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Xiang X, Shen Q, Wang G, Chen T. Video-assisted thoracic surgical repair of iatrogenic subclavian vein injury from central venous catheterization. J Vasc Access 2021; 23:989-991. [PMID: 33982629 DOI: 10.1177/11297298211015084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Xiang Xiang
- Department Critical Care Medicine, Chengdu Fifth People's Hospital, Chengdu, Sichuan, China
| | - Qin Shen
- Department Critical Care Medicine, Chengdu Fifth People's Hospital, Chengdu, Sichuan, China
| | - Guoxiang Wang
- Department Critical Care Medicine, Chengdu Fifth People's Hospital, Chengdu, Sichuan, China
| | - Taojiang Chen
- Department Critical Care Medicine, Chengdu Fifth People's Hospital, Chengdu, Sichuan, China
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2
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Staniszewska A, Anwar M, Hamady M, Nott D. Hybrid repair of proximal subclavian artery transection. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408620934364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although rare, subclavian artery injuries are associated with significant mortality and morbidity, with almost two-thirds of patients dying before reaching hospital. Recent advances in technology have resulted in increasing use of endovascular therapy in management of these injuries. In this report, we present a case of a successful hybrid repair of traumatic left proximal subclavian artery transection. The employment of an Amplatzer Vascular Plug to control a short proximal subclavian artery stump and subsequent ligation of the distal segment of subclavian artery with its anastomosis to the carotid artery resulted in excellent clinical outcome without performing a sternotomy in a young patient.
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Affiliation(s)
- Aleksandra Staniszewska
- Department of Vascular Surgery, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Muzaffar Anwar
- Department of Vascular Surgery, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mohamad Hamady
- Department of Interventional Radiology, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - David Nott
- Department of Vascular Surgery, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
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3
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O'Connor JV, Moran B, Galvagno SM, Deane M, Feliciano DV, Scalea TM. Admission Physiology vs Blood Pressure: Predicting the Need for Operating Room Thoracotomy after Penetrating Thoracic Trauma. J Am Coll Surg 2020; 230:494-500. [PMID: 32007533 DOI: 10.1016/j.jamcollsurg.2019.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Approximately 15% of patients with penetrating thoracic trauma require an emergency center or operating room thoracotomy, usually for hemodynamic instability or persistent hemorrhage. The hypothesis in this study was that admission physiology, not vital signs, predicts the need for operating room thoracotomy. STUDY DESIGN We conducted a trauma registry review, 2002 to 2017, of adult patients undergoing operating room thoracotomy within 6 hours of admission (emergency department thoracotomies excluded). Demographics, injuries, admission physiology, time to operating room (OR), operations, and outcomes were reviewed. Data are reported as mean (SD) or median (IQR). RESULTS Of the 301 consecutive patients in this 15-year review, 75.6% were male, mean age was 31.1 years (11.5), and 41.5% had gunshot wounds. The median Injury Severity Score was 25 (range 16 to 29), time to operating room was 38 minutes (interquartile range [IQR] 19 to 105 minutes), and 21.9% had a thoracic damage control operation. Mean admission systolic blood pressure was 115 mmHg (SD 37 mmHg), with only 23.9% <90 mmHg; however, admission pH 7.22 (SD 0.14), base deficit 7.6 (SD 6.1), and lactate 7.2 (SD 4.5) were markedly abnormal. Overall, there were 136 (45.2%) patients with significant pulmonary injuries treated with 112 major nonanatomic resections, 17 lobectomies, and 7 pneumonectomies; respective mortalities were 2.7%, 11.8%, and 42.9%. There were 100 (33.2%) cardiac, 30 (9.9%) great vessel, 14 (4.7%) aerodigestive, and 58 (19%) combined thoracic injuries. Mortalities for cardiac, great vessel, and aerodigestive injuries were 7%, 0%, and 14.3%, respectively. Overall mortality was 6.6%, 15.2% after damage control, and 4.3% for all others. CONCLUSIONS Shock characterized by acidosis, but not hypotension, is the most common presentation in patients who will need operating room thoracotomy after penetrating thoracic trauma. Survival rates are excellent unless a pneumonectomy or damage control thoracotomy is required.
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Affiliation(s)
- James V O'Connor
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD.
| | - Benjamin Moran
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Samuel M Galvagno
- Department of Anesthesia, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Molly Deane
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - David V Feliciano
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Thomas M Scalea
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
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Long CA, Pappas TN, Southerland KW, Shortell CK. An analysis of the vascular injuries and attempted resuscitation surrounding the assassination of Martin Luther King Jr. J Vasc Surg 2019; 70:1652-1657. [PMID: 31653379 DOI: 10.1016/j.jvs.2019.06.203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/30/2019] [Indexed: 11/28/2022]
Abstract
Martin Luther King Jr was the most prominent civil rights leader in the United States in the 1960s. He was shot by an assassin in Memphis, Tennessee, on April 4, 1968. After the shooting he was taken to a local hospital where he had an unsuccessful resuscitation for a right subclavian artery transection. Despite the fact that the circumstances around the assassination have been frequently reported and reviewed in the past 50 years, the specific vascular care of the traumatic injury has not been analyzed. This paper reviews the medical aspects of the King assassination and the management of his subclavian injury.
