Vessel Exposures

Common femoral exposure

· Prep both legs & both groins, towel & adhesive drape over perineum

· Thigh abducted

· Vertical incision over artery mid inguinal point

— If saphenous vein also required then lazy-S

vertically over artery @ inguinal ligament

horizontal in groin crease & vertical over LSV

—   Divide: Skin, Subcutaneous tissue & superficial  fascia

—   The termination of LSV is identified and preserved. Any branches are divided as necessary. The superficial external pudendal artery is divided between 2/0 Vicryl ties as it passes between LSV and CFV.

—   Femoral sheath opened to expose CFV and CFA. The femoral branch of the genitofemoral nerve may pass through the anterior surface of the femoral sheath and must be preserved

PFA arises from the posterolateral side of the CFA

The femoral nerve lies laterally and usually in a deeper plane and is not seen. from & medial cutaneous N of thigh on fem artery

· Dissect out with lahey from lateral side, to avoid lymphatics, the CFA.

· Sling:

—   Common femoral

—   Superficial femoral

—   Profunda – care to avoid PFV passing behind artery

The ileofemoral junction can be exposed by division of the inguinal ligament preserving the deep inferior epigastric vein.

Exposure of the SFA in Hunter’s Canal

· Leg abducted, hip & knee flexed, externally rotated with a sandbag beneath the knee

· The surface marking of the SFA is in the line from ASIS to adductor tubercle

· Incision is made in skin and superficial fascia and the LSV is preserved in the posterior skin flap.

· Deep fascia of the thigh is divided between sartorius and vastus medialis

· The sartorius is retracted backwards to expose the SFA on adductor magnus

· The Saphenous nerve is separated

· The artery is separated carefully from surroundin veins.

Proximal popliteal exposure – above knee popliteal

· Leg abducted, hip & knee flexed, externally rotated with a sandbag beneath the knee

· Incision parallel to long axis of thigh starting 2cm proximal to adductor tubercle.

— Level with posterior border of femur/ anterior border sartorius

— » 10cm longer if fat / muscular

· Fat & fascia divided. Preserve LSV

· Sartotius retracted posteriorly

· Vascular bundle found between fibres of aductor magnus

· The tendon and fibers of adductor magnus are divided to expose the proximal popliteal

· The artery lies on the bone, the nerve medial and the vein in between.

There is a plexus of veins surrounding the popliteal artery which must be carefully separated and divided.

Collateral genicular branches of the popliteal must be preserved

Distal popliteal exposure

· Leg abducted, hip & knee flexed, externally rotated

· Incision parallel to long axis of lower leg

— Anterior border of gastrocnemius 1fb posterior to medial border of tibia

— » 10cm longer if fat / muscular

— Preserve LSV

· Fat , fascia & deep fascia divided

· Medial head of gastroc mobilised & retracted posteriorly

— semitendinosus & gracilis anteriorly

· Dissect between medial head & tibia to reveal n-v bundle

— Vein exposed 1st (medial)

— Dissect out artery with lahey’s & sling

· To expose tibioperoneal trunk & anterior tibial

— Divide attachment of soleus to medaial border of tibia

· To ­ exposure proximally, divide tendons of semitendinosus, sartorius & gracilis

· For embolectomy

— Longitudinal & distal arteriotomy

— Embolectomy as above

— Close with vein patch

Exposure of all popliteal

· Posterior approach

· Prone

· Lazy S through popliteal fossa with the upper limb medial

· Deepen through popliteal fascia, elevate flaps to define popliteal Õ

· Identify short saphenous vein and follow it dividing the popliteal fascia longitundianlly

· Find and preserve the Sural nerve

· Fat is cleared from the tibial and common peroneal nerves

· SSV is followed to the popliteal vein behind which lies the artery

· Artery deepest structure

Distal vessel exposure

· Anterior tibial

— Lateral approach

— Retract tibialis anterior & EDL anteriorly

— Artery lying on interosseous membrane

· Posterior tibial

— Medial approach

— Junction of gastrocnemius & tendoachilles

— Develop plane between gastroc & soleus

— Post tib vessels lying on surface of soleous under fascia

Subclavian exposure

· Transverse incision above medial 1/3 clavicle from SCM to trapezius

· Divide skin, s/c tissue, platysma

· Divide clavicular head of SCM

— Exposes fat pad on scalenus anterior contains scalene LN’s

· Dissect & retract fat pad superiorly off scalenus anterior

· Identify & preserve phrenic nerve

— Passes obliquely across muscle lateral ® medial

· Pass dissector round scalenus anterior to protect phrenic & divide muscle

· Exposes

— 2nd part subclavian with thyrocervical trunk, vertabral & internal mammary

— C8 nerve root above & T1 nerve root below 1st rib posterior to artery

— Thoracic duct on L side

· If further exposure required continue incision to midline & divide sternal head SCM

· If exposure of 1st part required split manubrium on R & trapdoor on L to 4th ics

