblique fashion

directed to ASIS

Transabdominal Exposure of the Superior Mesenteric Artery

Tips & Tricks

• Stay on top of the SMA to avoid branches

• Preserve & encircle all branches• Can safely clamp above the middle

colic branch• Longitudinal arteriotomy preferred to

transverse (vein patch)

Transabdominal Exposure of the Superior Mesenteric Artery

Tips & Tricks

• Lateral approach for bypasses• Mobilize 4th portion of duodenum to

expose both the subpancreatic portion of SMA and subjacent aorta

Infrarenal Aorta to Superior Mesenteric Artery Bypass

Tips & Tricks• Infrarenal aorta must be clampable

Iliac Artery to Superior Mesenteric Artery Bypass

Tips & Tricks• Do the inflow portion of the operation

first • Avoid redundancy in graft especially if

vein

Supraceliac Aorta to Superior Mesenteric Artery Bypass

Tips & Tricks• Expose as much as possible

supraceliac aorta to best visualize the anastomosis

• Side-biting camps seem ideal but make visualization of the aortic lumen challenging

Transabdominal Exposure of the Hepatic Arteries

Tips & Tricks

• Colon and small bowel inferiorly• Extend CA trunk exposure laterally for

CHA & GDA exposure or…• Incise hepatoduodenal ligament

cephalad to the duodenum (portal triad)

Transabdominal Exposure of the Renal Arteries

Tips & Tricks

• The renal arteries drape posteriorly over the spinal column

• RRA often divides behind the IVC

Transabdominal Exposure of the Renal Arteries

Tips & Tricks

• Incise the ligament of Treitz & reflect 4th portion duodenum

Transabdominal Exposure of the Renal Arteries

Tips & Tricks

• Ligate the lumbar +/_ lumbar branches of the L RV to expose the L RA

Transabdominal Exposure of the Renal Arteries

Tips & Tricks

• Mobilize duodenum, head of the pancreas, & hepatic flexure of colon

Transabdominal Exposure of the Renal Arteries

Tips & Tricks

• Ligate IVC lumbar veins prn

Suprainguinal Exposure of the External Iliac Artery

Tips & Tricks

• Lower quadrant incision for external iliac vessel exposure

Exposure of the Superficial Femoral Artery & Femoral Vein

Tips & Tricks

• Draw line from ASIS to medial condyle • FV and mid-distal SFA• Hunters canal

Exposure of the Superficial Femoral Artery & Femoral Vein

Tips & Tricks

• Incision follows lateral border of the Sartorius

Exposure of the Superficial Femoral Artery & Femoral Vein

Tips & Tricks

• Femoral vein exposure

Exposure of the Superficial Femoral Artery & Femoral Vein

Tips & Tricks

• Always preserve the PFV

Posterior Exposure of the Popliteal Artery

Tips & Tricks

• Not ideal for large popliteal artery aneurysms extending cephalad

• Relationship of nerve-vein-artery• Tibial & Sural nerves exposed

Medial Exposure of the Below Knee Popliteal Artery

Tips & Tricks

• Avascular plane between Gastrocnemius & Soleus m

Medial Exposure of the Below Knee Popliteal Artery

Tips & Tricks

• Avascular plane

Medial Exposure of the Below Knee Popliteal Artery

Tips & Tricks

• More proximal exposure• Divide tendons of the semitendinosus,

gracilis, and sartorius muscles for

• For TPT exposure• Divide tibial attachments of soleus

muscle

Exposure of the Posterior Tibial Artery

Tips & Tricks

• Stay close to the Tibial bone• Transect Soleus muscle fascia at the bone

Exposure of the Posterior Tibial Artery

Tips & Tricks

• Veins must be ligated• Complex of veins

Exposure of the Posterior Tibial Artery

Tips & Tricks

• Same principles apply mid calf• Transect Soleus muscle fascia at the bone• Veins parallel artery

Exposure of the Anterior Tibial Artery

Tips & Tricks

• Make incision mid Anterior Tibialis muscle

• Avascular plane within herring bone groove

• Branch vessels lead to neurovascular bundle sitting in yellowish glistening fat

Exposure of the Anterior Tibial Artery

Tips & Tricks• At the ankle, the ATA crosses the

anterior tibial surface beneath the extensor retinacula

Exposure of the Peroneal Artery

Tips & Tricks• Same incision as for PTA

Exposure of the Peroneal Artery

Tips & Tricks• Peroneal a lies deeper to next fascial

layer• Again, lies in neurovascular yellow fat

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