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Affiliation(s)
- Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC.
| | - Theodore N Pappas
- Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC
| | - Kevin W Southerland
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC
| | - Cynthia K Shortell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC
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Eighteen years' experience of traumatic subclavian vascular injury in a tertiary referral trauma center. Eur J Trauma Emerg Surg 2019; 45:973-978. [PMID: 30627733 PMCID: PMC6910889 DOI: 10.1007/s00068-018-01070-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 12/27/2018] [Indexed: 11/09/2022]
Abstract
Purpose Traumatic subclavian vascular injury (TSVI) is rare but often fatal. The precise diagnosis of TSVI remains challenging mainly because of its occult nature, less typical presentations, and being overlooked in the presence of polytrauma. Compared to penetrating injuries, it is even more difficult to identify TSVI in patients who have blunt injuries and no visible bleeding. The risk factors associated with TSVI in patients with thoracic trauma are unclear. The aims of this study were to identify risk factors for TSVI in a cohort of patients with thoracic vascular injuries and to report outcomes after clinical treatment. Methods From January 2009 to June 2017, 39586 patients were admitted to our hospital (a level I trauma center) due to trauma, and 136 patients with thoracic vascular injury were enrolled in this study. We retrospectively reviewed data from medical records including demographic characteristics, injury scoring systems (RTS, ISS, NISS, TRISS and AIS), management and outcomes. Patients were further divided into the TSVI group (patients with TSVI) and the non-TSVI group (patients with thoracic vascular injuries other than TSVI). Univariate and multivariate analyses were used to identify independent risk factors. Results The enrolled 136 patients suffered mostly from blunt trauma (89.0%) and 22 of them had TSVI. When compared to the non-TSVI group, the TSVI group had lower Glasgow Coma Scale (GCS) scores (p = 0.002; especially GCS ≤ 12), less concurrent abdominal injury (p < 0.001), lower Injury Severity Scales (ISS) (p = 0.007) and New Injury Severity Scales (NISS) (p < 0.002) but had higher Abbreviated Injury Scales (AIS) of the head ≥ 3 (p = 0.009) and rates of clavicular or scapular fractures (p = 0.013). No difference was detected between the two groups with regard to age, gender, trauma mechanism, vital signs on arrival, or rate of facial and extremities injury. In multivariate regression analyses, GCS ≤ 12, AIS of the head ≥ 3 and the presence of clavicular or scapular fractures were independent risk factors for TSVI (p = 0.026, p = 0.043 and p = 0.005, respectively) after adjustment for confounding factors. Open and endovascular repair were two surgical procedures utilized for these TSVI patients with an overall mortality rate of 18.2%. No difference was found between these groups with regard to mortality rate and the length of ICU stay, but the patients in the TSVI group had a shorter length of hospital stay. Conclusions Our results suggest that GCS ≤ 12, AIS of the head ≥ 3 and the presence of clavicular or scapular fractures were independent risk factors for TSVI in patients with thoracic vascular injuries. For patients with thoracic trauma, TSVI should be considered for prompt management when patients exhibit concurrent injuries to the head, clavicle or scapula.
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6
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Madsen AS, Bruce JL, Oosthuizen GV, Bekker W, Laing GL, Clarke DL. The Selective Non-operative Management of Penetrating Cervical Venous Trauma is Safe and Effective. World J Surg 2018; 42:3202-3209. [DOI: 10.1007/s00268-018-4595-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Penetrating injury to the neck has inspired considerable controversy with regard to its management, owing to the large number of important, susceptible structures contained in this area. Mandatory exploration of all wounds has generally given way to selective operative management. Clinical assessment has, once again, become the prime diagnostic tool. This review describes the evolution of management and the value of various diagnostic modalities. It concludes with a summary of appropriate operative techniques.
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Affiliation(s)
- Campbell MacFarlane
- Emergency Medical Services Training, Gauteng Provincial Government Department of Health and Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Carol Ann Benn
- Chris Hani Baragwanath Hospital, Johannesburg and Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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8
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Haq AA, Restrepo CS, Lamus D, Ocazionez-Trujillo D, Vargas D. Thoracic venous injuries: an imaging and management overview. Emerg Radiol 2016; 23:291-301. [PMID: 26965007 DOI: 10.1007/s10140-016-1386-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 02/17/2016] [Indexed: 10/22/2022]
Abstract
Thoracic venous injuries are predominantly attributed to traumatic and iatrogenic causes. Gunshot wounds and knife stabbings make up the vast majority of penetrating trauma whereas motor vehicle collisions are the leading cause of blunt trauma to the chest. Iatrogenic injuries, mostly from central venous catheter complications are being described in growing detail. Although these injuries are rare, they pose a diagnostic challenge as their clinical presentation does not substantially differ from that of arterial injury. Furthermore, the highly lethal nature of some of these injuries provides limited literature for review and probably underestimates their true incidence. The widespread use of multi-detector computed tomography (MDCT) has increased the detection rate of these lesions in hemodynamically stable patients that survive the initial traumatic event. In this article, we will discuss and illustrate various causes of injury to each vein and their supporting CT findings while briefly discussing management. The available literature will be reviewed for penetrating, blunt, and iatrogenic injuries to the vena cava, innominate, subclavian, axillary, azygos, and pulmonary veins.
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Affiliation(s)
- Aftab A Haq
- Department of Radiology, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
| | - Carlos S Restrepo
- Department of Radiology, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Daniel Lamus
- Department of Radiology, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | | | - Daniel Vargas
- Department of Radiology, University of Colorado, Denver, CO, USA
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Trap-door incision for penetrating thoracic trauma: an obsolete approach? Case Rep Surg 2014; 2014:798242. [PMID: 25165611 PMCID: PMC4137611 DOI: 10.1155/2014/798242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 07/12/2014] [Indexed: 11/18/2022] Open
Abstract
Penetrating injuries to the subclavian vessels are uncommon and very severe lesions. They are difficult to expose and carry a high mortality. "Trap-door" incisions have lately been dismissed as too mutilating for the occasional victim of a penetrating thoracic trauma with massive bleeding difficult that is to expose. We present a case of severe bleeding from a stab wound in the left subclavicular area in a heavy-built patient where a "trap-door" incision proved inevitable to expose and repair the injury, and most probably saved his life.
