VASCULAR TRAUMA: COMPLEX AND

CHALLENGING INJURIES, PART I 0039---6109/01 $15.00 + .00

ANATOMIC EXPOSURES FOR

VASCULAR INJURIES
David B. Hoyt, MD, FACS, Raul Coimbra, MD,
Bruce M. Potenza, MD, and Joseph F. Rappold, MD

Management of vascular injuries continues to be one of the most

challenging aspects of trauma surgery. Unlike elective surgery, the sur-
geon is often put in a position of confronting a hematoma with an
obvious associated injury without time for planning or the opportunity
to thoughtfully plan proximal and distal control. Because of this, it is
essential for any surgeon who cares for the injured patient to understand
the relationships of arteries likely to be injured and where proximal and
distal control can be achieved. In doing so, it is essential that the surgeon
learn critical maneuvers associated with each vessel and understand the
anatomy that allows adequate exposure. Even if one is not trained in
vascular surgery, it is essential to know these maneuvers so that hemor-
rhage can be controlled while waiting for additional help.
With these goals in mind, this article reviews the exposure of major
vessels throughout the body. The authors have chosen to divide this
anatomically into the neck, chest, abdomen, and extremities for ease of
discussion, but also because the approach to these arteries is often
limited to one body region. Where appropriate, overlap between the
regions and considerations for exposure have been covered, specifically
as they relate to the cervical thoracic junction, the thoracic abdominal
junction, and the lower abdominal, lower extremity junction. Study of
these areas and practice during elective surgery or in the cadaver lab
will ensure that the trauma surgeon can isolate these vessels when
needed during an emergency.

From the Division of Trauma, Burns, and Surgical Critical Care, University of California
San Diego Medical Center, San Diego, California

SURGICAL CLINICS OF NORTH AMERICA

VOLUME 81 • NUMBER 6 • DECEMBER 2001 1299

1300 HOYT et al

CAROTID ARTERY

The carotid artery is divided into three zones. Zone 1 extends from
the sternal notch to the base of the cricoid cartilage. Zone 2 extends
from the cricoid cartilage superior to the angle of the mandible. Zone 3
extends superior to the angle of the mandible to the base of the skull
and the carotid foramen." The anatomic zone of the injury governs the
workup and operative exposure techniques to the injury. Proximal and
distal control of the carotid artery may be straightforward or complex.
For example, Zone 2 injuries are readily accessible surgically, whereas
Zone 1 injuries require more extensive proximal intrathoracic control.
Exposure of a Zone 3 injury is difficult because of the retromandibular
position of the carotid artery, and arterial exposure and distal control
may require manipulation of the mandible. In all zones, the recognition
of major vascular, neuromuscular, and aerodigestive structures is para-
mount to successful operative intervention. If the patient's cervical spine
has been cleared of any fracture, slight rotation of the neck opposite to
the side of operation will afford the best approach for both carotid and
vertebral artery. The neutral position makes the dissection planes in the
neck more difficult to identify. A common mistake is to find the dissec-
tion is proceeding too far laterally."

Exposure of Zone I Carotid Artery Injuries

Zone 1 injuries involve the origin of the carotid artery and the
surrounding neurovascular structures. Optimal control of the proximal
carotid requires intrathoracic operative exposure through a midline
sternotomy. Zone 1 injuries are approached utilizing an anterior sterno-
cleidomastoid incision with more proximal exposure by way of median
sternotomy.
The approach to distal Zone 1 is performed by making a vertical
incision that will run in an oblique direction following the course of
the sternocleidomastoid muscle. Proximally, the incision begins at the
clavicular head and is extended superiorly and laterally to the mid-
cervical region. This incision may be extended superiorly to the angle of
the mandible. Zone 3 injuries may be approached by continuing the
incision posterior to the angle of the mandible and superiorly into the
postauricular area.
Dissection deep to the anterior border of the sternocleidomastoid
muscle reveals the carotid sheath. The sheath may be exposed along the
entire length of the neck into Zones 2 & 3 if necessary or move proxi-
mally in the median sternotomy. Care is taken to identify the vagus
nerve lying in a posterior lateral position within the sheath.
Proximal exposure of Zone 1 injuries is through a median sterno-
tomy in continuity with the sternocleidomastoid incision. Upon entry
into the mediastinum the brachiocephalic veins are seen deep to the
thymus. Dissection and superior and medial retraction of the left brachi-
 ANATOMIC EXPOSURES FOR VASCULAR IN}URIES 1301

ocephalic vein will reveal the aortic arch. Dissection along the arch will
reveal the origin of the innominate, left common carotid artery, and
posteriorly the left subclavian. The origin of the common carotid is
identified and encircled with vessel loops or DeBakey vascular clamps
to gain vascular control. Care to identify the left recurrent laryngeal
nerve and vagus nerve before clamping is essential. Initial attempts to
partially occlude the aorta with side-biting (partially occluding) clamps
may afford control of the origin of the carotid without complete occlu-
sion of the aorta. If this is not successful, then full clamping of the aorta
may be necessary. Exposure of the right common artery is carried out in
a similar fashion. Management of the patient's hemodynamic parameters
mandates full assistance of the anesthesiologist because of the profound
increase in afterload resistance that will develop. Vascular clamp time
should be kept to a minimum and should be restricted to within a 20-
to 30-minute time period. Dissection distally along the brachiocephalic
vein reveals the internal jugular vein. If needed, the internal jugular and
the brachiocephalic veins may be ligated. Exposure of the right common
carotid artery is carried out in a similar fashion. The brachiocephalic
artery is dissected out from its origin toward its bifurcation into the
right subclavian and right common carotid artery (Fig. 1).

