Trauma: Vascular Exposure

Exposure of the Great Vessels

Incisions/Technique

Innominate Artery

  • Access: Median Sternotomy
  • Patients in Extremis May Require a “Clamshell” Thoracotomy
  • May Require Division of the Left Innominate Vein to Expose the Aortic Arch

Common Carotid Artery

  • Proximal Access: Median Sternotomy
  • Distal Access: Traditional Cervical Incision Along the Anterior Border of the Sternocledomastoid Muscle

Right Subclavian Artery

  • Proximal Access: Median Sternotomy
  • Distal Access: Supraclavicular Incision

Left Subclavian Artery

  • *Generally Considered the Most Difficult to Expose
  • Proximal Access Options:
    • Anterior Left Thoracotomy Through the Third Intercostal Space
      • Exposure is Limited
    • Resuscitative Anterolateral Left Thoracotomy
      • Through the Fifth Intercostal Space
      • Can Be Extended into a “Clamshell” Thoracotomy
    • Median Sternotomy with Supraclavicular Extension
    • “Trap Door” Incision
      • Three Components: Anterolateral Left Thoracotomy, Partial Sternotomy & Left Supraclavicular Incision
      • Considered the Classical Incision but is Associated with More Severe Bleeding & Respiratory Complications
      • Generally Not Used in Modern Practice
    • Clavicular Resection
      • May Require Addition of Median Sternotomy to Improve Proximal Access
  • Distal Access: Supraclavicular Incision
    • Artery is Deeper & More Difficult to Expose than on the Right-Side
    • Can Resect the Clavicle to Improve Access

Vertebral Artery (Segment V1)

  • Access: Supraclavicular Incision
  • Segments V2-V4 Require Specialty Expertise Through Bony Segments

Exposure by Median Sternotomy

Exposure by Cervical Incision

Exposure by Supraclavicular Incision

Access to Left Subclavian (Thoracotomy, Trap Door & Clavicular Incisions)

Upper Extremity Vascular Exposure

General Thought

  • Can Consider a Single Line to Expose the Majority of the Upper Extremity Vessels
    • From the Infraclavicular Incision, Down the Bicipital Sulcus, Obliquely Across the Antecubital Fossa, & Along the Radial Volar Forearm
  • Separate Incision Needed Only for the Ulnar Artery

Axillary Artery

  • Incision: Infraclavicular Incision (Mid-Clavicle to Deltopectoral Fascia)
  • Divide the Pectoralis Major Muscle 2 cm from the Humeral Insertion
    • Can Spare if Stable with No Active Bleeding (Retract Medially or Split)
  • Divide the Pectoralis Minor Muscle to View the Second Portion of the Axillary Artery
    • Can Use an Army-Navy Retractor to Elevate & Assist Division
  • May Require Division of Medial Clavicle for Proximal Exposure
  • Associations:
    • Axillary Vein Generally Runs Inferior to the Artery
    • Brachial Plexus Can Be Easy to Confuse with the Artery

Brachial Artery

  • Incision: Longitudinal Medial Incision Over the Bicipital Sulcus (Between Biceps & Triceps)
  • Neurovascular Bundle Identified Between the Muscle Bellies
    • Take Care to Avoid Iatrogenic Injury
    • Easy to Confuse Artery with Median Nerve
  • To Expose the Bifurcation:
    • Extend Incision Obliquely Across the Antecubital Fossa
    • Divide the Bicipital Aponeurosis (Dense Fibrous Extension of the Bicipital Tendon) to Expose the Bifurcation
    • *Level of Bifurcation is Extremely Variable

Forearm Arterial Exposure

  • Radial Artery: Incision Along the Inferomedial Border of the Brachioradialis Muscle
    • Along the Radial Volar Forearm
    • Retract the Brachioradialis Muscle Laterally to Expose the Fat Pad
    • Proximal Radial Artery/Nerve Identified in this Fat Pad
  • Ulnar Artery: Separate Incision Along the Ulnar Volar Forearm
    • Neurovascular Bundle Identified in the Fat Pad Between the Flexor Digitorum Superficialis & Flexor Carpi Ulnaris
  • Oblique Incision Over the Antecubital Fossa May Be Required for Proximal Access to the Bifurcation

