Uncertain Patency of Covered Stents Placed for Traumatic Axillosubclavian Artery Injury

Editor's Choice - In Hospital and Long Term Outcomes After Repair of Subclavian and Axillary Artery Injuries

OBJECTIVE

To evaluate the in hospital and long term outcomes after open or endovascular repair of subclavian and axillary artery injuries.

METHODS

This was a retrospective, single centre study. Data were reviewed from patients with subclavian and or axillary injuries who presented to the authors' centre between January 2009 and December 2022. Outcome data included complications, death, amputations, and re-interventions. A p value < .050 was considered to be statistically significant.

RESULTS

Over the study period, 62 patients with subclavian or axillary trauma were admitted to the study hospital. Patients were young (median age 32.5 years, range 12 - 53) and most were men (85%); 32 patients experienced blunt trauma, and 30 penetrating trauma. The median injury severity score was 18 (interquartile range [IQR] 9, 34), and 47% of patients had a brachial plexus injury. The arterial injury was occlusion in 62% of patients, and the median ischaemia time was 12.5 hours (IQR 7.13, 24). All patients with subclavian injuries (n = 37) and 13 of 25 patients with an axillary injury underwent endovascular repair (stent graft placement). Open repair was performed in 12 patients with axillary injury (axillobrachial bypass in seven patients). At hospital discharge, the amputation free survival rate was 82% vs. 92% (p = .67), the mortality rate was 10% vs. 8% (p = 1.0), and the amputation rate was 10% vs. 0 (p = .57) for endovascular and open repair, respectively. The mean follow up time was 4.1 ± 3.5 years. After the seven year follow up, the stent primary patency was 42%. No re-interventions or amputations were performed after hospital discharge. Disability was related to fractures and soft tissue and brachial plexus injuries.

CONCLUSION

Endovascular treatment was preferred for patients with subclavian artery injuries. Open repair was preferred for patients with penetrating axillary injuries. In hospital and long term complications were related to fractures and soft tissue and brachial plexus injuries, rather than the treatment of arterial injuries. Measures are needed to reduce ischaemia time and improve brachial plexus injury repair.

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.

Impact of Endovascular Stenting on Outcomes in Patients with Traumatic Subclavian Artery Injury

BACKGROUND

Traumatic subclavian artery injury (SAI) remains uncommon but can lead to significant morbidity and mortality. Although open and endovascular repair offer excellent limb salvage rates, their role in blunt and penetrating injuries is not well defined. The goal of this study was to examine the effect of mechanism of injury and type of repair on outcomes in patients with traumatic SAI.

STUDY DESIGN

Patients undergoing procedures for traumatic SAI were identified from the Trauma Quality Improvement Program database between 2015 and 2018. Demographics, severity of injury and shock, type of subclavian repair (open vs endovascular), morbidity, and mortality were recorded. Patients with SAI were stratified by mechanism and type of repair and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality.

RESULTS

Seven hundred thirty-seven patients undergoing procedures for SAI were identified. Of these, 39% were penetrating. The majority were male (80%) with a median age and Injury Severity Score (ISS) of 37 and 21, respectively. 58% of patients were managed endovascularly. For patients with blunt injury, the type of repair affected neither morbidity (25% vs 19%, p = 0.116) nor mortality (11% vs 10%, p = 0.70). For patients with penetrating injuries, endovascular repair had significantly lower morbidity (12% vs 22%, p = 0.028) and mortality (6% vs 21%, p = 0.001). MLR identified endovascular repair as the only modifiable risk factor associated with reduced mortality (odds ratio, 0.35; 95% confidence interval, 0.14 to 0.87, p = 0.02).

CONCLUSIONS

SAI results in significant morbidity and mortality regardless of mechanism. Although the type of repair did not affect mortality in patients with blunt injury, endovascular repair was identified as the only modifiable predictor of reduced mortality in patients with penetrating injuries.

Endovascular repair of traumatic axillosubclavian artery injuries

Gun violence reached a 20-year peak in 2020, with the first-line treatment of axillosubclavian vascular injuries (SAVIs) remaining unknown. Traditional open exposure is difficult and exposes patients to iatrogenic venous and brachial plexus injury. The practice of endovascular treatment has been increasing. We performed a retrospective analysis of SAVIs at a level I trauma center. Seven patients were identified. Endovascular repair was performed in five patients. Technical success was 100%. The early results suggest that endovascular treatment of trauma-related SAVIs can be performed safely and effectively. However, complications such as stent thrombosis or occlusion can occur, demonstrating the need for surveillance.

