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Left Carotid to Subclavian Artery Bypass

Tuesday, August 1, 2017

Gwan-Nulla, Daniel (2017): Left Carotid to Subclavian Artery Bypass.
CTSNet, Inc.. https://doi.org/10.25373/ctsnet.5239570
Retrieved: 20:42, Jul 24, 2017 (GMT)

This video demonstrates a left carotid to subclavian artery bypass. Due to increased use of aortic stent grafts that sometimes cover or compromise the orifice of the left subclavian artery, cardiothoracic surgeons need to be familiar with revascularization of the extremity.

Comments

I was disappointed with the video- many important steps have not been mentioned. First of all - the clavicular head of the SCM can be sacrificed- there is no reason to keep it.The next step is to identify the Scalenus anterior and the phrenic nerve and preserve the nerve and cut the scalenus anterior. You will not be able to see the subclavian if you do not cut the scalenus anterior- in heavyset individuals the subclavian is very deep down and not so easy to expose- just a point to remember and there is not much of a room to fashion a bypass- in such situations i have done the bypass to the axillary artery below the clavicle. the video imaging is wonderful - but surprisingly has not shown the scalenus anterior muscle or the phrenic nerve and the routing of the graft.
I have to add further that on the L side watch out for the lymphatics draining into the jugular vein and tie them off if you see them or you can end up with a chyle leak
Interesting video. Regarding anterior scalenic muscle division is neccesary only for prevertebral or vertebral segments. For postvertebral segments of subclavian artery it is not neccesary to disect the frenic nerve and make the scalenotomy. I would ask about the cerebral protection on carotid and vertebral segments. No shunt? Not seen the left vertebral artery om MRA . Steal syndrome? Flow orientation and declamping strategy? Once again, tx for the video. Very useful especially for teaching.
Dear Drs. Kumar and Jerzicska, thank you for your comments. I agree, in order to expose the subclavian artery, it is often necessary to divide the anterior scalene muscle, and since the phrenic runs along the muscle anteriorly, it is important to identify it. After bluntly sweeping off the scalene fat pad (as briefly demonstrated in the video), you can easily identify the anterior scalene muscle and phrenic nerve. Unfortunately that part of the procedure was not captured in the video. For teaching purposes, I should have mentioned that in the narration. It is not necessary to sacrifice the clavicular head of the SCM, if you have good exposure of the carotid sheath. The routing of the graft underneath the jugular vein is shown in the video. Cerebral protection with a shunt or otherwise is not necessary as long as there is no significant internal carotid artery disease. Regarding clamping/declamping, we construct the graft to subclavian anastomosis first, then clamp the graft. The common carotid artery is then clamped proximally and distally. After constructing the anastomosis to the carotid artery, the proximal carotid and graft are declamped and flow is directed from the carotid to the subclavian. The distal carotid is later declamped. This prevents air and debris from going into the brain. Yes, the patient did have steal syndrome preop, which resolved after surgery. Thank you again for your comments.

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