Upper Extremity Incisions

Lower Extremity Vascular Exposure

Iliac Vessels

  • Common Iliac Vessels: Laparotomy
  • External Iliac Vessels:
    • Laparotomy (Most Expedient)
    • Retroperitoneal Approach
  • Retroperitoneal Approach:
    • Curvilinear Incision from the Inguinal Ligament to 2 cm Above the Anterior Superior Iliac Spine (ASIS)
    • Carried Down Through the Fat/Subcutaneous Tissue
    • Incise the Fascia of the External Oblique & Transversalis
    • Avoid Entry into the Peritoneum
    • Avoid Injury to the Ureter – Crosses Over the Bifurcation
    • Can Extend Incision Inferiorly (“Hockey Stick”) with Division of the Inguinal Ligament for More Distal Exposure

Iliac Exposure

Proximal Femoral Vessels

  • Incision: Vertical Incision 2-Fingerbredths Lateral to the Pubic Tubercle
    • Proximal Extent: Inguinal Ligament
      • Approximated by a Line from the Pubic Tubercle to the ASIS
      • Groin Crease Generally Results in the Incision Being Too Low
    • Extend Caudally Along the Medial Border of the Sartorius Muscle
  • Femoral Triangle
    • Borders:
      • Inguinal Ligament
      • Medial Border of the Sartorius Muscle
      • Medial Border of the Adductor Longus Muscle
    • Contents:
      • Common Femoral Artery (CFA)
        • Proximal Superficial Femoral Artery (SFA)
        • Proximal Profunda Femoral Artery (PFA)
      • Common Femoral Vein – Medial to Artery
      • Femoral Nerve – Lateral to Artery
  • Open the Femoral Sheath to Expose the Common Femoral Vessels & Bifurcation
  • Avoid Injury to the Lateral Femoral Circumflex Vein – Crosses Over the Profunda Femoral Artery at the Bifurcation

Distal Superficial Femoral Artery (SFA)

  • Incision: Along the Medial Border of the Sartorius Muscle
  • Retract the Sartorius Medially to Expose Hunter’s Canal
  • Unroof Hunter’s Canal to Expose the Distal SFA
  • Hunter’s Canal:
    • Canal Travelling Under the Sartorius Muscle Containing the Femoral Neurovascular Bundle
    • Extends from the Apex of the Femoral Triangle to the Adductor Hiatus

Proximal Femoral Exposure

Distal SFA Exposure

Femoral Triangle

Popliteal Artery

  • Positioned in a Frog-Leg
    • Hip Abduction with Slight Lateral Rotation & Knee Flexion
    • Bump Under the Knee to Maintain Position
  • Above the Knee Exposure:
    • Incision: Medial Lower Thigh Between the Vastus Medialis & Sartorius Muscles
    • Vascular Sheath Identified in the Fat Pad Between the Vastus Medialis & Sartorius Muscles
      • May Require Division of the Adductor Magnus or Sartorius Muscles
    • Popliteal Artery is Encountered First (Medial to the Vein)
    • Avoid Injury to the Saphenous Vein
  • Below the Knee Exposure:
    • Incision: Longitudinal Medial Incision 1 cm Posterior to the Tibia
      • 10 cm Length Starting 1-2 cm Distal to the Medial Femoral Condyle
    • Retract the Gastrocnemius Muscle Inferiorly
    • Dissect the Soleus Muscle Off the Posterior Tibia
    • Popliteal Vein is Encountered First (Medial to the Artery)
    • Trifurcation is Identified as the Popliteal Artery Crosses Over the Popliteus Muscle, Between the Gastrocnemius & Soleus
    • May Require Division of the Semimembranosus Muscle & Pes Anserinus (Conjoined Tendon of the Sartorius, Gracilis & Semitendinosus)

Popliteal Artery Exposure

Abdominal/Retroperitoneal Vascular Exposure

Maneuvers

  • Kocher Maneuver
  • Right-Sided Medial Visceral Rotation (Cattell-Braasch Maneuver)
  • Left-Sided Medial Visceral Rotation (Mattox Maneuver)
  • Cephalad Transverse Mesocolon Reflection
  • *Understand that There is Significant Overlap with the Maneuvers & They Should be Tailored to the Individual Patient

Exposure/Technique