Operative management of penetrating arch and great vessel injuries depends on the named vessel or vessels that are injured. The aortic arch can be divided into three segments: ascending, transverse aorta with the origins of the proximal great vessels (innominate, carotid, and subclavian arteries) and descending distal to the left subclavian artery and proximal to the main thoracic aorta. For instances of diagnosed or suspected injury to the first and second sections, a median sternotomy is the operative exposure of choice. (Figure 1). Care must be taken in these cases to avoid injury to the innominate vein, which crosses superficial to the aorta and proximal great vessels in the superior aspect of this exposure. Sternotomy followed by division of the innominate vein allows the pericardium to be opened for release of any associated cardiac tamponade. Once these maneuvers have been accomplished, a sternotomy provides visualization and control of the ascending aorta as well as the innominate and proximal right carotid and subclavian arteries (see Figure 1). Exposure of these vessels can be facilitated by extending the sternotomy incision proximally on the right as a longitudinal cervical or supraclavicular incision with division of the sternocleidomastoid muscle. The aortic arch traverses in an anteroposterior direction in the mediastinum, making exposure of the distal transverse arch and proximal left common carotid challenging through a median sternotomy. However, these vessels can be controlled using this approach alone or in conjunction with an extension to a left cervical or supraclavicular incision, including division of the sternocleidomastoid. Injuries of the arch distal to the left common carotid, including those to the left subclavian artery origin, typically require a high left anteromedial thoracotomy.
Penetrating Injuries to the Aortic Arch and Intrathoracic Great Vessels
Arterial Injuries in the Mediastinum
Epidemiology
Management
Open Operative Management
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