Subclavian artery avulsion following blunt trauma: A case report and literature review

Outcomes Comparison of Endovascular and Open Surgical Approaches for Subclavian Arterial Injury: A Nationwide Analysis

BACKGROUND

The management of patients with subclavian artery injury is rapidly evolving from an open to an endovascular approach. We aim to present an analysis of management and a comparison of outcomes according to the type of approach used to treat these challenging injuries.

METHODS

Adult patients with subclavian arterial injuries were abstracted from the National Inpatient Sample database from 2012-2014 and 2016-2021. Patients were divided according to the type of management, which was endovascular management (EM; stent placement) or open surgery (OS), and clinical outcomes were compared. A multivariable logistic regression model was used to determine risk factors associated with in-hospital mortality.

RESULTS

A total of 1200 cases were analyzed. The EM and OS groups had similar baseline characteristics, including age, sex, All Patient Refined Diagnosis-Related Groups severity of illness and risk of mortality scores, and Charlson Comorbidity Scores. The presence of shock on admission was similar between groups (EM: 23.1% vs. OS: 34.2%; P = 0.115). Median injury severity score was higher in the EM group but with a lower mortality rate (5.5% vs. 14.8%, P = 0.045) than OS. Additionally, EM was associated with a lower fasciotomy rate (P = 0.018). Hemorrhagic shock on presentation (odds ratio: 3.72) was associated with a marked increase in the odds of in-hospital mortality, while EM was associated with a 67% decrease (odds ratio: 0.33).

CONCLUSIONS

EM is associated with significantly better outcomes, including lower odds of in-hospital mortality and a decreased need for fasciotomy. Currently, EM is a feasible option in the management of subclavian arterial injuries.

The application of interventional methods in control of blood loss during giant upper extremity tumor resection

BACKGROUND

The purposes of this retrospective study were to determine the efficacy of interventional methods in control of intraoperative blood losses and investigate the perioperative complications.

METHODS

The cases of 44 patients in whom a giant upper extremity tumor had been operated between 2008 and 2022 were analyzed retrospectively. Of these, 29 patients were treated with interventional methods (Group A) and 15 were treated without (Group B). Group A was further divided based on the intervention methodss: Group C (combination of balloon occlusion and transarterial embolization [TAE], n = 11) and Group D (single TAE, n = 18). Within Group D, patients were categorized based on the timing of TAE relative to surgery into Group E (TAE on the same day as surgery) and Group F (TAE performed days before surgery). We compared demographic features, blood loss, ICU admission rates, and use of vasopressors during surgery.

RESULTS

We collected clinical records from 44 patients diagnosed with a giant upper extremity tumor who underwent surgery. Group sizes were as follows: A (29), B (15), C (11), D (18), E (7), and F (11). Tumor volumes in the interventional and non-interventional groups were similar (704.19 ± 812.77 cm³ vs. 1224.53 ± 1414.01 cm³, P = 0.127). Blood plasma transfusion was significantly higher in Group B compared to Group A (425.33 ± 476.20 ml vs. 155.90 ± 269.67 ml, P = 0.021). Although overall blood loss did not significantly differ between Group A and Group B (467.93 ± 302.08 ml vs. 1150 ± 1424.15 ml, P = 0.087), the rate of massive bleeding (defined as blood loss over 1000 ml) was lower in Group A (6.9% vs. 46.47%, P = 0.004). The proportion of minors (patients aged less than 18) in Group C was significantly higher than in Group D (27.7% vs. 0.00%, P = 0.045). The amount of RBC transfusion was also significantly higher in Group C compared to Group D (458.18 ± 292.22 ml vs. 164.44 ± 224.03 ml, P = 0.021). No significant perioperative complications were observed.

CONCLUSIONS

Interventional techniques have been shown to reduce both blood loss and the necessity for blood transfusions in patients with large upper extremity tumors. Furthermore, no significant perioperative complications have been observed.

Three episodes of basilar tip occlusion necessitating thrombectomies and a vertebral artery sacrifice in a patient with subclavian artery dissection distal to the vertebral artery origin: a case report

Background

While acute occlusion of the subclavian artery (SCA) proximal to the vertebral artery (VA) origin is an uncommon but recognized cause of embolic stroke, an occlusion distal to the VA is rare and can be easily overlooked.

Case Description

We describe the clinical presentation and evaluation of a previously healthy 56-year-old woman who experienced four life-threatening posterior circulation strokes within 1 month, three of which led to basilar artery (BA) occlusions requiring thrombectomies. Workup revealed an occlusion of the right SCA located less than 1 cm distal to the VA origin. After the fourth posterior circulation ischemic event and three BA thrombectomies, a decision was made to sacrifice the right VA origin. Following the sacrifice of the origin of the right VA, she recovered with minimal neurological deficits and regained complete functionality with no further ischemic episodes in the following 2 years.