Zone 2 Carotid Artery Injuries

Zone 2 exposure is best approached using a cervical incision along

the anterior border of the sternocleidomastoid muscle. This incision is
also excellent for exposure of the cervical esophagus. When approaching
the bifurcation of the carotid, one will encounter the facial vein. This
vein is frequently ligated to obtain better exposure of the carotid artery
bifurcation, which is located immediately deep to the vein. The bifurca-
tion of the carotid artery is typically located at the superior border of
the thyroid cartilage. Along the medial aspect of the carotid bifurcation
lies the carotid sinus. Manipulation of this may result in a vagal response
leading to bradycardia or hypotension.
Distal dissection of the external carotid artery will reveal its numer-
ous branches. Circulation from the contralateral facial artery maintains
back flow into an injured carotid system. Any of the branches of the
artery may be ligated if needed to gain control of a vascular injury. The
external carotid artery also may be ligated, transected, and used as an
internal carotid artery bypass graft.
If vascular control is needed distal to the bifurcation in the internal
carotid distribution, one should consider measuring stump pressures.
Distal internal carotid back bleeding and stump pressures of greater
than 50 mm Hg are felt to be sufficient to proceed without carotid
shunting. If the pressures are less than 50 mm Hg, shunting should be
considered. Shunting permits longer time periods to reconstruct the
artery if anticipated.
1302 HOYT et al

Unes of
possible
extension

Median
sternotomy

Figure 1. The extension of a median sternotomy into an anterior sternocleidomastoid

incision allows exposure of the thoracic inlet.

Zone 3 Carotid Artery Injuries

The retromandibular position of the distal carotid artery creates a

difficult challenge for operative exposure. Hemorrhage may be brisk in
this area because of the numerous arterial and venous tributaries. The
internal carotid artery is approached by extending the sternocleidomas-
toid incision superior and posterior to the ear into the postauricular
space. Further exposure of the internal carotid requires anterior subluxa-
tion of the mandible, or a mandibular osteotomy." The latter is time-
consuming and adds risk to the marginal mandibular and inferior alveo-
lar nerves. Anterior subluxation requires the patient to be nasotracheally
intubated so that one may wire the mandible and the maxilla to hold
exposure.n,35 Briefly, the concept is to wire the mandible to the maxilla
 ANATOMIC EXPOSURES FOR VASCULAR INJURIES 1303

to hold the subluxed position of the temporomandibular joint (Fig. 2).

This will move the mandible anteriorly 1 to 2 em and afford visualization
of the distal internal carotid field. One method is to use 24-gauge wire
and encircle the lower first and second molars on the side of the injury.
Another 24-gauge wire is used to encircle the upper contralateral incisor
and first molar. When the mandible is subluxed, the two wires are tied
together to hold the position in the lateral to medial direction (Fig. 2).27
In addition to subluxation, specific aspects of soft tissue dissection
are important. The digastric muscle is di vided, and the occipital artery
is ligated as it crosses over the internal carotid artery. For better expo-
sure, the styloid process ma y be excised after its attachments are dis-
sected free. These attachments include the stylohyoid, styloglossus and
stylopharyngeus muscles. The glossopharngeal nerve will come into

Figure 2. SUbluxation and temporary fixation of thejaw to dislocate the temporal mandibular
joint are held with a wire to maintain exposure.
1304 HOYT et al

view at this superior location and may be retracted medially. Dissection

can expose the distal carotid almost to the carotid foramen using these
maneuvers.

VERTEBRAL INJURIES

The vertebral artery can be divided into four anatomic zones. The
first portion of the vertebral artery (V-I) extends from the origin of the
vertebral artery off the subclavian artery to the foramen of the transverse
process of the sixth cervical vertebrae. This portion of the vertebral
artery is accessible for surgical exposure. The second portion (V-2), the
interosseous portion, ascends through the transverse foramina of C-6
through C-2. The third portion (V-3) begins as the artery leaves the
foramen of C-2 and courses superiorly toward the base of the skull and
the foramen magnum. The fourth portion of the artery (V-4) extends
from the foramen magnum to the confluence of the right and left
vertebral arteries forming the basilar artery.
There is a companion set of veins, usually paired veins, which
follow the course of the vertebral artery in a reverse direction. These are
multiple small bridging veins, which coalesce to form a singular verte-
bral vein near the lower cervical vertebrae. The vertebral vein enters the
subclavian vein adjacent to the internal jugular vein. On the left side,
the vertebral vein lies adjacent to the thoracic duct as both enter the
subclavian vein.
As with the carotid, the anatomic zones of the vertebral artery
determine the operative approach to this artery. In Zone 1, the artery is
easily accessible with operative dissection. Zone 2 requires dissection
through the transverse processes and unroofing the canal to expose the
artery. Zone 3 requires a posterior auricular approach, and Zone 4
lesions require a craniotomy with neurosurgical assistance. The degree
of difficulty in the approach to the vertebral artery has fostered newer
therapeutic angiographic techniques to deal with injuries to the vessel."
The importance of proximal and distal control of the artery hinders
therapeutic angiography- as distal control may be difficult to obtain.

Zone 1 Vertebral Artery Injuries

The approach to Zone 1 or the proximal vertebral artery is through

the anterior cervical vertical incision or a transverse supraclavicular
incision. The anterior cervical incision is an extension of the approach to
Zone 1 of the carotid artery. Medial mobilization of the carotid sheath
and the lateral mobilization of the sternocleidomastoid muscle permits
the exposure of the deep structures of the posterior lateral aspect of the
neck (Fig. 3). To gain additional exposure, the omohyoid muscle may be
transected.
The first structure encountered is the prescalene fat pad. This is
 ANATOMIC EXPOSURES FOR VASCULAR IN]1JRIES 1305

Figure 3. Relationships between the sternocleidomastoid and the upper thoracic inlet.
(From Wind GG, Valentine RJ: Anatomic Exposures in Vascular Surgery. Baltimore, WiI·
Iiams and Wilkins, 1991, pp 23-72; with permission.)

mobilized in a medial to lateral direction sharply. Deep to the fat pad

lies the anterior scalene muscle. Dissection reveals the phrenic nerve
lying along the medial border of the anterior scalene. The inferior thy-
roid artery may be ligated to obtain better exposure, and retraction of
the medial border of the anterior scalene muscle and the phrenic nerve
permits visualization of the vertebral artery.
Tracing the vertebral artery proximally, the upper borders of the
subclavian artery and vein are identified. The vertebral artery is located
between the more proximal common carotid artery origin. and the thyro-
1306 HOYT et al

cervical trunk distally. On the left side, the thoracic duct may be identi-
fied entering the subclavian vein between the internal jugular and verte-
bral vein. If necessary, this may be ligated. Any lymphatic tributaries
that are transected should be ligated to prevent a lymphocutaneous
fistula caused by the high flow of lymph at this portion of the thoracic
duct. Dissection to expose the origin of the right vertebral artery should
include close inspection for a right-sided lymphatic duct, which may be
present in some patients.
One should be able to expose the entire length of Zone 1 of the
vertebral artery from its origin from the subclavian artery until it dives
into the transverse foramen of the sixth cervical vertebra. Good back
bleeding suggests ligation will be well tolerated.
The transverse supraclavicular approach to Zone 1 of the vertebral
artery is begun 1 to 1.5 em superior to the clavicle, with the medial extent
of the incision over the sternoclavicular joint and extended laterally."
Dissection through the platysma will demonstrate the medial and lateral
bellies of the sternocleidomastoid muscle. Occasionally, it will be neces-
sary to partially transect the lateral belly of the sternocleidomastoid. At
this point, the fat pad of the anterior scalene muscle is identified, and
dissection continues as with the anterior cervical approach.

