The Transsternal Extension

Abstract

In some cases, the chronic obstructive fibrotic process involving the subclavian vein extends far medially. In this instance, the standard incision is inadequate to expose the normal innominate vein or to properly lay the patch at its proximal end. The problem is not so much the actual length of the obstructed segment of vein, but that, if the segment has obviously extended into the innominate vein behind the manubrium of the sternum, the exposure needed to lay a patch appropriately or to connect proximal and distal normal vein is impossible to achieve. Therefore the regular incision needs to be extended into the sternum in order to expose the innominate vein, in some cases even up to the origin of the superior vena cava (Fig. 20.1a, b). The surgeon must keep in mind several caveats and injunctions when contemplating the use of this extension. First, once the sternum is entered, it is of the utmost importance in the postoperative period to keep the patient’s arm immobilized for a minimum of 6 weeks postoperatively to allow the sternum to heal and to prevent a dehiscence. This will almost certainly occur if the patient is allowed to move the arm freely in all directions even if a proper sternal repair has been achieved at the end of the operation. Second, the extension should not be done until an attempt is made to use the regular incision to try to mobilize the vein into the operative field for placement of the venous patch (Fig. 19.11). Even when the clamps are already on the vein and the vein has been opened, extension of the incision can be carried out with the clamps in place until the manubrium of the sternum is divided. Because the patient has already been Heparinized, no thrombosis will occur.