Chapter 57 - Upper extremity vascular exposure

Question 1

Three zones of the upper extremity

Answer 1

1) intrathoracic zone (aortic arch, innominate, subclavian, SVC)
2) thoracic outlet (based of neck to axilla): subclavian, vertebral, axillary
3) arm (axilla to fingers)

Question 2

Rate of aberrant right subclavian

Answer 2

2%

Question 3

Course of the aberrant right subclavian

Answer 3

1) arise distal to left subclavian

2) course behind esophagus

Question 4

Rate of left vert from aortic arch

Answer 4

2-5%

Question 5

Exposure to get proximal left subclavian control

Answer 5

Anterolateral third interspace thoracotomy

Question 6

Medium sternotomy good for these arterial controls

Answer 6

1) proximal right subclavian
2) proximal left carotid
3) innominate

limited to 3rd interspace if aorta not needed

Question 7

Exposure of the proximal arch vessels

Answer 7

1) median sternotomy
2) ligate or preserve left innominate vein
3) protect right recurrent laryngeal and right phrenic
4) tease away fatty tissue and retract overlying veins

more distal exposure

5) extend incision to neck or supraclavicular area
6) partially divide SCM and anterior scalene

Question 8

Course of the right recurrent laryngeal nerve

Answer 8

loops around right subclavian artery just as it arises from innominate

Question 9

Course of the right phrenic

Answer 9

passes behind jugular and right innominate vein
anterior to right subclavian artery
anterolateral to innominate artery

Question 10

Course of the left recurrent laryngeal nerve

Answer 10

loops around aorta in area of ligamentum arteriosum

ascends anterior to arteries

Question 11

Trapdoor thoracotomy

Answer 11

3rd space sternotomy, supraclavicular incision

3rd space anterolateral thoracotomy

Question 12

Exposure of the proximal innominate vein

Answer 12

Sternoclavicular rotation

1) first space sternotomy
2) reattach after done

Question 13

Exposure of the right atrial appendage

Answer 13

1) use as outflow for complex venous occlusive disease
2) limited anterior 3rd interspace thoracotomy
3) enter pericardial sace
4) clamp with satinsky -type clamp

Question 14

Which SCM head is more easily sacrificed without consequence

Answer 14

Clavicular head

Question 15

When does the subclavian artery change name to the axillary artery

Answer 15

after crosses over the lateral border of the first rib

Question 16

Subclavian vein in relation to the artery

Answer 16

Inferior/caudal

Question 17

Exposure of the subclavian vein

Answer 17

Infraclavicular incision

Question 18

Proximal brachial exposure key points

Answer 18

1) Lies deep to vein and nerve
2) superficial nerves are sensory and can be sacrificed
3) deep brachial artery can also be sacrificed

Question 19

Vein coming up forearm that divides branches to the cephalic and basilic vein

Answer 19

Median antecubital vein

Question 20

Nerve to watch out for in the exposure of the radial artery

Answer 20

Radial sensory nerve