Zone 2 Vertebral Artery Injuries

The approach to Zone 2 (V-2 interosseous portion) of the vertebral

artery is by way of the anterior cervical sternocleidomastoid incision. IS
One of two dissection planes is created. Either the carotid sheath is
retracted medially and the sternocleidomastoid muscle laterally (Henry
procedure), or both are retracted medially, and the dissection takes place
laterally (modified Henry procedure)." Both of these approaches will
allow the surgeon to arrive at the posterior aspect of the neck by
visualizing the longus coli muscle. Deep dissection between these struc-
tures reveals the sympathetic chain lying superficial to the prevertebral
muscles (Fig. 4). The transverse processes of each of the cervical vertebra
can be palpated deep to the prevertebral muscle and lateral to the
sympathetic ganglia. A longitudinal incision is made through the lateral
aspect of the anterior longitudinal ligament. A periosteal elevator is
used to undermine and reflect the lateral anterior longitudinal ligament
and the longus muscles laterally (Fig. 5). This will expose the lateral
vertebral body and the transverse process. Continued lateral mobiliza-
tion of the longus muscles with the elevator will reveal the transverse
process and osseous covering of the vertebral canal.
The osseous component of the transverse process can be removed
using a bone rongeur or Kerrison dissector. This will expose the vertebral
artery and vertebral venous plexus. Brisk bleeding may be encountered
during this maneuver. Temporizing measures such as the placement of
Gelfoam (Upjohn Pharmaceuticals, Kalamazoo, MI) or cotton pledgets
may slow hemorrhage. The easiest method to control the hemorrhage is
 ANATOMIC EXPOSURES FOR VASCULAR INJURIES 1307

rvic D.

Symp thctic _--:~,.--~~,

lnmk

Middle
cervical
cardi n.

Venebnl v, _ _-+-_;;-'1- ,1:

VI D. --i-~m1

InlemaJ
juJlllat v, Il vian I .
Su lavi v.

Figure 4. Relationship of the vertebral artery to the C6-7 vertebral body and transverse
process. (From Wind GG, Valentine RJ: Anatomic Exposures in Vascular Surgery. Balti-
more, Williams and Wilkins, 1991, pp 23-72; with permission.)

by placing medium clips, securing proximal and distal control of the

artery. Care should be taken to visualize these structures when placing
the clips, as the cervical roots lie directly posterior to these structures.
Another option is to use an occluding substance and obtain proximal
and distal control. Bone wax, pledgets, or small Fogarty (Baxter Inc,
Irvine, CA) catheters placed in a proximal and distal direction within
the vertebral canal may aid in control of the hemorrhage. If the vessel
can actually be cannulated with the Fogarty, this is optimal. The Fogarty
catheters are left in place postoperatively for a number of da ys, until
1308 HOYT et al

Antorior
longitudinal
ligament

Figure 5. Dissection of the overlying fascia to allow any osseus exposure of the vertebral
artery. (From Wind GG, Valentine RJ: Anatomic Exposures in Vascular Surgery. Baltimore,
Williams and Wilkins, 1991, pp 23-72; with permission.)

thrombosis of the vessel occurs. If the vessel cannot be cannulated with

the Fogarty catheter, simply placing two larger Fogarty catheters, one
within the superior and one within the inferior transverse foramen, and
inflating will result in tamponade of the bleeding vessel. The catheters
are left in place postoperatively until the vessels have thrombosed. The
balloons may be deflated and the patient observed for signs of bleeding
before the Fogarty catheters are removed?

Zone 3 Vertebral Artery Injuries

Approach to the superior portion of the vertebral artery as it exits

the transverse foramen of C2 and enters the base of the skull may be
quite difficult. This segment of the vertebral artery is approached by
way of an extension of the anterior cervical into the postauricular area
directly over the mastoid process. The sternocleidomastoid is transected
off the mastoid and retracted laterally to create a posterolateral visualiza-
tion of Cl-Cz and the base of the skull. Occasionally, it will be necessary
 ANATOMIC EXPOSURES FOR VASCULAR INJURIES 1309

to transect the splenius capitis muscle from the mastoid process. Care
must be taken to identify the spinal accessory nerve, which runs 2 to 3
em below the mastoid tip and lies between the splenius cervicis and
levator scapula muscle. The lateral transverse process of Cl and C2 are
palpated, and the prevertebral fascia over the transverse process of Cl
is incised and reflected medially. The vertebral artery now comes into
view for a 1- to 2-em segment. When clipping of the artery in this area,
care must be exercised to not clip the rami of C2, which lies posterior to
the artery.

THORACIC VASCULAR INJURIES

Injuries to the aortic arch and great vessels usually are caused by
penetrating trauma. Morbidity and mortality rates of these injuries are
among the highest in vascular trauma. Most of these patients die prior
to hospital admission of profound shock secondary to massive bleeding.
Successful management of these injuries depends upon aggressive
resuscitation, often utilizing lower extremity intravenous lines, early
intubation, prompt diagnosis, and rapid surgical control of hemorrhage.
These injuries are accompanied by multiple clinical and radiological
signs such as shock, cardiac tamponade, pulse deficits, bruits, neurologi-
cal deficits, widened mediastinum, hemothorax, pleural capping, and
others. About one-third of these injuries will, however, have no obvious
clinical signs of vascular compromise except for a penetrating cutaneous
wound. Arteriography is the best diagnostic modality, but its use should
not delay an operative procedure in a hemodynamically unstable pa-
tient."

Incisions

Several incisions can be used to approach the intrathoracic vessels.

