LAUSR

Objective: The patient is a 58-year-old woman with a history of leftsidedmastectomy and axillary node dissection for cancer. She developed occlusive disease requiring extensive stenting of the left subclavian-axillary artery and subsequent carotid to proximal brachial artery prosthetic bypass, complicated by stroke. She was referred for critical ischemia of the left upper extremity and computed tomography angiography showing occlusion of the bypass with reconstitution of the proximal brachial artery. Methods: Conventional extrathoracic inflow options were thought to be unsuitable. We thus opted for more proximal inflow. Limited midline manubriotomy with partial upper median sternotomy was performed, and the innominate artery was mobilized. The most proximal right subclavian artery was chosen for inflow, and the left brachial artery was exposed in the upper arm. A tunnel was bluntly developed from the chest incision behind the clavicle along the anterior margin of the first rib to maintain a course ventral to the anterior scalene muscle. The completed tunnel was digitally inspected during abduction of the left shoulder, confirming ample caliber to accommodate the conduit without compressing the thoracic outlet’s contents. A cryopreserved homograft was used for the reconstruction, and a strong pulse was restored to the brachial artery and runoff at completion. Results: There was resolution of the ischemic pain, with residual “neuropathic” pain managed medically. Duplex ultrasound imaging and computed tomography angiography were available up to 16 months after the procedure, demonstrating patency of the graft, normal digital pressure, and lack of compression at the thoracic outlet. Conclusions: This case illustrates a new tunneling option in upper extremity revascularization when conventional routes are not feasible. Careful planning based on cross-sectional imaging is mandatory, and inspection of the tunnel during shoulder stress maneuvers is needed to avoid dynamic compression. Author Disclosures: A. J. Sharp: Nothing to disclose; A. T. Odugbesi: Nothing to disclose; J. Man: Nothing to disclose; A. E. Marjan: Nothing to disclose; M. J. Sharafuddin: Nothing to disclose.