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10
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Emergent Median Sternotomy for Mediastinal Hematoma: A Rare Complication following Internal Jugular Vein Catheterization for Chemoport Insertion-A Case Report and Review of Relevant Literature. Case Rep Anesthesiol 2014; 2014:190172. [PMID: 24592335 PMCID: PMC3926366 DOI: 10.1155/2014/190172] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Accepted: 10/07/2013] [Indexed: 11/17/2022] Open
Abstract
Mediastinal hematoma is a rare complication following insertion of a central venous catheter with only few cases reported in the English literature. We report a case of a 71-year-old female who was admitted for elective chemoport placement. USG guided right internal jugular access was attempted using the Seldinger technique. Resistance was met while threading the guidewire. USG showed a chronic clot burden in the RIJ. A microvascular access was established under fluoroscopic guidance. Rest of the procedure was completed without any further issues. Following extubation, the patient complained of right-sided chest pain radiating to the back. Chest X-ray revealed a contained white out in the right upper lung field. She became hemodynamically unstable. Repeated X-ray showed progression of the hematoma. Median Sternotomy showed posterior mediastinal hematoma tracking into right pleural cavity. Active bleeding from the puncture site at RIJ-SCL junction was repaired. Patient had an uneventful recovery. Injury to the central venous system is the result of either penetrating trauma or iatrogenic causes as in our case. A possible explanation of our complication may be attributed to the forced manipulation of the dilator or guidewire against resistance. Clavicle and sternum offer bony protection to the underlying vital venous structures and injuries often need sternotomy with or without neck extension. Division of the clavicle and disarticulation of the sternoclavicular joint may be required for optimum exposure. Meticulous surgical technique, knowledge of the possible complications, and close monitoring in the postprocedural period are of utmost importance. Chest X-ray showed to be routinely done to detect any complication early.
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Kalish J, Nguyen T, Hamburg N, Eberhardt R, Rybin D, Doros G, Farber A. Associated venous injury significantly complicates presentation, management, and outcomes of axillosubclavian arterial trauma. Int J Angiol 2013; 21:217-22. [PMID: 24293980 DOI: 10.1055/s-0032-1330969] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Axillosubclavian vessel injury (ASVI) is associated with high morbidity and mortality. Most studies are single-center experiences of small numbers of patients with penetrating injury. We assessed 21st-century presentation and management of ASVI and focused on outcomes of combined arterial/venous injury. We reviewed the National Trauma Data Bank for patients with isolated arterial ASVI (group 1) and combined arterial/venous ASVI (group 2). Demographics, injury severity parameters, interventions, complications, and outcomes were compared. We identified 581 patients with ASVI (mean age 35.1; 88.1% male), with 466 isolated arterial injuries and 115 combined arterial/venous injuries. Group 2 had lower presenting systolic blood pressure and Glasgow Coma Scale, and had higher rates of operative repair (55.7 vs. 43.1%, p = 0.016) and higher mortality (33.9 vs. 13.9%, p < 0.001). There were no differences in amputation (5.2 vs. 2.4%, p = 0.121), compartment syndrome (2.6 vs. 1.9%, p = 0.713), and deep vein thrombosis (0.9 vs. 0.2%, p = 0.357). When separated by mechanism of injury, combined injuries from blunt trauma did increase amputation rates (27.8 vs. 4.2%, p = 0.002). Multivariate analysis revealed that combined arterial/venous injury significantly increased risk of death (odds ratio [OR], 2.99; confidence interval [CI], 1.73 to 5.17; p = 0.0001). Penetrating injury had higher odds of death than blunt injury (OR, 1.96; CI, 1.03 to 3.73; p = 0.041). ASVI is rare but extremely lethal. Concomitant venous and arterial injury is not associated with worse limb-related outcomes, except in blunt injuries and resultant amputations, but is associated with a threefold increase in mortality rates compared with isolated arterial injury.
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Affiliation(s)
- Jeffrey Kalish
- Division of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, Massachusetts
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12
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Isolated subclavian vein injury: a rare and high mortality case. Case Rep Vasc Med 2013; 2013:152762. [PMID: 23781389 PMCID: PMC3676963 DOI: 10.1155/2013/152762] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Accepted: 05/12/2013] [Indexed: 11/17/2022] Open
Abstract
Isolated subclavian vein injuries are rarely seen without concomitant arterial injury, bone fracture, damage to brachial plexus, and thoracal traumas. Our case was brought to the emergency service 6 hours after he had been shot at the shoulder with a firearm. After detection of extravasation from the left axillary and subclavian vein on arteriographic and venographic examinations, he was operated on. An autogenous saphenous vein graft was interposed between subclavian and axillary veins. Cardiac arrest developed twice because of hypovolemia, which was resolved with medical therapy. Subclavian vein injuries have a more mortal course when compared with the injuries to the subclavian arteries. Its most important reason is excessive blood loss and air embolism because of delayed arrival to hospital. As is the case in all vascular injuries, angiography is the most important diagnostic examination. If the general health state of the patient permits, arteriography and venography should be performed in patients potentially exposed to vascular injuries. In patients with extreme blood loss and deteriorated health state, direct surgical exploration of the injury site, containment of the bleeding, and venous repair are life-saving approaches.