The decision as to what incision to use will depend on the vessel injured,
the hemodynamic status of the patient, and the surgeon's experience
(Fig. 6).9,21,23

Left Anterolateral Thoracotomy and Clamshell

Thoracotomy (Bilateral Anterolateral Thoracotomy)
Access to intrathoracic structures is quickly achieved through an
incision made in the left fourth or fifth intercostal space. It is the incision
of choice in the hemodynamically unstable patient, since it provides
rapid access to the pericardium, pulmonary hilum, and descending
aorta. Access to structures located in the superior and posterior mediasti-
num is difficult through this approach.
The incision can be extended across the sternum and converted into
the so-called "clamshell thoracotomy," to provide access to the right
1310

\ /
HOYT et al

--d \
\
\
, /
/
/
/

L---~~------~-------~

Figure 6. Extensions of a median sternotomy for cervical extension and bilateral exposure
of the subclavian artery.

pleural cavity, using a Gigli saw or knife. Care should be taken to

ligate the internal mammary arteries bilaterally. A bilateral thoracotomy
provides excellent access and exposure to the heart, lungs, ascending
aorta, arch, and major aortic branches, particularly the innominate artery,
and also to the superior vena cava and innominate vein. Exposure of
the thoracic esophagus and descending aorta is limited through this
incision.

Posterolateral Thoracotomy
A left posterolateral thoracotomy provides access to the descending
thoracic aorta, proximal left subclavian artery, left pulmonary hilum,
and distal esophagus. On the right side, this incision provides adequate
exposure of the trachea, right pulmonary hilum, azygous vein, and
proximal esophagus. This incision should be used preferentially in he-
modynamically stable patients after a specific injury has been diagnosed.
It is not an adequate incision for an "exploratory" thoracotomy in a
hemodynamically unstable patient.

Median Sternotomy
A median sternotomy is the incision of choice for hemodynamically
stable patients with proximal great vessel injury. This incision provides
adequate exposure of the heart, ascending aorta, aortic arch, and innomi-
nate artery and vein (Fig. 7). The advantage of a median sternotomy is
that it can be easily extended into the supraclavicular fossa and obliquely
 ANATOMIC EXPOSURES FOR VASCULAR INJURIES 1311

Figure 7. Relationship of the thoracic inlet vessels to the upper portion of a median
sternotomy.

anterior to the sternocleidomastoid muscle in the neck bilaterally to

approach the more distal innominate or carotid arteries, or into an
anterior thoracotomy associated with a supraclavicular extension, the
so-called trapdoor incision, used to provide access to the left subclavian
artery in selected cases.

Specific Injuries

Descending Thoracic Aorta

The majority of thoracic aortic pseudoaneurysms following blunt
trauma occur at the aortic isthmus, just distal to the take-off of the left
subclavian artery. If not recognized and repaired, the pseudoaneurysm
has an unpredictable course, and can rupture hours to even months or
years later. Aortography is the definitive test to diagnose this injury,
although CT scans and transesophageal echocardiography have been
used recently. This injury is best approached through a left fourth or
fifth intercostal space posterolateral thoracotomy. Proximal control is
usually obtained by placing a clamp distal to the left carotid proximal
to the left subclavian artery. An interposition graft is the treatment of
choice, and there is still debate whether these patients should undergo
1312 HOYT et al

total or partial bypass versus the classic cross clamp and sew technique.
The incidence of paraplegia following thoracic aortic repair has been
reported, varying from 1% to 20%. Recent studies suggest that the
incidence of paraplegia may be reduced by short-clamp times or by
the use of active or passive bypass when long cross-clamp times are
anticipated." 21, 23

Ascending Aorta
Injuries to the ascending aorta are rare. Patients sustaining such
injuries usually die at the scene. Few patients reaching the hospital alive
will present with cardiac tamponade. A median sternotomy provides
the best exposure for the ascending aorta (Fig. 7). Because of the large
diameter of this artery, bleeding from anterior wounds can be controlled
with digital compression and partial occlusion of the vessel."

Innominate Artery
Innominate artery injuries are most frequently caused by penetrat-
ing trauma. If diagnosed prior to the operation, a median sternotomy is
the incision of choice (Fig. 7). Care should be taken when dissecting the
vessels in the anterior and superior mediastinum in an attempt to
avoid injury to the innominate vein that may be surrounded by a
large hematoma. An inadvertent injury to this vein may cause massive
bleeding. The left innominate vein may be ligated to provide better
exposure of the supra aortic branches and aortic arch. During repair of
the innominate artery, consideration should be given to the need for
adequate cerebral blood flow and utilization of an intraluminal shunt,
Poor distal back bleeding, stump pressures in the carotid artery of
less than 60 mm Hg, or electroencephalogram (EEG) changes during
intraoperative monitoring suggest the need for shunt placementy,26
Minor arterial injuries can be repaired primarily or with a patch
graft, and major injuries require bypass grafting, usually originating
from the proximal aorta. Prosthetic or saphenous vein grafts usually are
used to restore arterial continuity. Alternatively, ligation and extratho-
racie bypass (carotid-carotid, subclavian-subclavian, axillary-axillary, and
subclavian-carotid) in the presence of gross contamination can be per-
formed.

Subclavian Artery
The subclavian artery (SCA) is divided into three different anatomic
portions. The first portion extends from its origin in the aorta (left side)
or innominate artery (right side), to the medial border of the anterior
scalene muscle. The second portion extends from the medial border of
the scalene muscle to the region where the artery crosses the clavicle
posteriorly, and the third portion extends from the clavicle to the medial
border of the pectoralis minor muscle (Fig. 8).
 ANATOMIC EXPOSURES FOR VASCULAR INJURIES 1313

Sternocleidomastoid
muscle

\
\
\
, Subclavian
,-\ artery
I
I
I

,,
I
, ... ,\
I ,
I

Figure 8. Supraclavicular incision of the subclavian artery on the left. (From Donovan, AJ:
Trauma Surgery-Techniques in Thoracic, Abdominal, and Vascular Surgery. SI. Louis,
Mosby, 1994, P 221; with permission.)