Conclusions

This case highlights an exceedingly rare etiology of posterior circulation stroke: an occlusion of the SCA distal to the VA origin. Though unconventional, the decision to sacrifice the VA origin proved crucial in this context and underscores the need for consideration in similar scenarios. Her recovery emphasizes the safety and effectiveness of recurrent thrombectomy procedures when appropriately indicated.

Endovascular treatment for 2 types of subclavian artery injury: A case report

RATIONALE

Subclavian artery (SCA) injuries, though rare, carry significant morbidity and mortality risks due to significant blood loss causing hypovolemic shock. Early diagnosis and adequate treatment are crucial to minimize bleeding and associated morbidity. Recent advances in endovascular techniques offer faster and more accurate treatment options compared to traditional open surgical repair. This study demonstrates the efficacy of endovascular treatment in 2 cases of SCA injury and reviews its indications, limitations, and precautions.

PATIENT CONCERNS

A 69-year-old man presented with a penetrating SCA injury from a steel bar, and a 38-year-old woman presented with a blunt SCA injury caused by a fall. Both patients were hemodynamically unstable upon presentation.

DIAGNOSES

Both patients were diagnosed with SCA injuries. The man had a penetrating injury, while the woman had a blunt injury, both resulting in hemodynamic instability and significant risk of hypovolemic shock.

INTERVENTIONS

Endovascular techniques, including the use of covered stent grafts, were employed to manage the injuries. These techniques allowed for rapid and efficient treatment, reducing the need for open surgical intervention.

OUTCOMES

Both patients were successfully treated using endovascular methods and were discharged without any complications. The endovascular approach minimized blood loss, transfusion needs, and hospital stay.

LESSONS

This study demonstrates the effectiveness of endovascular techniques in rapidly diagnosing, bridging, and definitively treating SCA injuries, suggesting their use as a first-line therapy.

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.

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.

Subclavian artery injury secondary to blunt trauma successfully managed by median sternotomy with supraclavicular extension: A case report and literature review

INTRODUCTION

Subclavian artery injury secondary to blunt trauma is rare and only a few cases have been documented in the literature. Subclavian arteries are protected by the clavicles, ribs, and chest wall. Clinical management and surgical approach vary depending on the specific injury. We present the case of a 50 year old male with blunt right subclavian transection.

CASE PRESENTATION

A 50-year-old male presented after being struck by a train. On exam, the patient had open injuries to the right upper chest/extremity. CTA showed a transection of the mid right subclavian artery along with a long traumatic occlusion distal to the defect. The patient was taken to the operating room where median sternotomy with supraclavicular extension was used to expose the transected ends of the subclavian artery and successfully perform a bypass graft. After a long hospital stay, he had a near-full functional recovery.

DISCUSSION

Blunt subclavian injury is rare and carries a high mortality. Adequate intervention requires prompt identification and proper surgical approach for repair. Median sternotomy offers the best approach to visualize the proximal right subclavian artery. Extension with a supraclavicular incision can be necessary for distal control. This approach offered timely intervention, which ultimately saved his life and allowed for return of pre-trauma functional status.

CONCLUSION

Prompt identification of subclavian artery injury is paramount as such injuries carry a high mortality. Median sternotomy with supraclavicular extension is an appropriate open surgical approach to successfully manage proximal right subclavian artery injuries.

Critical ischemia and myonecrotic sepsis following scapulothoracic dissociation in the setting of apparent hand perfusion: A case report

Scapulothoracic dissociation is a rare and devastating injury to the shoulder girdle. It is often caused by traction or severe blunt trauma injury to the upper extremity and is associated with both neurologic and vascular injuries. Scapulothoracic dissociation is a highly morbid and rare injury pattern that is often seen in conjunction with other traumatic injuries. The authors describe a case of scapulothoracic dissociation with associated complete brachial plexus injury and subclavian artery injury that was complicated by hypoperfusion, myonecrosis, and subsequent polymicrobial infection of the affected limb in the setting of a warm hand with brisk capillary refill. While capillary refill and hand warmth in the setting of a pulseless extremity have been used in previous cases of scapulothoracic dissociation as an indication for limb perfusion and nonoperative management, these markers cannot reliably be used to evaluate collateral circulation as exemplified in this case report. This case highlights multiple important aspects of the evaluation and management of scapulothoracic dissociation that orthopaedic surgeons and vascular surgeons should be familiar with and utilize when dealing with these challenging injuries.

Level of Evidence: V