Proximal Alternative (Cameron)
Because the left subclavian artery travels posteriorly from its origin on the aortic arch, proximal control through a median sternotomy is challenging.
The preferred approach for proximal control of the left subclavian artery is left anterolateral thoracotomy.
The patient is positioned supine, and a rolled towel is placed beneath the scapula to position the chest wall slightly anteriorly.
A transverse curvilinear incision is performed at the level of the fifth rib, extending from the lateral border of the sternum to the anterior axillary line.
Dissection is performed through the pectoralis fascia.
The intercostal muscles overlying the fifth rib are divided, the parietal pleura is exposed and incised, and the chest cavity is entered using a self-retaining rib spreader.
Inferior retraction of the superior lobe of the left lung will reveal the aortic arch through the mediastinal pleura.
Incising the mediastinal pleura exposes the origin of the left subclavian artery.
Care should be taken to avoid injury to both the vagus nerve and the thoracic duct in this region; the vagus nerve passes anterolateral to the artery, and the thoracic duct lies posteromedial in this approach.
The proximal right subclavian artery is best exposed through a median sternotomy.
Cervical extension of the sternotomy allows for exposure of the carotid sheath.
Mobilization of the left innominate vein allows visualization of the proximal right subclavian artery and the innominate artery, which is then followed to the bifurcation of the right common carotid artery.
Care must be taken to avoid injury to the right recurrent laryngeal nerve, which wraps around the inferior border of the proximal right subclavian artery and ascends medially between the esophagus and the trachea.

Axillary exposure

· Horizontal incision 1cm below lateral 1/3 clavicle » 10cm long

· Split fibres of pec major

· Infraclavicular fat pad exposed & pec minor tendon

· Divide tendon close to origin @ acromion

— May need to divide some branches of acromiothoracic vessels

· Expose 2nd part of axillary artery between cords of brachial plexus

Cameron:
Atherosclerotic lesions of the axillary artery are rare, and symptomatic occlusive disease is most commonly due to emboli and trauma.
The axillary artery is traditionally categorized into three segments: the first portion extends from the lateral border of the first rib to the pectoralis minor muscle; the second is located behind the pectoralis minor muscle; and the third extends from the lateral border of the pectoralis minor muscle to the teres major.
The first and second portions of the axillary artery are exposed optimally with the arm outstretched on an arm board.
An infraclavicular incision is made 2 cm from the lateral clavicular border to the deltopectoral groove, the fibers of the pectoralis major muscle are split, and the underlying clavipectoral fascia is incised. The head of the pectoralis minor muscle may be divided for better exposure of the second portion of the axillary artery; the axillary vein lies inferior and slightly anterior to the artery, and several branches may require division for optimal exposure of the artery.
Care should be taken to avoid injury to the lateral pectoral nerves, which may lead to postoperative atrophy of the pectoralis muscles.

Brachial exposure

Proximal

· Groove between biceps & brachialis in inner aspect of arm

— Surrounded by cords of brachial plexus forming median nerve

Distal

· Lazy S antecubital fossa over artery

— Medial arm ® radial forearm

Cameron:

  Similar to the axillary artery, symptomatic atherosclerotic lesions of the brachial artery are uncommon.
Embolism and trauma account for the majority of lesions requiring revascularization for symptomatic ischemia.
Optimal arm position is 90 degrees abduction on an arm board attached to the operating table.
A longitudinal incision is made between the biceps and triceps muscle in the medial arm along the bicipital groove.
Dissection through the subcutaneous tissues and the deep fascia of the biceps brachii muscle is performed.
The basilic vein is usually found traveling medial to the brachial sheath, and the median nerve usually lies adjacent the artery during the surgical approach, in a more superficial location, and should be preserved.
Paired brachial veins are frequently encountered surrounding the brachial artery.
They may be divided to allow sufficient mobilization of the brachial artery for surgical revascularization.
Alternatively, the distal brachial artery and its bifurcation into the radial and ulnar arteries can be exposed by making a longitudinal incision in the antecubital fossa just distal to the elbow crease and dividing the bicipital aponeurosis.
If more exposure is required, a standard “lazy S” incision across the elbow crease will prevent scar contracture.

Radial and Ulnar
Cameron:
Exposure of the radial artery at the mid-forearm is best achieved with a longitudinal incision following a line from the antecubital crease to the styloid process of the radius.
The fascia is dissected along the medial border of the brachioradialis muscle.
In the proximal forearm, the radial artery lies beneath the medial fibers of the brachioradialis muscle.
In the distal forearm, the radial artery lies deep to the antebrachial fascia between the tendons of brachioradialis and the flexor carpi radialis muscles.
At the wrist, the radial artery is exposed by incising the antebrachial fascia just medial to the radius.

The ulnar artery in the proximal forearm may be exposed by dissecting through a plane between the flexor carpi ulnaris and flexor digitorum superficialis.
In the middle third of the forearm, the artery lies deep to the flexor carpi ulnaris muscle adjacent to the ulnar nerve.
In the distal forearm, dissection through the antebrachial fascia exposes the ulnar artery just beneath the antebrachial fascia.

Bypass to the forearm arteries is rarely necessary and is most often used for trauma and neglected embolic occlusions.
Sympathectomy, both cervicothoracic and digital, can lead to temporary improvement in skin blood flow, but its poor durability has limited it to highly selected patients who cannot be revascularized.