The recommended approaches to the subclavian artery are described

in Table 1. To expose the subclavian artery at the clavicular level, it
may be necessary to disarticulate the clavicle from the sternum (not
recommended because of high complication rates), resect the middle
third of the clavicle, or divide the clavicle in half. Care should be taken
to divide the clavicle in a subperiosteal plane and to avoid injury to the
subclavian vein located adjacent to the inferior border of the clavicle.
Proximal control of the left subclavian artery is difficult to obtain.
In hemodynamically stable patients, a trapdoor incision (Fig. 9) or a
left lateral thoracotomy in conjunction with a supraclavicular incision
provides adequate exposure. In unstable patients, hemostasis can ini-

Table 1. SURGICAL APPROACHES TO THE SUBCLAVIAN ARTERY

Portion of the Subclavian

Artery (SeA) to Be Exposed
Proximal right SCA (first portion)
Right or left (second portion)
Right or left (third portion)
Proximal left SCA
Incision
Median sternotomy with right cervical extension
Supraclavicular incision with infraclavicular
extension (&-shaped incision)
Same as above
Left lateral thoracotomy and supraclavicular
incision or left anterolateral thoracotomy,
sternotomy, and supraclavicular extension
(trap door)
1314 HOYT et a1

Jugular
vein

Common
carotid Vagus
arl ery nerve

Innominal

SternlllTl ---l1o+.l.1':!r

Figure 9. Trapdoor extension to expose the proximal subclavian artery on the left. (From
Donovan, AJ: Trauma Surgery-Techniques in Thoracic, Abdominal, and Vascular Surgery.
St. Louis, Mosby, 1994, P 221; with perrnlsslon.)

tially be obtained by performing a left anterolateral thoracotomy and

applying pressure to the apex of the left pleural cavity and, subsequently,
placing a clamp at the origin of the artery in the aortic arch.
Figure 10 demonstrates the third portion of the subclavian artery
exposed through an intraclavicular approach.
Penetrating trauma continues to be responsible for the majority of
subclavian artery injuries. Mortality from these injuries is close to 5%.
The great majority of subclavian artery injuries may be repaired by
primary anastomosis or interposition graft.v 12,24

Venous Injuries
Injuries to the superior vena cava (SVC) should always be repaired
and may require temporary shunting to allow venous return to the
 ANATOMIC EXPOSURES FOR VASCULAR INJURIES 1315

.-----
"",
""- -"~
,
\ I
\
\1
,
\
\ \
I
,I
I
I
I
I
,
I
.. -
I " '\
Figure 10. Exposure of the subclavian artery folloWing clavicular resection on the left.
(From Donovan, AJ: Trauma Surgery-Techniques in Thoracic, Abdominal, and Vascular
Surgery. Sl. Louis, Mosby, 1994, P 225; with permission.)

heart during repair. Although repair of innominate venous injuries is

desirable, ligation is tolerated in most cases. Both SVC and innominate
vein injuries may be a source for air embolization. In the event of this
complication, immediate direct aspiration of air from the pulmonary
artery, right ventricle, atrium, and SVC is required. Subclavian venous
injuries can be ligated with relative impunity.
Azygous vein injury is rare but may cause massive bleeding. The
best approach to the azygous vein is through a right posterolateral
thoracotomy; however, most of these patients will present with hemody-
namic instability and major bleeding through the chest tube, requiring
emergent anterolateral thoracotomy, which will need to be extended
posteriorly for adequate hemostasis. Azygous vein injuries can be li-
gated,21,23

ABDOMINAL VASCULAR INJURIES

Abdominal vascular injuries occur in approximately 30% of all

patients with vascular trauma. Major abdominal vascular injuries are
more common after penetrating rather than blunt trauma. Mortality
rates range from 40% to 60%. Patients with penetrating abdominal
wounds that do not respond adequately to initial fluid resuscitation
have a major vascular injury until proven otherwise. Most of these
injuries will be diagnosed intraoperatively. Associated intraabdominal
1316 HOYf et al

injuries are commonly present. Retroperitoneal vascular injury remains

one of the most frequent causes of death following abdominal trauma.
A systematic approach to these injuries is of utmost importance.P- 22, 25
All patients should receive preoperative antibiotics, and the chest,
abdomen, and thigh should be prepared for surgery. A midline incision
from the xiphoid to the symphysis pubis is made, and once the abdomen
is opened, the surgeon may face two different situations: free intraperito-
neal bleeding or contained hematoma.
If free intraperitoneal bleeding is found, the first critical maneuver
is to pack all four quadrants and the pelvis. This maneuver will allow
bleeding to be temporarily controlled, and the anesthesiologist will
"catch up" with fluids and blood transfusion. If the patient remains
hypotensive, a left thoracotomy and aortic cross clamp or aortic clamp-
ing at the hiatus is done.
Intestinal injuries should be temporarily closed with sutures, staples,
or intestinal clamps to avoid further spillage of intestinal contents. Solid
organ injuries with active bleeding are best managed with packing until
definitive control of major vascular injuries is obtained. After pack
removal, major bleeding should be controlled initially with vascular
clamps, if arterial, or sponge sticks, if venous. After major bleeding is
controlled, adequate proximal and distal control is achieved, and all
retroperitoneal and/or mesenteric hematomas then should be explored
to provide enough exposure for adequate repair," "
Retroperitoneal hematomas are classified according to their location
into central (supra and inframesocolic), lateral, and pelvic (Fig. 11). This
classification is important, because it helps surgical planning.'?
In general, patients with central supra mesocolic hematomas (that
extend cephalad from or above the transverse mesocolon) are best ap-
proached through a left side medial visceral rotation." Possible major
vascular injuries in this area include the supraceliac and visceral aorta,
the celiac axis, the proximal superior mesenteric artery, renal arteries
and veins, and the superior mesenteric vein (Fig. 12).
Central inframesocolic hematomas (below the transverse mesoco-
lon) are usually approached by displacing the small bowel to the right
upper quadrant and pulling up on the transverse colon to expose the
retroperitoneal area as it is done for repair of ruptured abdominal aortic
aneurysms (Fig. 13). This approach exposes the infrarenal aorta from the
left renal vein to the bifurcation. Aortic control can be obtained at the
level of the renal vessels, and if necessary, control of the inferior vena
cava (lYe) can be obtained through medial mobilization of the right
colon and a Kocher maneuver (Fig. 14).
Nonexpanding lateral or perirenal hematomas caused by blunt
trauma should not be explored. Hematomas caused by penetrating
trauma, however, should always be explored. The approach to hemato-
mas in this area is similar to that described for central inframesocolic
hematomas. The transverse colon is displaced superiorly and the small
bowel displaced to the right. Control of the renal pedicle prior to open-
 ANATOMIC EXPOSURES FOR VASCULAR INJURIES 1317

Zone 1

Zone 3

Zone 2

Zon04

Figure 11. Anatomic zones of retroperitoneal hematomas. Zone 1 = periaortic; Zones 2

and 3 = perinephric; Zone 4 = pelvic.

ing the Gerota's fascia is controversial. The kidney can be mobilized

first, and vascular control obtained at the hilum with equal efficiency.
Pelvic hematomas secondary to penetrating trauma are best ap-
proached by displacing the small bowel superiorly, the cecum and as-
cending colon or the sigmoid medially, opening the retroperitoneum,
and obtaining proximal control of the common iliac arteries at the level
of the aortic bifurcation. Distal control of the external iliac artery is
obtained at the level of the inguinal ligament.

