Feasibility of endovascular repair in penetrating axillosubclavian injuries: A retrospective review

Damage control surgery: old concepts and new indications

PURPOSE OF REVIEW

While the principles of damage control surgery - rapid hemorrhage and contamination control with correction of physiologic derangements followed by delayed definitive reconstruction - have remained consistent, forms of damage control intervention have evolved and proliferated dramatically. This review aims to provide a historic perspective of the early trends of damage control surgery as well as an updated understanding of its current state and future trends.

RECENT FINDINGS

Physiologically depleted patients in shock due to both traumatic and nontraumatic causes are often treated with damage control laparotomy and surgical principles. Damage control surgery has also been shown to be safe and effective in thoracic and orthopedic injuries. Damage control resuscitation is used in conjunction with surgical source control to restore patient physiology and prevent further collapse. The overuse of damage control laparotomy, however, is associated with increased morbidity and complications. With advancing technology, catheter- and stent-based endovascular modalities are playing a larger role in the resuscitation and definitive care of patients.

SUMMARY

Optimal outcome in the care of the most severely injured patients requires judicious use of damage control surgery supplemented by advancements in resuscitation and surgical adjuncts.

Management of Vascular Injuries in Penetrating Trauma

Management of vascular trauma remains a challenge and traumatic injuries result in significant morbidity and mortality. Vascular trauma can be broadly classified according to mechanism of injury (iatrogenic, blunt, penetrating, and combination injuries). In addition, this can be further classified by anatomical area (neck, thoracic, abdominal, pelvic, and extremities) or contextual circumstances (civilian and military).

Major vascular traumas to the neck, upper limbs, and chest: Clinical presentation, diagnostic approach, and management strategies

Major vascular traumas to the neck, upper limbs, and chest may arise from penetrating and/or blunt mechanisms, resulting in a range of clinical scenarios. Lesions to the carotid arteries may also lead to neurologic complications, such as stroke. The increasing use of invasive arterial access for diagnostic and/or interventional purposes has increased the rate of iatrogenic injuries, which usually occur in older and hospitalized patients. Bleeding control and restoration of perfusion represent the two main goals of treatment for vascular traumatic lesions. Open surgery still represents the gold standard for most lesions, although endovascular approaches have increasingly emerged as feasible and effective options, particularly for management of subclavian and aortic injuries. In addition to advanced imaging (including ultrasound, contrast-enhanced cross-sectional imaging, and arteriography) and life support measures, multidisciplinary care is required, particularly in the setting of concomitant injuries to the bones, soft tissues, or other vital organs. Modern vascular surgeons should be familiar with the whole armamentarium of open and endovascular techniques needed to manage major vascular traumas safely and promptly.

Axillary Artery Transection and Brachial Plexus Injury After Open Inferior Glenohumeral Dislocation: A Case Report

CASE

A judo athlete presented with an open inferior shoulder dislocation that occurred during competition. Examination revealed a transection of the axillary artery and neuropraxia of the posterior cord. Neuropraxia was resolved within 2 weeks. The axillary artery was repaired with a femoral vein graft. He regained full strength, range of motion, and function at 8 months.

CONCLUSION

Inferior glenohumeral dislocations are rare, and their management can be complicated by vascular and neurological injuries. We emphasize the importance of examination, diagnosis, and treatment of neurovascular pathologies to avoid catastrophic outcomes.

Vascular Surgery Role in Vascular Trauma: 11-Year Analysis of Peripheral Vascular Trauma Management at a Level-1 Trauma Center

BACKGROUND

Vascular surgeons are increasingly relied upon in the management of complex peripheral vascular trauma. The degree however that vascular surgery (VS) is involved in vascular trauma care is not well established. We hypothesize that VS consultation is required in a high portion of complex lower extremity vascular trauma.

