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FIGURE 15

Cervicothoracic Incisions

A. For thoracic outlet injuries (zone 1 cervical injuries), median sternotomy may be combined with either a right or left classic anterior neck incision, which allows for proximal vascular control.

B. For injury to the proximal extrathoracic subclavian artery, supraclavicular extension of a median sternotomy allows for proximal control as well as exposure should division or removal of the clavicle be required for exposure and repair of the injury.

FIGURE 16

Median Sternotomy with a Cervical Extension for Access to an Injury to the Left Proximal Common Carotid Artery

A neck incision or a median sternotomy, alone, is insufficient for control and reconstruction of injury to the left proximal common carotid artery; however, a combined incision, aided by two retractors, affords excellent exposure. Note the location of the left vagus nerve with its recurrent laryngeal nerve around the aortic arch. Also, note the lateral location of the left phrenic nerve.

FIGURE 17

Subclavian Artery Anatomy

This illustrates the cervical anatomy of the subclavian arteries, with arms at the patient's sides, which places the clavicles at their lowest positions. The arms in the outward, extended positions result in clavicles covering the subclavian arteries. Note that both the right and left subclavian arteries have four branches (internal mammary arteries coming off the undersides of the subclavian arteries are not shown).

FIGURE 18

Anatomy of the Thoracic Duct

At the base of the mesentery, anterior to the abdominal aorta and very near the left renal vein, the cisterna chyli collects lymph from the mesenteric lymphatic channels and carries lymph upward, continuing anterior to the thoracic aorta on to the thoracic outlet, via the thoracic duct. Other numerous lymphatic collateral channels join this thoracic lymphatic duct, where it bifurcates in the upper posterior chest. Although the left thoracic duct is the larger, a thoracic duct empties into the right superior subclavian vein just as it receives the corresponding internal jugular vein. Note that the thoracic duct is anterior to the subclavian artery and posterior to the subclavian vein.

FIGURE 19

Controlling Hemorrhage from the Left Subclavian Artery

A. Temporary vascular control is achieved via short anterior third interspace incision with a vascular clamp applied to the intrathoracic left subclavian artery.

B. Alternately, control can be achieved using a Rumel tourniquet.

Note: In the emergency room, this injury can be immediately temporarily controlled with the tamponading finger or an inflated 30-mL Foley balloon.

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