Specific Injuries
Celiac Axis
The celiac axis is surrounded by dense fibrous ganglionic and lym-
phatic tissue. Dissection in this area is usually difficult, but exposure
1318 HOYT et al

Figure 12. Left visceral rotation to expose the celiac access and retroperitoneal aorta.

can be obtained through right medial visceral rotation and dissecting

the proximal abdominal aorta, just below the diaphragm. If active bleed-
ing occurs in this area, proximal aortic control in the chest should be
obtained.
The celiac axis can be ligated, provided the superior mesenteric
artery (SMA) is patent. The common hepatic artery also can be ligated,
provided the gastroduodenal artery and the portal vein are patent.
Ligation of the splenic vein may cause a splenic infarct and should be
avoided, or if necessary, followed by splenectomy.'? 25

Superior and Inferior Mesenteric Arteries

The mortality rate associated with SMA injuries varies from 45% to
75%, Proximal control of the SMA at the aortic level is obtained after left
side medial visceral rotation. Proximal injuries can also be approached
through an incision in the root of the mesentery and dissection beneath
the pancreas or through the lesser sac (Fig. 15). Certain injuries beneath
the pancreas are best approached by transecting the pancreas, or by
performing medial rotation of the spleen, pancreas, and left colon, leav-
ing the left kidney in place.' Injuries of the SMA between the inferior
 ANATOMIC EXPOSURES FOR VASCULAR INJURIES 1319

TflII\ V·

of 1'n:11I lhv l.

' n r~ri"r
\'l:N cava

Figure 13. Mesenteric route exposure of the superior mesenteric artery by division of the
ligament of Treitz. (From Carrico CJ, Thai ER, Weigelt JA: Operative Trauma Management:
An Atlas. New York, McGraw-HIli, 1998, p 247; with permission.)

Figure 14. Kocher maneuver with exposure of the inferior vena cava and right renal vein.
1320 HOYT et al

- Pl'lnlnul 'u "fl UI'

."., III rio: • e po'-C\l

Figure 15. Elevation of the pancreas with exposure to proximal superior mesenteric artery.
(From Carrico CJ, Thai ER, Weigelt JA: Operative Trauma Management: An Atlas. New
York, McGraw-Hili, 1998, p 269; with permission.)

margin of the pancreas and the transverse mesocolon can be repaired

by using the same approach for more proximal injuries.
In rare instances, there is a complete transection of the SMA from
its origin in the aorta. Theoretically, ligation should not impose any
problems with regard to intestinal blood flow, since collateral flow from
the celiac axis and the inferior mesenteric artery should supply blood
flow to the midgut. Unfortunately, shock and vasoconstriction prevent
adequate perfusion of the midgut from collaterals, and usually necrosis
of the distal small bowel and right colon develops. All alternative to
ligation is an aorta-SMA bypass with saphenous vein or polytetrafluo-
roethylene (PTFE). In injuries of the SMA distal to the transverse mesoco-
lon, repair should always be attempted because of the high risk of bowel
necrosis. A second-look operation is warranted also.
The inferior mesenteric artery (IMA) originates from the aorta distal
to the renal arteries. Proximal control at the aortic level is obtained by
displacing the small bowel to the right and the transverse mesocolon
superiorly. Injuries to the IMA can be treated by ligation without major
consequences of bowel viability, because of the extensive collateral circu-
lation.

Renal Vessels
Renovascular Injuries are more frequently seen after penetrating
trauma. They may present either as a central retroperitoneal hematoma
 ANATOMIC EXPOSURES FOR VASCULAR INJURIES 1321

or as a lateral perirenal hematoma. Exposure is obtained by dissecting

the aorta and medially rotating the colon and other viscera. Control of
the renal vessels prior to opening Gerota's fascia is desirable; however
it is unclear if this maneuver decreases the number of nephrectomies.
Penetrating injuries of the renal artery may be repaired with a lateral
arteriorrhaphy. The saphenous vein is the optimal conduit when an
interposition graft is required to revascularize the kidney; however, in
the hemodynamically unstable patient with multiple injuries, nephrec-
tomy remains the appropriate treatment if the contralateral kidney is
functional." 21
The left renal vein can be safely ligated near the IVC, provided that
the adrenal and gonadal veins are patent. Primary repair is the optimal
treatment of injuries to the right renal vein; however, in rare circum-
stances this vessel can also be Iigated.'

Iliac Vessels
Iliac artery and vein injuries are primarily caused by penetrating
trauma. Mortality associated with these injuries varies from 10% to 40%.
Because of high complication rates and significant risk of limb loss,
repair of injuries to the common or external iliac arteries should always
be attempted. Because of the extensive collateral circulation, injuries to
the internal iliac arteries can be ligated."
Exposure of the iliac vessels is obtained by displacing the small
bowel to the right and dividing the posterior peritoneum in the midline
to expose the aortic bifurcation (Fig. 16). Clamps, vascular tapes} or
vessel loops should be used to obtain proximal vascular control at the
origin of the common iliac artery. During this maneuver} care must be
taken to avoid injury to the common iliac vein. Distal control is obtained
by dissecting the external iliac artery proximal to the inguina 1 ligament.
If back bleeding from the internal iliac artery occurs, this artery can be
exposed by dissecting the common iliac artery distally.
Injuries to the common or external iliac arteries can be managed by
lateral arteriorrhaphy, limited resection} and end-to-end anastomosis,
graft interposition} or utilizing the ipsilateral internal iliac artery to
replace the external iliac artery. In the presence of massive hemorrhage,
the common iliac artery may be ligated followed by a femorofemoral by-
pass.
Iliac venous injuries are exposed using an approach similar to that
for arterial injuries, Bleeding can be controlled by external compression
using sponge sticks. Vascular tapes or vessel loops passed around the
common iliac veins should be avoided because of the risk of further
bleeding from the posterior wall of these vessels. The right iliac vein is
difficult to expose} and sometimes it will be necessary to transect the
right common iliac artery to adequately expose the injured vein (Fig.
17). Iliac vein injuries are best treated with venorraphy. Ligation should
be reserved for patients with multiple associated injuries} prolonged
shock, or gross contamination.
 1322 HOYT et al

Spleen

Pancreas ---+--t-'<'-

..J;;;~r--'r-+---f-- Superior
I~-''-'''' __,-< mesenteric
artery

r,,"-+-~---~~-- Inferior
Small-----+,,/1

..
mesenteric
intestine
artery

Colon ------f---->;~ ....

