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

How I Do It: Aortic Arch Debranching Exposures, Tunnels and Techniques No disclosures Warren Gasper MD Assistant Professor of Surgery UCSF Vascular Surgery 4/14/2016 2 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 Into the arch Zone 2 – preserve the left subclavian Assess the origin of the vertebral artery to ensure it is preserved � Zone 2 Preoperative carotid duplex – treat occlusive disease concomitantly • Occlude the left subclavian artery � Left carotid to left subclavian bypass � Zone 1 • Short, prosthetic bypass from common carotid to subclavian • Occlude the left carotid and left • Need to ligate/occlude the subclavian proximal to the vertebral subclavian arteries • Preferred if there is LIMA-coronary bypass, no need to interrupt LIMA flow � Zone 0 � Left subclavian to carotid transposition • Occlude the innominate, left carotid and left subclavian arteries • No bypass conduit, proximal subclavian artery is oversewn • Can be difficult to get proximal to the vertebral and internal mammary J Endovasc Ther 2002;9:suppl 2; II98–105 3 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 4 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 1 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Carotid-subclavian bypass Carotid-subclavian bypass � Supraclavicular incision � Supraclavicular incision � Divide the platysma � Divide the platysma � Divide the clavicular head � Divide the clavicular head of the SCM if needed of the SCM if needed � Divide the omohyoid � Divide the omohyoid � Ligate the external jugular if needed Rutherford Atlas of Vascular Surgery 1993 Valentine Vascular Exposures 2003 5 Aortic Arch Debranching | UCSF Vascular Symposium 2016 6 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 4/14/16 Carotid-subclavian bypass Carotid-subclavian bypass � Mobilize the inferior and � Mobilize the inferior and medial edges of the medial edges of the scalene fat pad and retract scalene fat pad and retract superolateral superolateral � Divide the thoracic duct if � Divide the thoracic duct if needed needed � Identify the phrenic nerve � Identify the phrenic nerve running anterior to the � Divide the anterior scalene anterior scalene muscle (bovie, bipolar, scissors) Valentine Vascular Exposures 2003 Rutherford Atlas of Vascular Surgery 1993 7 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 8 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 2 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Carotid-subclavian bypass Carotid-subclavian bypass � Divide the SCM or retract it medially � Expose the lateral edge of � Proximal and distal control the internal jugular and of the subclavian artery retract medially � Expose the left common carotid artery while protecting the vagus nerve Rutherford Atlas of Vascular Surgery 1993 Rutherford Atlas of Vascular Surgery 1993 9 Aortic Arch Debranching | UCSF Vascular Symposium 2016 10 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 4/14/16 Carotid-subclavian bypass Carotid-subclavian bypass � Pass above or below the phrenic nerve � Prosthetic graft � Pass below the internal • 6 or 8mm PTFE or Dacron jugular vein � Sew the graft end-to-side to � Use 5mm aortic punch the subclavian artery first (optional) and sew end-to- side � Ligate the subclavian proximal to vertebral or use an endovascular plug � Close the platysma and skin over a JP drain Ouriel Atlas of Vascular Surgery 1998 Ouriel Atlas of Vascular Surgery 1998 11 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 12 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 3 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Zone 1: Preserve the left carotid and left subclavian arteries Carotid-carotid-subclavian bypass tips � Expose right common carotid with a longitudinal incision and the left common carotid and subclavian through a supraclavicular incision Right carotid – left carotid – left subclavian bypass � Be aware of the vagus nerves = 4 anastomoses • In an unlucky situation, injury to both nerves can cause bilateral vocal cord paralysis and airway compromise Alternative: Right carotid – left subclavian – right � Bypass technique: carotid bypass • 6 or 8mm PTFE or Dacron = 3 anastomoses • Right common carotid – Left subclavian – Left common carotid � Tunnel choices � Ligate/occlude the proximal left subclavian and left common carotid arteries Perspect Vasc Surg Endovas Ther 2012;24(4) 184–192 13 Aortic Arch Debranching | UCSF Vascular Symposium 2016 14 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 4/14/16 Tunnels Rarely used option: subclavian-subclavian bypass Anterior Retropharyngeal Valentine Vascular Exposures 2003 Ouriel Atlas of Vascular Surgery 1998 15 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 16 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 4 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Rarely used option: subclavian-subclavian bypass Rarely used option #2: axillo-axillary bypass Ouriel Atlas of Vascular Surgery 1998 Ouriel Atlas of Vascular Surgery 1998 17 Aortic Arch Debranching | UCSF Vascular Symposium 2016 18 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 4/14/16 Rarely used option #2: axillo-axillary bypass 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 Ouriel Atlas of Vascular Surgery 1998 19 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 20 Aortic Arch Debranching | UCSF Vascular Symposium 2016 4/14/16 5 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]