Chapter 98 - Brachiocephalic artery disease - open surgery

Question 1

Aortic arch configurations

Answer 1

TABLE 98.1

Question 2

Indications for repair asymptomatic bracheocephalic artery lesions

Answer 2

1) subclavian stenosis with IMA CABG 2) preservation of AV access 3) preservation of Ax-based bypasses 4) planned sternotomy and reconstruction of arch

Question 3

Kommerell diverticulum

Answer 3

Abberant right subclavian artery aneurysms can fistulize to esophagus

Question 4

Syphilis and TB in aneurysm of brachiocephalic

Answer 4

Subclavian artery most common

Question 5

Indication for treatment following dissection or traumatic injury to arch vessels

Answer 5

1) symptomatic 2) large defect otherwise treatment is antipaltelet DELAYED reason: 1) active hemorrhage 2) enlarging pseudoaneurysm 3) recurrent thromboembolic events

Question 6

Management of isolated brachiocephalic artery aneurysm

Answer 6

1) screen for genetic disease 2) repair regardless of size due to nerve compression and thromboembolic events (16%)

Question 7

Perioperative mortality with innominate artery aneurysm repair

Answer 7

11%

Question 8

Indication to watch bracheocephalic aneurysms

Answer 8

1) high surgical risk 2) asymptomatic 3) < 2cm 4) no intraluminal thrombus

Question 9

Arch vessel endarterectomy indication

Answer 9

1) ok for midsection of innominate or CCA 2) not orificial 3) not bovine arch

Question 10

Transthoracic bypass to arch vessel key points

Answer 10

1) avoid pre-made bifurcated grafts - hard to close sternotomy 2) trendelenburg position to avoid air embolism 3) side biting clamp on ascending aorta after ensuring on TEE that it’s free of disease

Question 11

Total arch replacement strategies to decrease neurologic morbidity

Answer 11

1) retrograde cerebral perfusion 2) cardiopulmonary bypass 3) profound hypothermia 4) circulatory arrest

Question 12

First aorto-innominate bypass done by

Answer 12

DeBakey 1957

Question 13

Mortality of arch bypass transthoracic and patency

Answer 13

mortality 4.7 - 8% stroke 2.9-8%

Question 14

Carotid-subclavian transposition steps

Answer 14

1) transverse supraclavicular incision between two heads of SCM 2) platysmal flaps 3) avoid EJ injury 4) divide omohyoid 5) control CCA 6) divide thoracic duct 7) divide vertebral vein 8) identify subclavian artery

Question 15

Contraindication to carotid-subclavian transposition

Answer 15

1) early origin of vertebral 2) patent internal mammary coronary bypass 3) contralateral vert occlusion 4) aberrant termination of vert into posteroinferior cerebellar artery

Question 16

Mortality, stroke and patency of carotid-subclavian transposition

Answer 16

mortality: 0-2.2% STroke: 1-2.2% patency 99% in 61 months

Question 17

Carotid subclavian bypass steps

Answer 17

1) transverse supraclavicular incision extend lateral to clavicular head of SCM 2) divide platysma and retract SCM medially 3) identify CCA and control 4) scalene fat pad ligated medially and retracted laterally 5) protect phrenic nerve 6) divide anterior scalene on first rib 7) ligate thoracic duct 8) divide thyrocervical trunk 9) subclavian anastomosis first

Question 18

Conduit for carotid subclavian bypass

Answer 18

PTFE 8mm or dacron better than vein in patency

Question 19

Carotid subclavian bypass mortality, stroke, patency

Answer 19

1% mortality 2.1% stroke 86-94% patency 5 year

Question 20

Carotid carotid bypass steps

Answer 20

1) usual carotid exposure 2) parynx identified medially 3) blunt dissection posterior to pharynx and anterior to prevertebral fascia 4) inflow anastamosis first 5) distal can be end-to-end or end-to-side

Question 21

Carotid-carotid bypass mortality stroke patency

Answer 21

0% mortality 4-6% stroke 92% patency

Question 22

Axilloaxillary bypass steps

Answer 22

1) usual axillary exposure 2) tunnel superficially

Question 23

Axilloaxillary bypass uses

Answer 23

1) maintain cerebral flow durign total arch debranching prior to zone 0 aortic endograft deployment