Figure 16. Right visceral rotation with exposure of the inferior vena cava.

Figure 17. Division of the right iliac artery to expose the bifurcation of the vena cava and
the right iliac vein. (From Salam AA, Stewart MT: New approach to wounds of the aortic
bifurcation and inferior vena cava. Surgery 98:105-108,1985; with permission.)
 ANATOMIC EXPOSURES FOR VASCULAR INJURIES 1323

Inferior Vena Cava

Inferior vena cava (IVC) injuries occur after both blunt and penetrat-
ing trauma. IVC injuries caused by blunt trauma are rare: however, they
carry a higher mortality rate because of massive hemorrhage and multi-
ple associated injuries." 6
Injuries can be located in the retrohepatic, suprarenal and infrarenal
IVe. Injuries in the infrarenal rvc are easily repaired and carry the
lowest mortality rates. The outcome of infrarenal IVC injuries is related
to the tamponade effect of the retroperitoneum. Injuries in this location
are approached by medial visceral rotation of the right colon and by
performing an extended Kocher maneuver, exposing the NC from the
renal veins to its bifurcation.
Single injuries in the anterior wall are primarily repaired. Through-
and-through wounds can be repaired by enlarging the anterior wound:
the posterior wound is then repaired through the anterior injury. Occa-
sionally, patients in prolonged shock, with extensive wounds, multiple
associated injuries, and in the presence of coagulopathy are best served
by ligation of the infra renal NC. Lower limb edema, secondary varices
of the lower extremities, deep venous thrombosis, and pulmonary embo-
lism have been reported after ligation of the IVC; however, these compli-
cations are rare. If ligation is necessary during the postoperative period,
it is imperative to maintain adequate intravascular volume, elevate both
lower extremities, and use elastic stockings." 6, 17
Suprarenal IVC injuries carry higher mortality rates when compared
with infrarenal injuries. Deaths usually occur because of other severe
associated injuries such as those to the aorta, mesenteric vessels, renal
vessels, pancreas and duodenum. The surgical approach consists of an
extended Kocher's maneuver, medial rotation of the right colon and
duodenum, and retraction of the liver superiorly. Injuries in this location
can be repaired with lateral venorraphy. Larger wounds with partial loss
of the vessel wall require patches or interposition grafts. Ligation is not
indicated, as it leads to renal failure, although there are reports of
survivors following this procedure." 17
Mortality rates of retrohepatic IVC injuries are higher than in other
locations, and usually exceed 50%. Deaths are secondary to massive
hemorrhage, associated injuries, and difficult surgical approach. Injuries
in this portion of the IVC are suspected when bleeding from the right
upper quadrant coming from behind or below the liver does not stop
after clamping the porta hepatis. Surgical control can be obtained by
mobilizing the right hepatic lobe and directly approaching the retrohe-
patic portion of the IVC through an extensive hepatotomy or by placing
an intraluminal atriocaval shunt. Vascular hepatic isolation, by means of
occluding the abdominal aorta, the suprarenal vena cava above and
below the liver associated with a Pringle's maneuver is another alterna-
tive. Criticism of this technique is related to acute complications follow-
ing multiple vascular occlusions such as shock, arrhythmias, and cardiac
1324 HOYT et al

arrest caused by decreased venous return to the heart. Renal and hepatic
ischemia also has been reported.v- 17
Intracaval shunts are used in an attempt to maintain venous return
and create a relatively bloodless surgical field. This procedure requires
a right thoracotomy or median sternotomy, with or without a phrenot-
amy. Care should be taken to place the shunt and the vessel loops in
the appropriate position in the abdominal !Ve, above the renal veins, to
avoid bleeding and decreased venous return to the heart (Fig. 18).
Complications following the use of intracaval shunts include air embo-
lism, increase of the size of the initial injury, bleeding, and thrombosis.
Results of intracaval shunts are not encouraging; however, in most cases
the shunt has been used as a last desperation option."

Injuries to the Porta Hepatis

Injuries to the portal vein are difficult to manage because of the
proximity to vital structures (hepatic artery, the common bile duct,

Figure 18. Placement of an intravascular retrohepatic vena caval shunt using a chest tube.
 ANATOMIC EXPOSURES FOR VASCULAR IN]1.JRIES 1325

duodenum, pancreas, liver, and IVC) and rapid exsanguination. The

portal vein is posteriorly located in relation to the hepatic artery and
common duct, which makes the proximal and distal isolation of this
vessel challenging. The mortality rate of portal vein injury approaches
60%, and massive bleeding is the most common cause of death. IS, 30,31
If bleeding in the porta hepatis area is identified, the first step is to
perform a Pringle's maneuver. The portal vein is then exposed by
medially retracting the common bile duct and dissecting posteriorly to
the common duct (Fig. 19). Proximal injuries of the portal vein may
require transection of the pancreas to obtain hemostasis. Lateral venorr-
haphy or primary anastomosis achieves repair if possible. Other alterna-
tives of portal vein repair include ligation, resection with end-to-end
anastomosis, interposition grafting, or portosystemic shunting. Extensive
injury may require ligation, which is tolerated in 90% of cases if hepatic
artery flow is maintained. A second-look operation within 24 hours
after portal vein ligation is advisable. Concomitant hepatic artery injury
mandates portal vein repair. IS, 30
Injuries to the common hepatic artery can be safely ligated provided
the portal vein is uninjured. Repair should be attempted in injuries of
the proper hepatic artery, particularly in patients in prolonged shock, or
with previous liver disease. Following ligation of the hepatic artery, a
cholecystectomy is mandatory.
Superior mesenteric vein (SMV) injuries can be ligated if the clinical
condition of the patient precludes more extensive repair or prolonged
surgical times. After SMV ligation, aggressive fluid resuscitation is re-
quired to minimize the effects of splanchnic sequestration on the venous
return."

