Alloplastic carotid-subclavian bypass for left subclavian artery stenosis

Skin incision approx. 1 cm above and parallel to the clavicle, with orientation at the sternoclavicular joint and at the anterior edge of the trapezius muscle. Division of the platysma. Ligation and division of superficial lymphatic collectors and neck veins.

Medial to the sternocleidomastoid muscle and the internal jugular vein exposure of the common carotid artery and looping with two vessel loops.

Attention:

Preservation of the vagus nerve! Lesions lead to hoarseness, because the recurrent fibers in the vagus nerve run caudally and only then return to the neck below the aortic arch.

Exposure and division of the external jugular vein between transfixion ligatures. Small lymphatic vessels are secured with clips in the supraclavicular fat pad and divided.

Exposure of the phrenic nerve on the anterior scalene muscle. Successive transection of the muscle with careful preservation of the nerve.

Tip:

The anterior scalene muscle can also be undermined with an Overholt clamp and sharply transected in one step between the opened branches of the clamp. However, there is a risk that the subclavian artery may be injured with the Overholt clamp. The presented method is therefore likely to be the safer one.

Preparation of the now visible subclavian artery, which is looped with two vessel loops. The thyrocervical trunk should be divided to enable an anastomosis. The vertebral artery is provided with a bulldog clamp.

Tips:

1. The subclavian artery as well as its side branches exhibit a relatively fragile wall due to the high proportion of elastic fibers and are therefore very tearable. Therefore, careful preparation!

2. The vertebral artery and internal mammary (thoracic) artery must be preserved.