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Sinha S, Patterson BO, Ma J, Holt PJ, Thompson MM, Carrell T, Tai N, Loosemore TM. Systematic review and meta-analysis of open surgical and endovascular management of thoracic outlet vascular injuries. J Vasc Surg 2013; 57:547-567.e8. [DOI: 10.1016/j.jvs.2012.10.077] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 09/26/2012] [Accepted: 10/04/2012] [Indexed: 10/27/2022]
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Mizuta K, Kuze B, Yamada N, Hayashi H, Aoki M, Ito Y. [Surgery in the lateral area of the cervicothoracic border]. ACTA ACUST UNITED AC 2012; 115:910-6. [PMID: 23214049 DOI: 10.3950/jibiinkoka.115.910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Surgery is not usually indicated for the involvement of cervical lymph node metastasis to the subclavian vein. Although surgery is indicated for the involvement of cervical lymph node metastasis to the venous angle, the usual visual field associated with cervical lymph node dissection cannot sufficiently visualize the subclavian vein, and the possibility exists of causing great vessel injury when involved lymph nodes are large and their mobility is restricted. In such cases, surgical excision may be avoided based on the expectation that ligating or cutting the internal jugular vein will be difficult. We examined 10 patients who underwent surgery for the adhesion or invasion of the primary tumor or involved lymph nodes to the venous angle or subclavian vein. The clavicle was removed or displaced to secure the visual field. The sternoclavicular joint was conserved and the clavicle, separated from the first rib, was lifted in 4 patients, while the medial two thirds of the clavicle was removed in 6 patients. Involved lymph nodes could be securely dissected without causing great vessel injury. A chylous leak occurred in one patient undergoing the procedure on the left side.
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Affiliation(s)
- Keisuke Mizuta
- Department of Otorhinolaryngology, Gifu University Graduate School of Medicine, Gifu, Japan
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15
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Sciarretta JD, Asensio JA, Vu T, Mazzini FN, Chandler J, Herrerias F, Verde JM, Menendez P, Sanchez JM, Petrone P, Stahl KD, Lieberman H, Marini C. Subclavian vessel injuries: difficult anatomy and difficult territory. Eur J Trauma Emerg Surg 2011; 37:439. [PMID: 26815414 DOI: 10.1007/s00068-011-0133-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 06/19/2011] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Thoracic and thoracic related vascular injuries represent complex challenges to the trauma surgeon. Subclavian vessel injuries, in particular, are uncommon and highly lethal. Regardless of the mechanism, such injuries can result in significant morbidity and mortality. MATERIALS AND METHODS Systematic review of the literature, with emphasis on the diagnosis, treatment and outcomes of these injuries, incorporating the authors' experience. CONCLUSIONS These injuries are associated with significant morbidity and mortality. Patients who survive transport are subject to potentially debilitating injury and possibly death. Management of these injuries varies, depending on hemodynamic stability, mechanism of injury, and associated injuries. Despite significant advancements, mortality due to subclavian vessel injury remains high.
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Affiliation(s)
- J D Sciarretta
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - J A Asensio
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA.
| | - T Vu
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - F N Mazzini
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - J Chandler
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - F Herrerias
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - J M Verde
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - P Menendez
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - J M Sanchez
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - P Petrone
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - K D Stahl
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - H Lieberman
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - C Marini
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
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Nguyen T, Kalish J, Woodson J. Management of Civilian and Military Vascular Trauma: Lessons Learned. Semin Vasc Surg 2010; 23:235-42. [DOI: 10.1053/j.semvascsurg.2010.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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17
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Sobnach S, Nicol A, Nathire H, Edu S, Kahn D, Navsaria P. An Analysis of 50 Surgically Managed Penetrating Subclavian Artery Injuries. Eur J Vasc Endovasc Surg 2010; 39:155-9. [DOI: 10.1016/j.ejvs.2009.10.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Accepted: 10/17/2009] [Indexed: 11/25/2022]
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18
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Penetrating thoracic great vessel injury: impact of admission hemodynamics and preoperative imaging. ACTA ACUST UNITED AC 2010; 68:834-7. [PMID: 20065882 DOI: 10.1097/ta.0b013e3181b250df] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The management of penetrating great vessel (PGV) injury is challenging. Patients in shock require rapid evaluation, whereas in stable patients, imaging studies may optimize the surgical approach. We reviewed our experience with PGV injury to determine the impact of admission blood pressure and accuracy of imaging studies, both angiography and computed tomographic angiography (CTA). METHODS Retrospective review of the trauma registry from 2001 to 2007 identifying patients with PGV injury. Demographics, admission systolic blood pressure, imaging studies, specific injuries, incision, methods of repair, hospital and intensive care length of stay, complications, and mortality were recorded. Shock was defined as systolic blood pressure <90 mm Hg. RESULTS Thirty-six consecutive patients were identified, average age was 28 (+/-10) years, of whom 20 (56%) presented in shock. Those in shock had more combined arterial-venous injuries (60% vs. 25%), concomitant thoracic injuries requiring resection (45% vs. 19%), and units of packed red blood cells (5.8 +/- 2 vs. 2.7 +/- 1.5), p < 0.01. For those in shock, the mean time to the operating room was 27 minutes +/- 9 minutes and 75% had sternotomy. Among stable patients, 56% had a periclavicular approach and 31% partial sternotomy. All 16 stable patients had imaging; angiography in 3 patients and CTA in 7 patients. In six patients who had both angiography and CTA, the results were concordant; therefore, CTA accurately diagnosed arterial injury in all 13 patients. Imaging changed the choice of incision in 4 (25%). Intensive care length of stay was significantly longer in the shock group 3.1 (+/-2.1) days versus 1.4 (+/-1.6) days (p = 0.01). There were 5 (14%) complications and no deaths. CONCLUSION Patients in shock require rapid evaluation. Sternotomy affords excellent exposure to all PGV injuries, and partial sternotomy is useful in stable patients. In stable patients, CTA can be valuable in defining the injury and may influence the surgical approach. Surgical results are surprisingly good, even in unstable patients and may be related to rapid transport and operation.