'-77--f-- -- - tc

Figure 19. Exposure of the portal vein in the inferior and medial aspect of the portal triad.
GB = gallbladder; LI = liver; HF = hepatic flexure; PV = portal vein; IC = inferior vena
cava. (From Aunf, so: Critical Maneuvers in Trauma Surgery. New York, Springer-Verlag,
1982, p 135; with permission.)
1326 HOYT et al

VASCULAR EXPOSURE OF THE UPPER EXTREMITY

Vascular exposure and repair of the arterial vessels of the upper

extremity require a detailed, organized approach to their evaluation
secondary to the proximity of bones, nervous structures, and venous
drainage. The axillary artery is approximately 15 em in length and is a
continuation of the subclavian artery. Its origin is at the lateral border of
the first rib and ends at the inferior border of the teres major muscle. It
is divided into three parts: proximal, beneath and proximal to the pecto-
ralis minor muscle with one branch (superior thoracic artery); middle,
deep to the pectoralis minor muscle with two branches (thoracoacromial
and lateral thoracic arteries); and distal, distal to the pectoralis minor
muscle with three branches (subscapular, ant/post circumflex humeral
arteries) (Fig. 20).
Surgical exposure of the axillary artery can be accomplished by way
of an incision over the cephalic vein in the deltopectoral groove. If
necessary, the pectoralis major and minor tendons may be divided if
additional exposure is required. Standard vascular principles apply to
repair of the axillary artery including debridement of vessel edges and
Fogarty catheter embolectomy of the distal arterial supply, including
individual embolectomies of the ulnar and radial arteries if possible to
remove thrombus. Repair may be undertaken either primarily with
mobilization of proximal and distal segments or by way of autologous
saphenous vein graft.
The brachial artery is a continuation of the axillary artery. It origi-
nates at the inferior border of the teres major muscle. It terminates
approximately 2.5 em distal to the transverse skin crease in the antecubi-

Figure 20. Anatomic landmarks and course of the maxillary artery and relationship to the
pectoralis minor muscle. (From Graham JM, Mattox KL, Feliciano DV, et al: Vascular
injuries of the axilla. Ann Surg 195:232-238, 1982; with permlssion.)
 ANATOMIC EXPOSURES FOR VASCULAR INJURIES 1327

tal fossa. It typically follows the course of the inner border of the biceps
muscle. Surgically, the brachial artery is approached by way of a medial
longitudinal incision along the course of the artery. If necessary to go
across the antecubital fossa, an S-shaped extension should be used to
avoid scarring and contracture. Great care must be taken to preserve the
medial nerve during mobilization of the distal segment of the brachial
artery. Vascular repair is accomplished with either direct repair or by
way of an autologous saphenous vein graft.

VASCULAR EXPOSURE OF THE LOWER EXTREMITY

The common femoral artery is a direct continuation of the external

iliac artery and arises deep to the inguinal ligament midway between
the anterior superior iliac spine and pubic symphysis. The profunda
femoral artery arises from the posterolateral aspect of the common
femoral artery approximately 4 em below the inguinal ligament. Surgical
approach is by way of a longitudinal incision over the femoral vessels
and should bisect the femoral triangle. It may be extended superiorly
and laterally to obtain exposure and control of the external iliac artery.
The inguinal ligament may be taken down at the anterior superior iliac
spine or divided to facilitate exposure and proximal arterial control.
Distal exposure can be obtained by either taking down the sartorious
muscle or mobilizing it laterally where the superficial femoral artery
passes under sartorious muscle and into Hunter's canal. Standard vascu-
lar principles apply to surgical repair and may include either autologous
saphenous vein graft or polytetrafluoroethylene (Cortex, Gore h1C, Flag-
staff, AZ) interposition grafts. The profunda femoral artery may be
ligated with relative impunity, but if a simple repair will suffice, it
should be undertaken.
The superficial femoral artery (SFA) is a continuation of the common
femoral artery, and its course changes from an anterior structure proxi-
mally to a posterior medial position distally. The SFA is best approached
by way of a longitudinal incision along the anterior border of the
sartorious muscle. Standard surgical principles apply to repair and
should include consideration of lower extremity fasciotomies if pro-
longed ischemia has occurred. Repair of concomitant femoral vein injur-
ies is warranted and should be undertaken at the same time as arterial
repair.
The popliteal artery begins as a continuation of the SFA as it exits
from the adductor canal. The proximal portion of the popliteal artery
lies posterior to the distal third of the femur. It courses posterior to
the knee capsule deep within the popliteal fossa. The popliteal artery
terminates at the distal border of the popliteus muscle. One approach to
the popliteal artery is with the patient in the prone position by way of
a modified S incision to avoid a flexion contracture across the popliteal
fossa. The incision may be carried medially above the knee joint to
facilitate exposure, and distally it may be carried laterally to obtain
1328 HOYT et al

........_or--.,-Gracllls
/
/
~Ww::~- Semimembranosus

.lsemitendlnosus

~"""""~;.';-I ,L Popliteal artery

'
I """

Medial
epicondyle ~~~~~ IUJ GastrocnemIus
latoral head
....

Figure 21. Relationship of the popliteal artery to the sartorius, gracilis, semimembranosus,
semitendinosus, and gastrocnemius. (From Muscat JD, Rogers W, Cruz AB, et al: Arterial
injuries in orthopaedics: The posteromedial approach for vascular control about the knee.
J Orthop Trauma 10:476-480, 1996; with permission.)

adequate exposure. This approach is only useful in blunt injuries where

angiographic demonstration of a limited injury is clear.
The best approach to the popliteal artery is with the patient in the
supine position with the leg flexed and supported with towels. The
incision is made parallel to the sartorious muscle. The muscle is retracted
posteromedially to facilitate exposure. Division of the gracilis, semimem-
branous, semitendinosus, and the medial head of the gastrocnemius are
possible and will expose the entire popliteal artery (Fig. 21). The ideal
replacement conduit for the popliteal artery has yet to be identified, but
current practice is to use an autologous saphenous vein graft.

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 ANATOMIC EXPOSURES FOR VASCULAR INJURIES 1329

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Address reprint requests to

David B. Hoyt, MD, FACS
Division of Trauma, Burns, and Surgical Critical Care
University of California, San Diego, Medical Center
200 West Arbor Drive, Mail Code 8896
San Diego, CA 92103-8896

e-mail:dhoyt@ucsd.edu