In-hospital outcomes of patients with non-iatrogenic civilian vascular trauma

Background: Morbidity, lesion pattern, management and short-term outcomes of civilian vascular trauma are rarely evaluated. Therefore, analysis of in hospital results in patients with non-iatrogenic vascular trauma in a tertiary referral hospital was performed. Patients and methods: Retrospective evaluation of patients with vascular trauma from 2007-2017 was done. 48 patients (34 male, 14 females, mean age 56 years) were included. Excluded were patients with iatrogenic vascular complications. Major cause of vascular trauma were traffic accidents in 43.8 %, fall from great heights in 27.1 %, sport and home related injuries in 16.8 %, suicidal injuries in 4.2 % and gunshot wounds in 2.1 % (other 6.3 %). 60.4 % of patients presented with blunt, 39.6 % of patients with penetrating vascular trauma. More than half of the cases included polytraumatized patients (54.4 %). Results: Most commonly affected were the popliteal (25.0 %) and the axillar artery (18.8 %). Aortic injuries were present in 14.6 % of cases, whereas the femoral and subclavian artery were involved in 12.6 % and 10.4 %. Vascular reconstruction was performed by interposition graft in 45.9 %, direct suture in 18.8 %, patchplasty in 10.4 %, ligation in 12.4 %, and implantation of stentgraft in 12.5 %. Postoperative complication rate was 54.2 %. Rate of in-hospital major amputation was 14.6 % and in-hospital mortality was 14.6 % as well. Comparison between blunt and penetrating trauma as to postoperative complication (p = 0.322), blood transfusion (p = 0.452) and amputation (p = 0.304) showed no significant differences, whereas lethality in blunt trauma was 20.6 % vs. 5.2 % in penetrating trauma. Injury severity score (ISS) was significantly elevated for blunt trauma patients (mean ISS Score blunt 32 vs 21 penetrating, p = 0.043). Conclusions: The majority of vascular lesions is caused by blunt trauma. Blunt lesions do also show a severe injury pattern, compared to penetrating trauma, and the complication rate remains high. However, by means of vascular reconstruction, limb salvage is feasible in a high percentage of cases.

Axillo-subclavian dissection and pseudoaneurysm following inferior glenohumeral dislocation: Case report and literature review

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This is a rare case of Axillo-subclavian dissection and pseudoaneurysm following blunt chest injury.

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Inferior shoulder dislocation is uncommon but may cause serious vascular injury and life-threatening hemorrhage.

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An endovascular approach was life-saving for our patient considering her advanced age and medical comorbidities.

Introduction

Axillo-subclavian arterial injuries are generally associated with penetrating trauma. On rare occasion, blunt mechanisms can cause these injuries in the setting of high-energy trauma, humeral head or neck fractures, and severe glenohumeral dislocations. Glenohumeral dislocations sustained from ground-level falls are generally reduced in the emergency department without associated morbidity.

Presentation of case

An 80-year-old woman presented with an inferior glenohumeral dislocation after a ground-level fall that was found to be complicated by axillary dissection, pseudoaneurysm, and acute hemorrhage. Endovascular intervention with a balloon-inflatable stent successfully controlled extravasation and restored perfusion to the affected upper extremity. After a short hospitalization, the patient was discharged with intact neurovascular status.

Discussion

Blunt axillary artery injury and inferior glenohumeral dislocations are both uncommon entities. A correlation exists between inferior dislocations and neurovascular complications. Accordingly, there may be a role for diagnostic vascular imaging for patients with inferior glenohumeral dislocations. Endovascular stenting was successful in our case and backed by case series and cohort studies in the literature. Some controversy exists regarding stent patency and follow-up planning in trauma patients.

Conclusion

This case represents a critical vascular injury from an unexpected mechanism. Inferior glenohumeral dislocations, regardless of injury mechanism, should raise the index of suspicion for vascular involvement. Endovascular repair in our patient was life-saving given her advanced age, acute blood loss anemia, rarity and severity of her injuries and multiple medical comorbidities.

Management and Outcomes of Isolated Axillary Artery Injury: A Five-Year National Trauma Data Bank Analysis

BACKGROUND

The aim of this study is to evaluate recent national trends in the clinical characteristics, management, and outcomes of patients with isolated axillary artery injuries.

METHODS

The National Trauma Data Bank was queried to identify records submitted from 2011 to 2015 that contained an ICD-9-CM diagnosis code for an injury to axillary artery (903.01) and an external cause of injury code indicating blunt or penetrating trauma. Records that contained a diagnosis code for an injury to an additional blood vessel (900.00-903.00, 903.2-904.9), an injury to a nonupper extremity or unclassifiable body region, or whose operative management could not be discerned were excluded. The final study sample included 221 patients with isolated axillary artery injury. The patient's clinical management was the primary outcome of interest. The study sample was stratified by trauma type, and descriptive statistics were performed on all variables.