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Ntlhe LM, Ghoor FO, Ngcobo TK, Sebego KL. Temporary thoracoscopic control of the proximal left subclavian artery for trauma. THE JOURNAL OF TRAUMA 2009; 66:E9-E12. [PMID: 18277302 DOI: 10.1097/01.ta.0000236672.25214.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Letlhogela Meshack Ntlhe
- Department of Surgery, Medunsa Campus, University of Limpopo, Dr George Mukhari Hospital, Medunsa, Republic of South Africa.
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du Toit DF, Lambrechts AV, Stark H, Warren BL. Long-term results of stent graft treatment of subclavian artery injuries: management of choice for stable patients? J Vasc Surg 2008; 47:739-43. [PMID: 18242938 DOI: 10.1016/j.jvs.2007.11.009] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Revised: 11/08/2007] [Accepted: 11/08/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND The management of penetrating subclavian artery injuries poses a formidable surgical challenge. The feasibility of stent graft repair is already established. General use of this modality is not widely accepted due to concerns regarding the long-term outcome in a generally young patient population. We review our stent graft experience to examine long-term outcomes. METHODS All patients with penetrating subclavian artery injuries were evaluated for stent graft repair. Patients were excluded when hemodynamically unstable or unsuitable on other clinical and angiographic grounds. Patients were followed prospectively for early (<30 days) and late (>30 days) complications. Clinical and telephone evaluation, Doppler pressures, duplex Doppler, and angiography (when indicated), were used to asses patients at follow-up. Outcomes were recorded as technical success of procedure, graft patency, arm claudication, limb loss, the need for open surgical repair, the presence or absence of other complications, and death. RESULTS Fifty-seven patients underwent stent graft treatment during the 10-year period. Mean age was 34, and 91% were men. There were 53 stab wounds and four gunshot injuries. Pathology included false aneurysms (n = 42), arteriovenous fistula (n = 12), and three arterial occlusions. Early complications: One patient (2%) had a femoral puncture site injury which was managed with open surgical repair. One patient died early due to multiple organ failure related to concomitant injuries. Three patients (5%) presented with graft occlusion and nonlimb threatening ischemia in the first week after treatment. All three patients were managed successfully with a second endovascular intervention. Late complications: Twenty-five (44%) of the 57 patients with subclavian artery injuries were followed-up with a mean duration of 48 months. Two patients died as a result of fatal stab wounds months after their first injuries. Five patients (20%) and three patients (12%) presented with angiographically significant stenosis and occlusions, respectively. The stenotic lesions were successfully managed with endovascular intervention, and the occluded lesions were managed conservatively. No patient experienced life or limb loss or any incapacitating symptoms at the end of the study period. There was no need for conversion to open surgery. CONCLUSIONS This study has reaffirmed the feasibility and safety of stent graft repair in treating stable patients with selected penetrating subclavian artery injuries. The results of this study also confirmed acceptable long-term follow-up without any limb or life threatening complications. We conclude that endovascular repair should be considered the first choice of treatment in stable patients with subclavian artery injuries.
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Affiliation(s)
- Daniel F du Toit
- Department of Surgery, University of Stellenbosch, Tygerberg Hospital, Tygerberg, South Africa.
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Vascular Trauma. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Aksoy M, Tunca F, Yanar H, Guloglu R, Ertekin C, Kurtoglu M. Traumatic injuries to the subclavian and axillary arteries: a 13-year review. Surg Today 2005; 35:561-5. [PMID: 15976953 DOI: 10.1007/s00595-005-2990-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2003] [Accepted: 11/16/2004] [Indexed: 12/20/2022]
Abstract
PURPOSE By reviewing our experience, we evaluated the presentation, management, and long-term outcome of patients with subclavian and axillary artery injuries resulting from trauma. METHODS We retrospectively reviewed the data of 38 patients who received treatment for subclavian or axillary artery injuries in the Emergency and Trauma Department of Medical Faculty of Istanbul, Istanbul University between January 1989 and July 2002. RESULTS Arterial injuries were repaired with an end-to-end anastomosis in 10 (26.3%) patients, primary repair in 6 (15.7%), autologous vein graft interposition in 16 (42%), ligation in 5 (13.1%), and a proximal subclavian-brachial artery bypass in 1 (2.6%). One (2.6%) of the arterial reconstructions failed in the perioperative period. Fourteen (36%) patients presented with a neurological deficit, which recovered after the intervention in 2 (5.2%) patients. A wound infection developed in 8 (21%) patients and 2 (5.2%) patients died of concomitant injuries. Thirteen (36.1%) of the remaining 36 patients were followed up for a mean period of 7 months. CONCLUSION Successful management of subclavian and axillary artery injuries requires prompt diagnosis because the occult nature of these injuries necessitates a high index of suspicion. Although revascularization procedures are often successful, it is the associated neurological, orthopedic, and soft tissue injuries that affect the functional outcome of the limb.
