MODULE 2�Extremity Vascular Exposures

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Course Lab Two

Deployment Equipment

Supplies

• 20cc syringe w/ Olive Tip, Angiocath
• Vessel Loops
• 3-0 to 6-0 Prolene Sutures
• Butterfly Needles
• Heparin
• Thrombin/Gelfoam

Deployment Equipment

Instruments

• Castro-Viejo needle drivers
• Gerald Forceps
• Potts-Smith scissors
• Adson-Beckman Retractor
• Adson-Cerebellar Retractor

Adson-Beckman�Retractor

Adson-Cerebellar�Retractor

Gerald Forceps

Castro-Viejo Needle Driver

Potts-Smith Scissors

Satinsky-Debakey

Wiley Hypogastric

Profunda

Deployment Equipment

Clamps

• Profunda clamps
• Wylie Hypogastric Clamps
• Satinsky-DeBakey Clamps
• Deitrich Bulldog Clamps�(Straight, Angled)

Deitrich Bulldog�Angled

Deitrich Bulldog� Straight

Argyle Shunts�(Straight)

Shunts & Catheters

• Fogarty catheters
• Shunts

Deployment Equipment

Sundt Shunts�(Can be Looped)

Pruit-Inahara Shunts�(Secured via Balloon, has Side Port)

Fogarty Catheters

Javid Shunts�(Tapered)

Workup of Vascular Injuries

Hard Signs

• Pulsatile Bleeding
• Expanding Hematoma
• Pulselessness
• Bruit, thrill, neurological deficit

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• Hx of bleeding
• Non-expanding Hematoma
• Neurological Deficit
• Proximity to major vessel

Soft Signs

Injured Extremity Index - IEI�(Ankle-Brachial Index - ABI)

• Comparison of the systolic blood pressure in the injured extremity to the non-injured extremity
• IEI <0.9 is considered abnormal
• A normal IEI has a high (>0.9) negative predive value and is very effective for ruling out clinically significant injuries, especially with the absence of soft signs.

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CT and Traditional Angiography

• Multidetector Computed Tomography Angiography (MDCTA)
• More advanced form of CTA option for visualizing peripheral vasculature
• Multiple detectors, higher resolution images
• Approaches 100% sensitivity and specificity for �clinically significant arterial injuries.
• Availability of CTA is variable in the austere �environment! Traditional angiography plays �an important role in military setting.

Exposure of Subclavian Artery

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Course Lab Two

The proximal subclavian artery branches off to the vertebral artery, the internal mammary (or internal thoracic) artery, and the thyrocervical trunk. This portion of the subclavian artery extends from its origin to the medial border of the anterior scalene muscle, beyond which it becomes the axillary artery. 

Procedural Sequence

1. To expose the subclavian artery above the clavicle, an incision is made parallel to and 1 cm above the medial half of the clavicle 
2. The incision is carried down through the platysma and the attachment of sternocleidomastoid to the clavicle is divided about one cm from the clavicle to expose the underlying internal jugular vein and the scalene fat pat 
3. The anterior scalene muscle which lies between the subclavian vein and the subclavian artery is exposed and the phrenic nerve, which courses obliquely from the superior lateral to the inferior medial aspect of the muscle, is identified and preserved 
4. The anterior scalene muscle is divided about one cm from the clavicle to expose the underlying subclavian artery which can then be controlled 

Supraclavicular Exposure of the Subclavian Artery �(Above the Clavicle)

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Course Lab Two

• To expose the subclavian artery above the clavicle, an incision is made parallel to and 1 cm above the medial half of the clavicle ���
• The incision is carried down through the platysma and the attachment of sternocleidomastoid to the clavicle is divided about one cm from the clavicle to expose the underlying internal jugular vein and the scalene fat pat 

Supraclavicular Exposure of the Subclavian Artery �(Above the Clavicle)

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Course Lab Two

Supraclavicular Exposure of R Subclavian Artery

Clavicle

The anterior scalene muscle lies between the subclavian vein and the subclavian artery is exposed. The phrenic nerve courses obliquely from the superior lateral to the inferior medial aspect of the muscle, and is identified and preserved. 

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Course Lab Two

Supraclavicular Exposure of R Subclavian Artery

The anterior scalene muscle is divided about one cm from the clavicle to expose the underlying subclavian artery, which can then be controlled 

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Course Lab Two

Supraclavicular approach to subclavian vessels

Proximal Right Subclavian Exposure�(Median Sternotomy)

Proximal exposure and control of the right subclavian can be achieved via a median sternotomy 

2. Clear soft tissues from manubrium and sternum

3. Apply sternum or gigli saw to open the sternum

1. Mid-line skin incision

Proximal Right Subclavian Exposure�(Median Sternotomy)

Proximal exposure and control of the right subclavian can be achieved via a median sternotomy 

5. Place Finochietto Retractor

4. Clear tissues from sternum

6. Identify right subclavian vessels

Proximal Left Subclavian Exposure�(Anterior Thoracotomy)

• Obtaining proximal control of the left subclavian is also possible through an anterior thoracotomy in the left third intercostal space.
• For muscular individuals with a well-developed pectoralis major muscle or in the setting of other intrathoracic injuries, this incision may be inadequate 
• For unstable trauma patients, the initial approach may be a resuscitative thoracotomy at the 5th interspace, extended across to a clamshell incision; this provides excellent access to the origin of both subclavian arteries for proximal control 

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Exposure of Popliteal Artery

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Course Lab Two

Popliteal Artery Exposure�(Anatomy)

Adductor (Hunter’s) Canal

Head

Suprageniculate Popliteal Exposure

(Right, Above the Knee)

Incision is made in the groove between the Vastis Medialis and the Sartorius muscles

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Course Lab Two

Vastus medialis

Sartorius

Hunter’s Canal�Popliteal fat pad

Suprageniculate Popliteal Exposure

(Right, Above the Knee)

1. Continue dissection to the deep fascia.
2. Identify and protect the Medial Cutaneous Nerve
3. Continue dissection to expose and release the Sartorius Muscle along the anterior border.
4. Retract Sartorius muscle posteriorly.
5. Deepen dissection to expose suprageniculate neurovascular bundle

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Course Lab Two

Suprageniculate Popliteal Exposure

(Right, Above the Knee)

6. Use a finger to enter the neurovascular bundle through the fat pad to “hook” the popliteal vessels from the underside of the femur
7. Identify, control the popliteal vein and artery

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Course Lab Two

Infrageniculate Popliteal Exposure

(Right, Below the Knee)

1. Longitudinal incision posterior to the tibia
2. Carry incision down to expose the superficial posterior compartment
3. Open compartment, take Soleus fibers off the underside of tibia
4. Enter the deep posterior compartment

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Course Lab Two

Infrageniculate Popliteal Exposure

(Right, Below the Knee)

6. Identify neurovascular bundle, the popliteal vein overlies the popliteal artery
7. Dissect popliteal vein from popliteal artery
8. Control popliteal vein and artery

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Course Lab Two

Further dissection will expose the trifurcation of the popliteal artery

Infrageniculate Popliteal Exposure

(Right, Below the Knee)

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Course Lab Two

If need be the Pes Anserinus (gracilis, sartorius, and semitendinous tendons) can be divided for more complete exposure

Infrageniculate Popliteal Exposure

(Right, Below the Knee)

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Course Lab Two