What is the preferred incision, Schobinger or modified Schobinger, for vascular access complications?

Comparison of Schobinger vs. Modified Schobinger Incision for Vascular Access Complications

The modified Schobinger incision is preferred over the standard Schobinger incision for managing vascular access complications due to its superior exposure to neck lymphatics and anatomical structures, despite requiring more time for closure. 1

Characteristics of Modified Schobinger Incision

• Provides the best exposure to neck node levels compared to other incisions (Macfee, Modified Macfee, and Reverse Hockey Stick), making it optimal for accessing and managing vascular structures 1
• Includes extension of the vertical line of incision below the subclavicular area to the nipple-areola complex, which is the principal modification from the standard Schobinger incision 2
• Offers unobstructed vision of anatomic landmarks and distal surgical elements, which is crucial when addressing vascular access complications 2
• Provides increased blood supply for the flap through recruitment of new arterial vessels from the first through fourth internal mammary perforators 2

Benefits of Modified Schobinger for Vascular Access Complications

• If flap necrosis occurs, it will not compromise the coverage of the great vessels of the neck, which is critical in vascular access procedures 2
• The flap's excessive mobility permits its use in facial areas, facilitating reconstruction when needed 2
• Allows protection of vital anatomic structures in both pre- and post-operative periods 2
• Results in an inconspicuous and aesthetically acceptable final scar, though not as cosmetically favorable as the Macfee incision 1, 2

Clinical Considerations

• Vascular access complications occur in up to 9% of percutaneous coronary interventions and may be higher with larger access sheaths used in procedures like TAVR 3, 4
• When managing vascular access complications, proper exposure is critical for identifying the exact location and nature of the injury 3
• Common vascular injuries include tears (11%), dissections (38%), and vessel rupture (19%), which require excellent visualization for proper repair 3
• The majority of vascular repairs are done primarily (64%), with patch (28%) and bypass (8%) techniques used less frequently 3

Potential Drawbacks

• Modified Schobinger incision requires more time for closure (mean 51.90 minutes) compared to other incisions like the Macfee (mean 32.60 minutes) 1
• Partial necrosis may occur in approximately 11% of cases, though healing typically occurs spontaneously 2
• Pharyngocervical fistula development is a rare complication (1.8% of cases) 2

Recommendations for Practice

• For complex vascular access complications requiring extensive exposure, the modified Schobinger incision should be the first choice 1, 2
• For cases where cosmesis is the primary concern and adequate exposure can still be achieved, the Macfee incision may be considered as an alternative 1
• When planning the incision, consider the location of the vascular injury (common femoral artery 49%, superficial femoral artery 11%, external iliac artery 41%) to ensure adequate exposure 3
• Careful patient selection and proper access techniques are fundamental in minimizing complications, regardless of incision choice 3

The modified Schobinger incision provides superior surgical access for managing vascular complications while maintaining acceptable cosmetic outcomes, making it the preferred choice over the standard Schobinger incision in most cases requiring extensive exposure.