DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right subclavian artery steal syndrome.
POSTOPERATIVE DIAGNOSIS: Right subclavian artery steal syndrome.
OPERATION PERFORMED: Right common carotid artery to subclavian artery bypass.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Negligible.
INDICATION FOR SURGERY: The patient is an (XX)-year-old female with a history of right subclavian artery stenosis, who has had progressive vertebral basilar insufficiency symptoms with dizziness, coordination problems, poor balance and difficulties walking. Head CT scan was negative for stroke. Duplex scan showed reversal flow on right vertebral artery and a severe stenosis on the right subclavian artery, greater than 90%. The patient was recommended the above operation, which the patient was agreeable to.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and given general endotracheal anesthesia, which the patient tolerated well. The right neck, shoulder and upper chest were prepped and draped in the usual fashion. A transverse incision was made in the right lower neck, about a fingerbreadth above the clavicle. The platysma muscle was incised. Crossing veins were ligated and divided between silk ties. We first exposed the right common carotid artery. The sternocleidomastoid muscle was mobilized off the common carotid artery and identified the right jugular vein and dissected it free and mobilized it off the common carotid artery as well. The common carotid was dissected free. The artery was soft with a good strong pulse and suitable for inflow. The preoperative carotid angiogram showed no significant disease. It was dissected free and encircled with vessel loops. During course of dissection, the ansa cervicalis nerve was identified, mobilized off the common carotid artery and preserved intact. The right subclavian artery was then exposed. The right sternocleidomastoid muscle was first divided near its attachment to the clavicle. The right scalene lymph nodes and fat pad was then mobilized off the right anterior scalene muscle. We then identified the right phrenic nerve and dissected it free; it branched. Both branches were preserved intact. We then were able to divide the right anterior scalene muscles. This allowed exposure of the right subclavian artery. The site of the cervical arterial trunk was identified and dissected free and the arterial trunk preserved intact but we did divide the vein. The subclavian artery had a very poor pulse. We dissected it free and encircled it with vessel loops. Enough of the artery was exposed to facilitate the anastomosis for the graft.
The patient was given 5000 units IV heparin. Vascular clamps were applied to the right common carotid artery. A longitudinal arteriotomy incision was made. Dacron 8 mm graft was used for the bypass. One end was spatulated and beveled to appropriate length and anastomosed in an end-to-side fashion with a running 5-0 Prolene suture. Prior to the completion of the suture line, flushing was performed. On release of the vascular clamps, there was excellent pulsatile flow through the graft. Of note, the patient's systolic blood pressure had increased, about 155-165 mmHg, when vascular clamps were applied to the common carotid. We subsequently let the blood pressure become normalized. The graft was tunneled deep to jugular vein to the right subclavian artery. Appropriate orientation was maintained. Vascular clamps were applied proximally and distally on the right subclavian artery and a longitudinal arteriotomy incision was made. The artery was soft without significant atherosclerotic disease. The end of the graft was spatulated and beveled to appropriate length and anastomosed in an end-to-side fashion, using running 5-0 Prolene suture. Prior to the completion of suture line, flushing was performed. On release of the vascular clamps, there was excellent pulsatile flow through the Dacron graft. There was noted to be some redundancy in the graft. To eliminate this, we re-clamped the graft, excised the redundant section, then reanastomosed the graft in an end-to-end fashion with a running 5-0 Prolene suture. This eliminated the redundancy and made a much smoother lie of the graft.
At this point, the wounds were irrigated and hemostasis secured. Topical hemostatic agents were applied. Heparin was reversed with protamine. Topical Tisseel was then applied to the wound bed. The sternocleidomastoid muscle was then reapproximated with 2-0 Vicryl horizontal mattress sutures. The deeper soft tissue layer was then closed with running 3-0 Vicryl suture over the graft. The platysma muscle was also closed with a running 3-0 Vicryl suture and the skin incision closed with a running 4-0 Monocryl subcuticular stitch. Topical Dermabond and sterile dressing was applied. The patient tolerated the procedure well. No complications occurred.