METHODS

A single-center retrospective review of all consecutive patients who sustained traumatic arterial injury of the lower extremity requiring open operative repair at a level-1 trauma center (from February 2009 to May 2020) was performed. Patients who underwent surgical repair were stratified by the service that performed the operation (VS versus trauma surgery [TS]). Secondary outcomes assessed included location of arterial injury, type of repair, and clinical outcomes.

RESULTS

A total of 111 patients underwent operative repair of lower extremity arterial injury (mean age 34.5 ± 15.5 years, 89% male). The most common vessels requiring intervention were the superficial femoral artery (n = 42, 38%), popliteal artery (n = 35, 31.5%), and tibial vessels (n = 19, 17.1%). The most common intervention required in patients was an autologous bypass (n = 85, 76.5%), followed by ligation (n = 9, 8.1%) and primary repair (n = 6, 5.4%). Most interventions overall required VS involvement (n = 95, 86%). VS performed a higher proportion of autologous graft procedures compared to TS (n = 79, 92.9% vs. n = 6, 7.1%). VS case load overall was likewise predominantly autologous grafts (n = 79/95, 83.2%). TS operated on a higher proportion of injuries to the tibial vessels (44% vs. 13%, P = 0.01), whereas VS intervened more frequently on popliteal injuries (36% vs. 6%, P = 0.02). With regard to the method of arterial repair, TS was more likely to perform ligation (38% vs. 3 %, P < 0.001) or primary repair (13% vs. 3%, P = 0.04) compared to VS. However, VS was more likely to perform repair with autologous graft (83% vs. 38%, P < 0.001). There were no significant differences in rates of mortality, limb loss, transfusions requirement, fasciotomy, deep venous thrombosis, hematoma formation, or length of stay between groups. Although, surgical site infections were more common in the TS group (38% vs. 15%, P = 0.04).

CONCLUSIONS

Vascular surgeons play a large role in managing complex lower extremity vascular trauma. In particular, VS remains integral for the management of more difficult injuries (e.g., popliteal injuries) and is more likely to provide more complex repairs (e.g., autologous grafts).

Role of Interventional Radiology in the Management of Non-aortic Thoracic Trauma

Trauma remains a leading cause of death for all age groups, and nearly two-thirds of these individuals suffer thoracic trauma. Due to the various types of injuries, including vascular and nonvascular, interventional radiology plays a major role in the acute and chronic management of the thoracic trauma patient. Interventional radiologists are critical members in the multidisciplinary team focusing on treatment of the patient with thoracic injury. Through case presentations, this article will review the role of interventional radiology in the management of trauma patients suffering thoracic injuries.

Subclavian artery laceration following clavicle fracture, successfully treated with a combined endovascular and open surgical approach

Subclavian artery injury is a rare complication of clavicle fracture. The fractured clavicle can lacerate the underlying subclavian artery. Life-threatening haemorrhage can occur secondary to arterial laceration, and if distal blood flow is impaired, upper limb ischaemia can develop. There is little discussion in the literature regarding combined (or ‘hybrid’) endovascular and open surgical management of acute subclavian injuries secondary to clavicle fracture. We report a case of subclavian artery laceration secondary to clavicle fracture, managed with a combined endovascular and open surgical approach. An endovascular balloon was used for proximal arterial control, while surgical exposure and primary repair of the subclavian artery was completed, followed by fixation of the clavicle. There was no sustained vascular or neurological impairment at follow-up. We suggest that select traumatic injuries of the subclavian artery can be safely and successfully managed with a combined endovascular and open surgical approach.

Open vs Endovascular Treatment of Traumatic Peripheral Arterial Injury: Propensity Matched Analysis

BACKGROUND

Arterial injuries occur in the setting of blunt and penetrating trauma. Despite increasing use, there remains a paucity of data comparing long-term outcomes of endovascular vs open repair management of these injuries. The aim of our study was to compare outcomes and readmission rates of open vs endovascular repair of traumatic arterial injuries.