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Affiliation(s)
- Murat Aksoy
- Department of General Surgery, Istanbul Medical Faculty, Istanbul University, Turgut Ozal Cad., Capa 34310, Istanbul, Turkey
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Oktar GL, Balkan ME, Akpek S, Ilgit E. Endovascular stent-graft placement for the management of a traumatic axillary artery pseudoaneurysm-a case report. Vasc Endovascular Surg 2004; 36:323-6. [PMID: 15599485 DOI: 10.1177/153857440203600412] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 24-year-old woman with a right infraclavicular gunshot wound developed an axillary artery pseudoaneurysm. She was successfully treated by using a 5 cm Hemobahn stent-graft with a diameter of 6 mm. Postimplantation arteriography revealed normal flow through the axillary artery without evidence of leakage of contrast medium. Five months after the procedure, stenoses developed within the stent-graft owing to intimal hyperplasia and were treated by balloon angioplasty. The patient has been followed up symptom-free for 6 months after the second procedure.
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Affiliation(s)
- G Levent Oktar
- Division of Cardiovascular Surgery, Emergency and Traumatology Hospital, Ankara, Turkey.
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Jeroukhimov I, Altshuler A, Peer A, Bass A, Halevy A. Endovascular stent-graft is a good alternative to traditional management of subclavian vein injury. THE JOURNAL OF TRAUMA 2004; 57:1329-30. [PMID: 15625470 DOI: 10.1097/01.ta.0000151272.19438.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Affiliation(s)
- Igor Jeroukhimov
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler Faculty of Medicine, Tel Aviv University, Israel
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Aerts NR, Poli de Figueiredo LF, Burihan E. Emergency room retrograde transbrachial arteriography for the management of axillosubclavian vascular injuries. THE JOURNAL OF TRAUMA 2003; 55:69-73. [PMID: 12855883 DOI: 10.1097/01.ta.0000073135.07925.b7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Our purpose was to determine the accuracy of single-injection, retrograde transbrachial arteriography (RTBA), performed in the emergency room, for suspected axillosubclavian injuries. METHODS Thirty-three patients were prospectively assigned for RTBA. Clinical indications for RTBA included high-risk mechanism of injury, decreased (n = 19) or absent (n = 5) brachial pulse, neurologic deficits (n = 11), external or intrathoracic bleeding (n = 4), and bruit (n = 2). Brachial artery was cannulated with an 18-gauge catheter. A sphygmomanometer cuff was placed at the forearm and inflated to 250 mm Hg. Twenty milliliters of nonionic contrast media was injected countercurrent and a single anteroposterior chest radiograph was obtained. Small intimal flaps were followed by serial ultrasound. Surgical findings were used to establish RTBA accuracy. RESULTS RTBA was successfully performed in all cases. Arterial lesions were detected in 28 (84.8%) patients, including thrombosis (n = 8), arteriovenous fistula (n = 8), and false aneurysm (n = 7) as the most frequent lesions. A sensitivity of 96.5%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 80% were observed with RTBA. CONCLUSION We conclude that RTBA is a safe and accurate technique to be used in the emergency room for the rapid detection of axillosubclavian arterial injuries.
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Affiliation(s)
- Newton R Aerts
- Department of Surgery, Federal University of São Paulo, São Paulo, Brazil
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Lin PH, Koffron AJ, Guske PJ, Lujan HJ, Heilizer TJ, Yario RF, Tatooles CJ. Penetrating injuries of the subclavian artery. Am J Surg 2003; 185:580-4. [PMID: 12781890 DOI: 10.1016/s0002-9610(03)00070-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Penetrating injuries of the subclavian artery occurs infrequently but represent a surgical challenge. We reviewed our experience with penetrating injury of the subclavian artery and identify factors that influenced morbidity and mortality. METHODS A retrospective review was performed on 54 consecutive patients who sustained penetrating injury to the subclavian artery during a 10-year period. RESULTS The causes of injuries were gunshot wounds in 46 patients (85%), stab wounds in 5 patients (9%), and shotgun wounds in 3 patients (6%). The overall mortality was 39%. Operative management of the subclavian artery injury included primary repair in 38 patients, interposition grafting in 13 patients, and ligation in 3 patients. The most common associated injury was subclavian vein (44%) followed by brachial plexus (31%). Predictors of survivability include mechanism of penetrating injuries, hemodynamic status of patients on arrival, and three or more associated injuries involving other structures. Associated brachial plexus injury accounts for the majority of long-term morbidity in survivors. CONCLUSIONS Penetrating injuries of the subclavian artery are associated with high morbidity and mortality. Multiple concomitant injuries, unstable vital signs upon presentation, and gun shot injuries greatly increase mortality.
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Affiliation(s)
- Peter H Lin
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
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Wansbrough M. Answer. CAN J EMERG MED 2003; 5:63-4. [PMID: 17659157 DOI: 10.1017/s1481803500008162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Michael Wansbrough
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Abstract
Injuries to the subclavian or axillary vessels are associated with a high mortality rate and only patients with short prehospital periods or contained bleeding survive long enough to be treated. The surgical exposure of these vessels can be difficult and excellent knowledge of the local anatomy is critical. This article describes the anatomy, epidemiology, diagnosis, and surgical exposure of these injuries. Newer diagnostic and therapeutic modalities are discussed also.
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Affiliation(s)
- D Demetriades
- Trauma and Surgical Intensive Care Unit, University of Southern California and the Los Angeles County and University of Southern California Medical Center, Los Angeles, USA.
