The Paraclavicular Approach

Abstract

This approach is a combination of a supraclavicular and an infraclavicular incision. It is designed to expose the subclavian vein, the origin of the jugular vein and part of the innominate vein combined with a direct repair of the vein with or without patching, and to accomplish a thrombectomy combined with decompression of the thoracic inlet. The combination of these two incisions together allows for the simultaneous removal of the subclavius tendon, the costoclavicular ligament and the first rib. The approach was introduced by Cormier and Amrane [1] in order to achieve adequate exposure of the vessels of the thoracic outlet, used mostly for arterial repairs in patients with cervical ribs. The approach was later termed “Paraclavicular” by Thompson [2]. Satisfactory results have recently been reported by Melby [3]. The dual incision approach is adequate as long as the entire innominate vein does not need to be exposed, because it only provides limited visualization of the most proximal part of that vein. Therefore the approach is not sufficient in cases where the innominate vein has already endovascular stents placed or if the fibrous process has advanced into the innominate vein. A different incision must be utilized in these instances as described below. The paraclavicular approach has the merit of not dividing or partially removing the clavicle, which creates a very obvious chest deformity in the patient. The approach also allows the surgeon to repair directly the vein if necessary, and is preferable to any transaxillary approach to relieve the obstruction of the subclavian vein. Its clear limitations pertain to cases of chronic subclavian obstruction extending into the innominate (as noted above) or in patients who had been treated previously with implants and in whom there is a need to clamp the innominate vein near the superior vena cava in order to apply a patch to enlarge the vein. In such cases, we definitely prefer to use the transmanubrial extension of the subclavicular incision to obtain adequate control of the entire involved venous component.