STUDY DESIGN

The National Readmission Database (2011-2014) was queried for all adult (age ≥ 18 y) patients presenting with peripheral arterial (axillary, brachial, femoral, and popliteal) injuries. Patients were stratified into 2 groups based on intervention: open vs endovascular approach. Propensity score matching (1:2 ratio) was performed. Outcomes measures were complications, length of stay (LOS), 30-day readmission, and cost of readmission.

RESULTS

A matched cohort of 786 patients was obtained (endovascular: 262, open: 524). Mean age was 45 ± 17 years, and 79% were males. Median LOS was 4 (range 2-6) days for the endovascular group vs 3 (range 2-5) days for the open group (p < 0.01). The endovascular group had higher rates of seroma (4% vs 2%; p = 0.04) and arterial thrombosis (13% vs 7%; p < 0.01) during index hospitalization. Patients who underwent endovascular repair had higher 30-day readmission (11% vs 7%; p = 0.03) and a higher 30-day open-reoperation rate (6% vs 2%; p < 0.01). On subanalysis of the patients who were readmitted, the median cost of each readmission was higher in the endovascular group $47,000 ($27,202-$56,763) compared with $21,000 ($11,889-$43,503) in the open group.

CONCLUSIONS

Endovascular repair for peripheral arterial injuries was associated with higher rates of in-hospital complications, readmissions, and costs. As this new technology continues to undergo refinement, a thorough re-evaluation of its indications, risks, and benefits is warranted.

Management of traumatic subclavian artery injuries in a high-volume vascular surgery center in Iran

Introduction: Subclavian artery injury is an uncommon vascular trauma with potential morbidity and mortality. Management of subclavian artery trauma requires open and endovascular techniques and timely and efficacious decision is mandatory. We retrospectively reviewed traumatic subclavian artery injuries in a high-volume vascular surgery center in Iran.

Methods: In a retrospective study, we assessed subclavian artery injuries during 6 years in ShohadaTajrish Medical Center. Background characteristics, type of incision, type of operation and outcome of patients were evaluated.

Results: A total of 14 patients had subclavian artery injury (mean age 29.9 ± 13.4 years, 92.9% male). Trauma was in left and right sides in eight (57.1%) and six patients (42.9%) respectively. Arteriorrhaphy, interposition and ligation of injured artery was done in 7 (50.0%), 3 (21.4%) and 4 (28.6%) patients respectively. Associated nerve injury was present in six patients (42.9%). Endovascular proximal control was obtained in six patients (42.9%) prior to vascular exposure. Time of patient referral did not have significant association with shock or type of operation (P > 0.05).

Conclusion: Although traumatic subclavian artery injuries are rare, its vascular exposures and reconstructions are of potential clinical concern. Endovascular interventions can facilitate proximal control. In addition, endovascular repair by covered stent is an alternative to open surgery.

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.

Comminuted Bilateral Simultaneous Fracture and Luxation of the Proximal Humerus with an Injury to the Right Axillary Artery

Introduction

Among all of the shoulder dislocation cases, only 1% is related to fractures. The simultaneous bilateral fracture and dislocation happen very rarely and it is seldom related to a trauma. An injury to the axillary artery related to a humerus fracture is an exceptional event.

Case Report

A 58-year-old male with no particular background who, after falling from a 5 m height, presented a fracture and dislocation of both of his shoulders and showed no pulse in his right arm due to an injury to his axillary artery. The peculiarity of this injury increases when the axillary artery injury is added to the bilateral fracture and luxation of the humerus. We present the case and revise literature.

Conclusion

The treatment for these complex injuries requires a multidisciplinary surgical approach. To treat these injuries, an early diagnose is essential regarding the fact that the prognosis is directly related to the time elapsed without blood circulation. That is why it is necessary to look for these arterial injuries in case of a proximal humerus fracture.