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Gasparri MG, Lorelli DR, Kralovich KA, Patton JH. Physical examination plus chest radiography in penetrating periclavicular trauma: the appropriate trigger for angiography. THE JOURNAL OF TRAUMA 2000; 49:1029-33. [PMID: 11130484 DOI: 10.1097/00005373-200012000-00009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To determine the role of physical examination, chest radiography, and angiography in the management of periclavicular penetrating trauma. METHODS A retrospective review of the last 100 patients who suffered periclavicular penetrating trauma was performed. Patients with hard signs of vascular injury went either directly to the operating room or first to the angiography suite depending on their hemodynamic stability. All others underwent angiography and subsequent intervention if needed. The results were examined to determine the role of arteriography in the absence of hard signs of vascular injury. RESULTS Of the 100 patients in the study, there were 81 without hard signs of vascular injury. All underwent angiography, with 11 "occult" injuries discovered. Each of these patients exhibited some physical examination or chest radiographic finding that may have predicted the presence of vascular injury. Using clinical criteria, physical examination was found to have a sensitivity of 82%, a specificity of 91%, a positive predictive value of 60%, and a negative predictive value of 96%. When coupled with the chest radiographic findings, these numbers were 100%, 80%, 44%, and 100%, respectively. Using these criteria would have eliminated the need for angiography in 56 (69%) patients and would not have missed any injuries. CONCLUSIONS In patients with periclavicular penetrating trauma, a normal physical examination and chest radiographic excludes vascular injury. Proximity alone does not warrant angiography, although the test may be useful for therapeutic interventions or to plan operative approaches. A prospective study is essential to validate these findings.
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Affiliation(s)
- M G Gasparri
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan, USA
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Vikram K, Patel V, Tagoe A, Weaver W. Six-Year Experience with Management of Subclavian Artery Injuries. Am Surg 2000. [DOI: 10.1177/000313480006601004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Penetrating injuries of the subclavian artery are rare; however, the associated morbidity and mortality may be high. Retrospective data on 25 patients who sustained penetrating subclavian artery injuries are reported. Diagnosis of subclavian artery injuries was made clinically and was followed by expedient surgical exploration in 65.4 per cent of patients. Patients who were hemo-dynamically unstable at presentation (26.9%) underwent immediate operation. The remaining hemodynamically stable group of patients with hard signs indicative of vascular injury were also expediently taken to the operating room after initial evaluation and resuscitation. Angiographic evaluation was performed in 34.6 per cent of patients who were stable hemodynamically. Preoperative angiography localized the injury and helped in planning the optimal incision and approach to obtain vascular control. Vascular flow was reestablished in all patients operated except for three who underwent ligation of subclavian artery. Limb salvage rate was 100 per cent, and operative mortality was less than 5 per cent. Morbidity was related to hemodynamic stability at presentation and associated injuries. A low morbidity and mortality rate was achieved by aggressive initial resuscitation and early surgical intervention coupled with selective use of preoperative angiography in hemodynamically stable patients.
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Affiliation(s)
- Kalakuntla Vikram
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
| | - Vijaykumar Patel
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
| | - Albert Tagoe
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
| | - William Weaver
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
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Surgical diseases of the great vessels. Curr Probl Surg 2000. [DOI: 10.1016/s0011-3840(00)80019-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
BACKGROUND The aim of this study was to review the management and outcome of proximal axillary and subclavian artery injuries, and to estimate the prehospital mortality rate for subclavian injury through forensic pathology autopsy data. METHODS Data were collected prospectively for 260 patients who presented between 1977 and 1996 with trauma to the proximal axillary and subclavian arteries. RESULTS The majority of victims (214, 82 per cent) were admitted following stab injury. Some 154 patients (59 per cent) presented within 24 h of sustaining an injury and, of these, 59 (38 per cent) required immediate surgery. An additional 67 patients (26 per cent) attended 2 days or more after injury. Comparison of these data with those from forensic autopsy reports suggests that the prehospital mortality rate for penetrating subclavian trauma was approximately 75 per cent. CONCLUSION Approximately 25 per cent of subclavian artery injuries caused minimal initial symptoms but delayed complications prompted attendance for medical attention. The majority of patients who survived subclavian artery injury and attended for medical attention were haemodynamically stable on admission; selective arteriography provided valuable information in these patients. Supraclavicular and infraclavicular incisions avoided clavicular division and reduced the postoperative morbidity associated with distal subclavian artery injuries.
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Affiliation(s)
- A G McKinley
- Vascular Surgical Unit, Royal Victoria Hospital, Belfast, UK
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35
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Gonzalez RP, Falimirski ME. The Role of Angiography in Periclavicular Penetrating Trauma. Am Surg 1999. [DOI: 10.1177/000313489906500803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Our objective was to evaluate whether physical examination in conjunction with chest X-ray can accurately diagnose the presence of significant vascular injury in penetrating periclavicular trauma. Results from a management protocol for penetrating periclavicular trauma were reviewed for the period January 1992 through December 1996 at an urban Level I trauma center. All patients requiring angiography for periclavicular penetrating trauma with trajectory of the injury falling between the lateral border of the manubrium and the anterior axillary line were entered into the management protocol. All patients underwent anterior-posterior chest radiography on arrival to the trauma center and 6 hours after admission. Tube thoracostomy was placed if clinically indicated on presentation or for X-ray findings. Clinical assessment was performed on all patients, with emphasis placed on the presence of “hard” signs for vascular injury. In addition to accepted hard signs for vascular injury, significant chest tube output (>1000 cc) and chest X-ray findings consistent with significant hemorrhage were also considered hard signs for vascular injury. Assuming hemodynamic stability, all patients with suspected subclavian/axillary arterial injury based on wound trajectory or clinical findings consistent with vascular injury underwent angiography. Forty-six patients were entered into the protocol with 30 left-sided injuries and 16 right sided injuries. The majority of injuries were secondary to gunshot wounds (31), with 14 stab wounds and 1 shotgun injury. Emergency room chest X-ray results revealed 32 negative chest X-rays, 7 pneumothoraces, 2 hemopneumothoraces, 2 hemothoraces, and 3 chest tubes placed before initial chest X-ray. A total of 7 injuries were diagnosed, with 1 missed injury, resulting in a sensitivity of 86 per cent for clinical assessment. The missed injury was a pseudoaneurysm of an axillary artery secondary to a self-inflicted shotgun wound. One mortality occurred in this series, which was a death in the operating room secondary to blood loss from an axillary artery injury. We conclude that clinical assessment can adequately diagnose the presence of surgically significant vascular injury in periclavicular penetrating injuries with trajectories lateral to the manubrium.
