Eighteen years' experience of traumatic subclavian vascular injury in a tertiary referral trauma center

Long-Term Outcomes of Open and Endovascular Axillosubclavian Interventions After Traumatic Injury Reveal High Rates of Limb Dysfunction

BACKGROUND

Arterial axillosubclavian injuries (ASIs) are currently managed with open repair (OR) and endovascular stenting (ES). The long-term prognosis of patients with these and associated brachial plexus injuries is poorly understood. We hypothesize that OR and ES for ASI have similar long-term patency rates and that brachial plexus injuries would confer high long-term morbidity.

METHODS

All patients at a level-1 trauma center who underwent procedures for ASI over a 12-year period (2010 to 2022) were identified. Long-term outcomes of patency rates, types of reintervention, rates of brachial plexus injury, and functional outcomes were then investigated.

RESULTS

Thirty-three patients underwent operations for ASI. OR was performed in 72.7% (n = 24) and ES in 27.3% (n = 9). ES patency was 85.7% (n = 6/7) and OR patency was 75% (n = 12/16), at a median follow-up of 20 and 5.5 months respectively. In subclavian artery injuries, ES patency was 100% (n = 4/4) and OR patency was 50% (n = 4/8) at a median follow-up of 24 and 12 months respectively. Long-term patency rates were similar between OR and ES (P = 1.0). Brachial plexus injuries occurred in 42.9% (n = 12/28) of patients. Ninety percent (n = 9/10) of patients with brachial plexus injuries who were followed postdischarge had persistent motor deficits at median follow-up of 12 months, occurring at significantly higher rates in patients with brachial plexus injuries (90%) compared to those without brachial plexus injuries (14.3%) (P = 0.0005).

CONCLUSIONS

Multiyear follow-up demonstrates similar OR and ES patency rates for ASI. Subclavian ES patency was excellent (100%) and prosthetic subclavian bypass patency was poor (25%). brachial plexus injuries were common (42.9%) and devastating, with a significant portion of patients having persistent limb motor deficits (45.8%) on long-term follow-up. Algorithms to optimize brachial plexus injuries management for patients with ASI are high-yield, and likely to influence long-term outcomes more than the technique of initial revascularization.

Brazilian guidelines on diagnosis and management of traumatic vascular injuries

Trauma is a leading cause of death, permanent disability, and health care cost worldwide. The young and economically active are the most affected population. Exsanguination due to noncompressible torso hemorrhage is one of the most frequent causes of early death, posing a significant challenge to trauma and vascular surgeons. The possibility of limb loss due to vascular injuries must also be considered. In recent decades, the approach to vascular injuries has been significantly modified. Angiotomography has become the standard method for diagnosis, endovascular techniques are currently incorporated in treatment, and damage control, such as temporary shunts, is now the preferred approach for the patients sustaining physiological derangement. Despite the importance of this topic, few papers in the Brazilian literature have offered guidelines on vascular trauma. The Brazilian Society of Angiology and Vascular Surgery has developed Projetos Diretrizes (Guideline Projects), which includes this publication on vascular trauma. Since treating trauma patients is a multidisciplinary effort, the Brazilian Trauma Society (SBAIT) was invited to participate in this project. Members of both societies reviewed the literature on vascular trauma management and together wrote these guidelines on vascular injuries of neck, thorax, abdomen, and extremities.

Concurrent Spinal Trauma in Patients with Traumatic Head Injury: A Seven-Year Retrospective Analysis

BACKGROUND Assessing spinal injuries in patients with traumatic head injuries is crucial due to their potential to alter functionality and increase mortality rates. This single-center retrospective study was conducted to understand the prevalence and characteristics of concurrent spinal injuries in adults with traumatic head injury from April 2015 to April 2022. MATERIAL AND METHODS The study incorporated demographic, clinical, traumatological, and hemodynamic data from 1,501 adult patients presenting with traumatic head injuries. Spinal injuries were identified through symptoms, physical signs, and radiological findings. RESULTS During the study period, 179 patients (12%) were reported with associated spinal injuries. These patients were predominantly male (p=0.0012), aged 65 years or above (p=0.0452), had thoracic injuries (p=0.0004), and arrived at the emergency department more than three hours post-trauma (p=0.0004). Most injuries were caused by motor vehicle accidents (p=0.0412) or falls from heights greater than 3 meters (p=0.0481). In addition, these patients had higher Abbreviated Injury Scale scores (≥2, p=0.0391), Eppendorf-Cologne Scale scores (≥2, p=0.0412), and lower systolic and diastolic blood pressure readings (p=0.0481, p=0.0412) along with lower heart rates (p=0.0482). However, no correlation was found between systolic and diastolic pressures and age among patients with spinal injuries. CONCLUSIONS This study reveals that the prevalence and severity of spinal injuries in patients with traumatic head injuries are influenced not only by demographic and clinical parameters, but also by the degree and extent of head trauma.

The spectrum of computed tomography findings in blunt trauma of the subclavian/axillary artery: a pictorial essay

Traumatic injuries of the subclavian and axillary arteries are uncommon but have high morbidity and mortality. In contrast to penetrating injuries, which are often lethal, blunt injuries present a wide and heterogeneous spectrum of imaging findings. If a vessel tear or transsection is a life-threatening circumstance, minor injuries might be overlooked in an emergency setting but could cause or aggravate the functional loss of a limb. The aim of this pictorial essay is to acquaint radiologists with the spectrum of imaging findings that could be encountered during the radiological evaluation of the subclavian/axillary artery (SAA) in trauma patients and offer tips and tricks to improve the diagnostic workup of patients with suspected blunt SAA injuries.

Does endovascular repair of post-traumatic thoracic vascular injury of the subclavian/axillary arteries followed by brachial plexus injury improve outcome?

Traumatic injuries to the axillary artery or subclavian artery along with a brachial plexus injury are infrequent. Although the traditional management has been conservative because of robust collaterals, the functional improvement of the limb depends on the degree of brachial plexus injury and on the revascularization status. We report three cases of endovascular repair post-traumatic axillo-subclavian artery injuries followed by brachial plexus injury with good functional outcomes. Endovascular repair of post-traumatic subclavian and axillary artery injuries followed by brachial plexus injury is safe and feasible, and improves limb outcomes.

Damage control for subclavian artery injury

Mortality from penetrating traumas involving the subclavian vessels can be as high as 60% in pre-hospital settings. Operating room mortality is in the range of 5-30%. This paper presents a case in which a strategy for damage control was employed for a patient with an injury to the origin of the left subclavian artery, using subclavian ligation, with no need for any other intervention, and maintaining viability of the left upper limb via collateral circulation. The authors also review surgical approaches and treatment strategies with a focus on damage control in subclavian vessel injuries.