RESULTS

Seventy-one percent of patients received operative management. Patients with penetrating injury were 24% more likely to be managed operatively than bluntly injured patients (76.9% vs. 62.1%, P = 0.0178). In operatively managed patients, the open repair rate was 82.8% and endovascular repair rate was 10.2%. Graft repair was performed most often (28.0%), followed by placement of a temporary intravenous shunt (17.8%) and surgical occlusion (10.2%). Surgical vessel occlusion was significantly more likely to be performed on patients with penetrating injury than with blunt injury (14.6% vs. 1.9%, P = 0.0124). Patients with penetrating injury had significantly shorter median emergency department length of stay (87.0 min vs. 152.0 min, P < 0.0001), intensive care unit length of stay (2.0 days vs. 3.0 days, P < 0.0388), hospital length of stay (4.0 days vs. 5.0 days, P = 0.0026), and time-to-operative management (1.6 hr vs. 3.9 hr, P < 0.001) compared to bluntly injured patients. Patients with blunt injury had a higher reportable in-hospital complication rate (13.8% vs. 6.0%, P = 0.0477). The overall mortality rate was 3.1% for isolated axillary artery injuries and did not significantly differ by trauma type.

CONCLUSIONS

Axillary artery injury is more often caused by penetrating trauma. Despite introduction of novel endovascular techniques, the majority of patients with isolated axillary artery injury are managed using open repair. Penetrating axillary artery injury is significantly more likely to be managed using open repair and by surgical occlusion. Patients with blunt injury have higher complication rates and longer hospital length of stays. The mortality rate is lower than previously published.

Late presentation of axillary arterial ischemia following a gunshot wound: Case report

Penetrating injuries of axillary artery are uncommon and associated with high mortality and morbidity rate. Clinical presentation of these injuries may vary; therefore, a high index of suspicion is essential. We are reporting a case of late presentation of axillary arterial ischemia, 10 days after a gunshot wound, which occurred to a 20-year-old male. The patient was treated successfully with open surgical intervention.

Endovascular Therapy of Vascular Trauma—Current Options and Review of the Literature

Objective:

To review the current use of endovascular techniques in trauma.

Summary Background Data:

Multiple studies have demonstrated that, despite current guidelines, endovascular therapies are used in instances of arterial trauma.

Methods:

The existing literature concerning arterial trauma was reviewed. Studies reviewed included case reports, single-center case series, large database studies, official industry publications and instructions for use, and society guidelines.

Results:

Endovascular therapies are used in arterial trauma in all systems. The use of thoracic endografts in blunt thoracic aortic trauma is accepted and endorsed by society guidelines. The use of endovascular therapies in other anatomic locations is largely limited to single-center studies. Advantages potentially include less morbidity due to smaller incisions as well as shorter operating room times. Many report using endovascular therapies even with hard signs of injury. Long-term results are limited by a lack of long-term follow-up but, in general, suggest that these techniques produce acceptable outcomes. The adoption of these techniques may be limited by resource and surgeon availability.

Conclusions:

The use of endovascular therapies in trauma has gained acceptance despite not yet having a place in official guidelines.

Endovascular Repair of a Penetrating Axillary Artery Injury

We report a 16-year-old boy who sustained a gunshot injury on his upper left side of the chest that resulted in an injury to the left axillary artery and was treated with endovascular repair. An endovascular repair has been increasingly accepted for the management of hemorrhage in critically ill trauma patients; using covered endovascular stents provides an alternative modality for both controlling hemorrhage and preserving flow.

Contemporary management of subclavian and axillary artery injuries-A Western Trauma Association multicenter review

BACKGROUND

Subclavian and axillary artery injuries are uncommon. In addition to many open vascular repairs, endovascular techniques are used for definitive repair or vascular control of these anatomically challenging injuries. The aim of this study was to determine the relative roles of endovascular and open techniques in the management of subclavian and axillary artery injuries comparing hospital outcomes, and long-term limb viability.

METHODS

A multicenter, retrospective review of patients with subclavian or axillary artery injuries from January 1, 2004, to December 31, 2014, was completed at 11 participating Western Trauma Association institutions. Statistical analysis included χ, t-tests, and Cochran-Armitage trend tests. A p value less than 0.05 was significant.

RESULTS

Two hundred twenty-three patients were included; mean age was 36 years, 84% were men. An increase in computed tomography angiography and decrease in conventional angiography was observed over time (p = 0.018). There were 120 subclavian and 119 axillary artery injuries. Procedure type was associated with injury grade (p < 0.001). Open operations were performed in 135 (61%) patients, including 93% of greater than 50% circumference lacerations and 83% of vessel transections. Endovascular repairs were performed in 38 (17%) patients; most frequently for pseudoaneurysms. Fourteen (6%) patients underwent a hybrid procedure. Use of endovascular versus open procedures did not increase over the duration of the study (p = 0.248). In-hospital mortality rate was 10%. Graft or stent thrombosis occurred in 7% and graft or stent infection occurred in 3% of patients. Mean follow-up was 1.6 ± 2.4 years (n = 150). Limb salvage was achieved in 216 (97%) patients.

CONCLUSION

The management of subclavian and axillary artery injuries still requires a wide variety of open exposures and procedures, especially for the control of active hemorrhage from more than 50% vessel lacerations and transections. Endovascular repairs were used most often for pseudoaneurysms. Low early complication rates and limb salvage rates of 97% were observed after open and endovascular repairs.

LEVEL OF EVIDENCE

Prognostic/epidemiologic, level IV.