Vascular Exposure: Thoracic

Vascular Exposure: Thoracic

David Ray Velez, MD

Table of Contents

Anatomy
Arterial Exposure
Venous Exposure

See Also:
*See Thoracic Vascular Injury
*See Vascular Exposure: Subclavian

Anatomy

Aortic Arch Branches

  • Innominate/Brachiocephalic Artery
    • Right Subclavian
    • Right Common Carotid
  • Left Common Carotid
  • Left Subclavian

“Bovine Arch”

  • Normal Variant (8-35% Incidence)
  • Common Origin of Innominate and Left Common Carotid

Descending Thoracic Aorta Branches

  • Bronchial Branches
  • Esophageal Branches
  • Posterior Intercostal Arteries
  • Becomes the Abdominal Aorta After the Diaphragm

Venous Drainage

  • Superior Vena Cava (SVC)
    • Drains into the Right Atrium
    • The Brachiocephalic Veins (Bilateral) Combine to form the SVC
    • The Azygous Vein Also Drains into the SVC
  • Brachiocephalic (Innominate) Vein
    • The Internal Jugular (IJ) Vein and Subclavian Vein Combine to Form the Brachiocephalic Vein
    • The Subclavian Vein is Formed by the External Jugular Vein and Axillary Vein
    • Additional Tributaries: Vertebral Vein and Inferior Thyroid Vein

Aortic Arch

Arterial Exposure

Aorta

  • Ascending Aorta: Median Sternotomy
  • Aortic Arch: Median Sternotomy with/without a Left Supraclavicular Extension
  • Descending Thoracic Aorta: Left Posterolateral Thoracotomy

Innominate Artery

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

Common Carotid Artery

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

Subclavian Artery

  • Proximal Access:
    • Right Subclavian: Median Sternotomy
    • Left Subclavian: Multiple Options (Thoracotomy, “Trap Door”, Clavicular Resection, etc.)
  • Distal Access: Supraclavicular Incision
  • *See Vascular Exposure: Subclavian

Vertebral Artery

  • Segment V1: Supraclavicular Incision
  • Segments V2-V4: Requires Specialty Expertise Through Bony Segments (Spinal Surgery or Endovascular Repair)

Venous Exposure

Access is Generally Similar to Arterial Counterparts

Superior Vena Cava (SVC): Median Sternotomy

Brachiocephalic (Innominate) Vein: Median Sternotomy 

  • Distal Left Brachiocephalic Vein May Require Exposure Similar to the Proximal Left Subclavian

Internal Jugular (IJ) Vein

  • Vein Runs Anterior and Lateral to the Carotid Artery
  • Proximal Access: Median Sternotomy
  • Distal Access: Traditional Cervical Incision Along the Anterior Border of the Sternocledomastoid (SCM) Muscle

Subclavian Vein

  • Proximal Access:
    • Right Subclavian: Median Sternotomy
    • Left Subclavian: Multiple Options (Thoracotomy, “Trap Door”, Clavicular Resection, etc.)
  • Distal Access: Supraclavicular Incision
  • *See Vascular Exposure: Subclavian