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Affiliation(s)
- Richard P. Gonzalez
- Departments of Surgery, Christ Hospital and Medical Center, Oak Lawn and University of Illinois Medical Center, Chicago, Illinois
| | - Mark E. Falimirski
- Departments of Surgery, Christ Hospital and Medical Center, Oak Lawn and University of Illinois Medical Center, Chicago, Illinois
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Demetriades D, Chahwan S, Gomez H, Peng R, Velmahos G, Murray J, Asensio J, Bongard F. Penetrating injuries to the subclavian and axillary vessels. J Am Coll Surg 1999; 188:290-5. [PMID: 10065818 DOI: 10.1016/s1072-7515(98)00289-0] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Subclavian and axillary vascular injuries are notorious for their mortality and their difficult surgical exposure. In the present study we analyze our experience with 79 patients and describe the techniques used for surgical access to these vessels. STUDY DESIGN Retrospective review of the medical records of all patients with penetrating injuries to the subclavian or axillary vessels who had been admitted to 2 Los Angeles trauma centers during a 4-year, 3-month period. RESULTS Seventy-nine patients were admitted during the study period January 1993 to March 1997 (58 gunshot injuries, 21 other penetrating injuries). The artery was injured in 59 patients and the vein in 40 (20 patients had both arterial and venous injuries). Eighteen patients (23%) were admitted with no signs of life or were in extremis and underwent an emergency room thoracotomy without any survivors. Fifty-eight patients underwent exploration in the operating room, 1 patient with an arteriovenous subclavian fistula was successfully managed with a radiologically placed endovascular stent, and 2 patients with minimal subclavian artery injuries were managed nonoperatively. Overall mortality was 34.2%. Excluding the ER thoracotomies the overall mortality was 14.8%. The mortality for isolated arterial injuries was 20.5%, for isolated venous injuries 50%, and for both vessels 45.0%. The mortality in venous injuries was significantly higher than in arterial injuries (p < 0.05). The standard clavicular incision provided adequate exposure in 32 (50.0%) of the operating room cases. In the other 50% of operating room cases a combination of a clavicular incision with a median sternotomy or thoracotomy was necessary. Proximal subclavian injuries may be accessed through a clavicular incision combined with a median sternotomy irrespective of left or right site location. CONCLUSIONS Subclavian and axillary vascular injuries remain lethal. A clavicular incision provides satisfactory surgical exposure in about half the patients. In patients with proximal injuries addition of a median sternotomy provides adequate surgical access in both right and left subclavian vessels.
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Affiliation(s)
- D Demetriades
- Department of Surgery, University of Southern California, Los Angeles 90033, USA
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Abstract
This article discusses the problems and controversies in the assessment of penetrating injuries of the neck. The role of physical examination and color-flow Doppler imaging in the initial assessment is highlighted. Complex injuries of major vessels, the aerodigestive tract, and the parotid are discussed and therapeutic options are presented.
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Affiliation(s)
- D Demetriades
- Division of Trauma and Critical Care, Los Angeles County/University of Southern California Medical Center 90033, USA
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Degiannis E, Velmahos G, Krawczykowski D, Levy RD, Souter I, Saadia R. Penetrating injuries of the subclavian vessels. Br J Surg 1994; 81:524-6. [PMID: 8205425 DOI: 10.1002/bjs.1800810412] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A study was made of 76 patients with subclavian vessel injury. The mechanism of trauma was stabbing in 40 patients (53 per cent) and gunshot in 36 (47 per cent). There were marked differences between the two groups in clinical presentation, operative management and outcome. The group with gunshot injury was characterized by a more immediate threat to life, and a greater need for a median sternotomy and use of interposition grafts. The mortality rate in patients with gunshot wounds was more than twice that in the group with stab injury.
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Affiliation(s)
- E Degiannis
- Department of Surgery, Baragwanath Hospital, Johannesburg, South Africa
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Abstract
In brief A 29-year-old expert male skier who had been drinking alcohol attempted a difficult slope and fell. His Injuries included a dislocated shoulder, a rib fracture, and subclavian vein transection caused by blunt trauma. He was transported to a medical clinic at the base of the mountain and was intubated, but died before the helicopter ambulance arrived. This skiing fatality is unusual: Head and spinal cord trauma are the leading causes of skiing deaths.
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Humphrey PW, Spadone DP, Silver D. Vascular disorders of the upper torso. Curr Probl Surg 1993; 30:817-912. [PMID: 8354079 DOI: 10.1016/0011-3840(93)90032-c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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