Chapter 212: Brachiocephalic Reconstruction 2173

at this level. The jugular vein is retracted

medially and the common carotid artery

Vascular Surgery
is controlled, with care taken to avoid
injury to the vagus nerve.
It is important to avoid an anastomosis on
the anterior surface of the common ca-rotid
artery because this may cause a kink in the
graft. A site on the lateral wall of the
common carotid arteriotomy should be
marked with ink prior to clamping. The
clamps can be used to rotate the artery to
facilitate the anastomosis. Following hepa-
rinization, a small arteriotomy is made in the
lateral wall of the common carotid and
enlarged with a coronary punch. We do not
routinely use a shunt. We make the arteri-
otomy relatively low in the neck so that the
graft lies almost parallel to the apex of the
subclavian artery and is as short as possible
(2 to 4 cm). We usually use an 8-mm PTFE
or Dacron graft, but the size should be cho-
sen to match the subclavian outflow. An end-
to-side anastomosis is made between the end
of the graft and the side of the ca-rotid artery
with a 5-0 polypropylene mono-filament
suture. The graft is routed poste-rior to the
jugular vein. The anastomosis to the
subclavian artery is usually placed dis-tal to
the origin of the vertebral artery. Small
Fig. 10. Debranching for endograft placement in aortic arch pathology. branches of the subclavian artery in-cluding
the thyrocervical trunk may be li-gated to
facilitate placement of the anasto-mosis. The
relationship of the phrenic nerve

Sternocleidomastoid muscle Sternocleidomastoid muscle

Anterior Anterior

Scalene muscle Scalene muscle

Internal Internal
Jugular vein Jugular vein
Phrenic nerve Phrenic nerve
Common Common

Carotid artery Carotid artery

Vertebral artery Vertebral artery

Thoracic duct Thoracic duct

Carotid Subclavian Bypass Thyrocervical trunk
A Subclavian vein and artery Subclavian vein and artery
B
Fig. 11. A: Synthetic carotid–subclavian bypass graft. B: Surgical exposure of the left subclavian artery and
common carotid artery through a supraclavicular incision.