O papel da ecografia vascular no manejo das complicações associadas ao acesso venoso central para hemodiálise em pacientes oncológicos: relato de dois casos e revisão da literatura

Central venous catheter implantation for hemodialysis is commonly performed in large centers and its complications are sometimes associated with insufficient training of those who perform it, but may also be related to the patient’s clinical condition. The present study reports two cases of complications related to use of a short-stay catheter for hemodialysis. In the first case, the cannula was inadvertently inserted into the left subclavian artery, causing arterial thrombosis, which was conservatively managed and good collateral perfusion was documented with vascular echography. The second case illustrates an incidental finding of Central Venous Septic Thrombosis in a patient who had used a catheter for a week, which was treated with antibiotic therapy, anticoagulation, and ultrasound control. In both cases, surgical intervention would have been high risk because of the patients' poor prognosis. Vascular ultrasonography enabled monitoring of these clinical situations and use of less aggressive treatments.

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.

A Comparative Analysis of Open versus Endovascular Techniques for Management of Non-Aortic Cervicothoracic Arterial Injuries

The objective of this study is to describe the contemporary management of proximal upper extremity and neck arterial injuries by comparing open and endovascular repair at a single institution. This is a retrospective study of 22 patients that sustained subclavian, axillary, and carotid artery injuries from 2011 to 2016 that were managed with open or endovascular repair. There were nine subclavian, eight axillary, and five carotid artery injuries of which 10 (45.5%) underwent endovascular repair and 12 (54.5%) underwent open repair. There was no statistically significant difference between the groups including injury severity score or preoperative hypotension. There were no deaths in the endovascular group, and three (25.0%) deaths in the open group. All patients in the endovascular group were discharged home. In the open group, seven (58.3%) patients had at least one inpatient complication with a mean of 1.1 (standard deviation 1.4) complications per patient. In the endovascular group, there were three (30.0%) patients with inpatient complications and a mean of 0.4 (standard deviation 0.7) complications per patient (P = 0.18). Endovascular management of nonaortic cervicothoracic arterial injuries was successfully performed in hypotensive patients and patients with other life threatening traumatic injuries. Further studies are warranted to look at long-term patency of these repairs and to help develop a protocol to guide decision-making in the management of cervicothoracic injuries.

Endovascular management for peripheral arterial trauma: The new norm?

BACKGROUND

Endovascular therapy is well studied in atraumatic conditions; and there appears to be a growing interest in its application to traumatic injuries. The objective of this study is to compare open and endovascular techniques in the management of peripheral arterial trauma.

METHODS

This is a retrospective review of patients admitted to a Level I Trauma Center sustaining injuries to the subclavian, axillary, superficial femoral, and popliteal arteries. Demographics, surgical interventions, complications, and clinical outcomes were evaluated in patients requiring open or endovascular repair between 2009 and 2015.

RESULTS

Sixty-eight patients with 70 total arterial injuries were identified. There were 10 subclavian, 14 axillary, 15 superficial femoral, and 31 popliteal artery injuries. Endovascular (n=20) compared to open repairs (n=50) were more commonly performed: by vascular surgeons (90% vs. 54%, p=0.01); in older patients (median age: 38 years vs. 25, p=0.01); primarily involving upper extremity injuries (60% vs. 24%, p=0.01). Furthermore, endovascular repairs less commonly required fasciotomy (15% vs. 46%, p=0.03) and trended towards lower transfusion requirements (50% vs. 77%, p=0.06). Patients undergoing open repair had lower pre-hospital systolic blood pressures (110 vs. 120, p=0.03) and lower initial hematocrit (31.5 vs. 36.2, p=0.02). However, outcomes between groups were trending higher in the endovascular group with respect to limb salvage rates at discharge (94% vs. 89%), median length of stay (14days vs. 9), and median follow-up (288days vs. 92) compared to the open group, but the data were not statistically significant. There was increasing utilization of endovascular repair over time (7% of total procedures in 2009; 50% in 2014).

