2 Aortic Arch Debranching UCSF Vascular Symposium /14/16. J Endovasc Ther 2002;9:suppl 2; II98 105

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1 How I Do It: Aortic Arch Debranching Exposures, Tunnels and Techniques Warren Gasper MD Assistant Professor of Surgery UCSF Vascular Surgery No disclosures 2 Aortic Arch Debranching UCSF Vascular Symposium /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 Zone 2 preserve the left subclavian Assess the origin of the vertebral artery to ensure it is preserved Preoperative carotid duplex treat occlusive disease concomitantly 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 J Endovasc Ther 2002;9:suppl 2; II Aortic Arch Debranching UCSF Vascular Symposium /14/16 4 Aortic Arch Debranching UCSF Vascular Symposium /14/16 1

2 Supraclavicular incision Divide the platysma Divide the clavicular head of the SCM if needed Divide the omohyoid Supraclavicular incision Divide the platysma Divide the clavicular head of the SCM if needed Divide the omohyoid Ligate the external jugular if needed 5 Aortic Arch Debranching UCSF Vascular Symposium /14/16 6 Aortic Arch Debranching UCSF Vascular Symposium /14/16 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 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) 7 Aortic Arch Debranching UCSF Vascular Symposium /14/16 8 Aortic Arch Debranching UCSF Vascular Symposium /14/16 2

3 Proximal and distal control of the subclavian artery 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 9 Aortic Arch Debranching UCSF Vascular Symposium /14/16 10 Aortic Arch Debranching UCSF Vascular Symposium /14/16 11 Aortic Arch Debranching UCSF Vascular Symposium /14/16 Prosthetic graft 6 or 8mm PTFE or Dacron Sew the graft end-to-side to the subclavian artery first 12 Aortic Arch Debranching UCSF Vascular Symposium /14/16 Pass above or below the phrenic nerve Pass below the internal jugular vein Use 5mm aortic punch (optional) and sew end-toside Ligate the subclavian proximal to vertebral or use an endovascular plug Close the platysma and skin over a JP drain 3

4 Zone 1: Preserve the left carotid and left subclavian arteries Carotid-carotid-subclavian bypass tips 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 /14/16 Perspect Vasc Surg Endovas Ther 2012;24(4) 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 /14/16 Tunnels Rarely used option: subclavian-subclavian bypass Anterior Retropharyngeal 15 Aortic Arch Debranching UCSF Vascular Symposium /14/16 16 Aortic Arch Debranching UCSF Vascular Symposium /14/16 4

5 Rarely used option: subclavian-subclavian bypass Rarely used option #2: axillo-axillary bypass 17 Aortic Arch Debranching UCSF Vascular Symposium /14/16 18 Aortic Arch Debranching UCSF Vascular Symposium /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 19 Aortic Arch Debranching UCSF Vascular Symposium /14/16 20 Aortic Arch Debranching UCSF Vascular Symposium /14/16 5