CONCLUSIONS

Overall, endovascular and open techniques were not statistically different in early outcomes. Endovascular therapy appears to provide some advantage when it comes to: challenging anatomy, decreasing blood product utilization, and minimizing physiologic derangement. However, patients with injuries resulting in free hemorrhage or significant external blood loss may still be best served with open repair. Despite this, given the increasing use of endovascular techniques, close collaboration is needed between trauma and endovascular specialists to properly select the optimal management for patients with peripheral arterial trauma.

Trends and Outcomes in the Operative Management of Traumatic Vascular Injuries: A Comparison of Open versus Endovascular Approaches

Controversy exists in vascular trauma regarding the best method of treatment—open versus endovascular techniques. Little has been published on this complex topic. Patients from 2005 to 2013 at a Level I trauma center with vascular injuries were identified via a prospectively trauma registry. Patient data, injury type/severity, treatment, and 30-day outcomes were obtained from the trauma registry and the chart review. Adverse events (limb loss, major disability, and death) were outcomes of interest. Univariate analysis and multivariate logistic regression were used to identify predictors of adverse events. In all, 346 patients were included (median age 34, range 1–93 years). Median Injury Severity Score (ISS) was 10(1–59). Endovascular repairs (n = 52) increased from 0 per cent (2005) to 32 per cent (2013), and demonstrated equivalent outcomes to open approaches (P = 0.24). On multi-variate analysis, higher ISS (P = 0.001), increasing age (P = 0.01), and lower extremity injuries (P = 0.001) were associated with adverse outcomes across the entire series. Endovascular approaches were most commonly used in vascular injuries of the chest/abdomen (39 of 52, 75% of all endovascular procedures in the series, P < 0.001), older patients(P = 0.003), blunt injury mechanism (P < 0.001), and patients with a higher ISS at presentation (P < 0.001). In conclusion, this large series, the use of endovascular procedures increased over time, and was associated with equivalent outcomes to open approaches, despite their higher usage in older patients, those with chest/abdominal injuries, and those with a higher ISS at presentation. Although these retrospective results are encouraging, further prospective study into the role of endovascular therapies in the treatment of vascular injuries.

Hybrid Repair of Complex Left Subclavian Artery Injury with Partial Transection and Complete Thrombosis in an Unstable Patient following Blunt Trauma

Blunt subclavian artery injuries are rare and are associated with high morbidity and mortality. Several case reports have suggested that endovascular repair is safe with short operative times and minimal blood loss. We report a case of a 20-year-old male patient involved in a high-speed motor vehicle collision that resulted in partial transection of left subclavian artery with complete luminal thrombosis. Patient also had a left main-stem bronchus avulsion along with major intra-abdominal injuries and multiple spine and long bone fractures. He underwent emergent abdominal exploration due to multisystem trauma and hemodynamic instability. Following laparotomy and resuscitation, the subclavian artery injury was repaired using a hybrid technique geared at protecting the patent vertebral and axillary arteries from embolization. We used supraclavicular dissection and arterial control with endovascular stent-graft placement in retrograde fashion to repair the left subclavian artery injury. At 6-month follow-up, computed tomography scan confirmed patency of the left subclavian artery stent and there was no evidence of vertebrobasilar insufficiency or left upper extremity ischemia. In conclusion, stent-graft repair of blunt subclavian artery injuries is expedient and safe. Supraclavicular vascular dissection and control are effective in preventing distal embolization in rare cases complicated with luminal thrombosis.

Endovascular solutions for the management of penetrating trauma: an update on REBOA and axillo-subclavian injuries

PURPOSE

Endovascular procedures continue to gain acceptance as management options for penetrating traumatic injuries. Currently, several areas of potential endovascular application are being investigated. However, the bulk of the literature on this topic is still limited to case series or small retrospective studies. Therefore, we performed a review of the published experience involving the application of endovascular therapy to trauma patients who have sustained penetrating injuries with focus on outcomes of resuscitative endovascular balloon occlusion of the aorta (REBOA) and endovascular repair of axillo-subclavian injuries.

METHODS

Published case reports, retrospective and prospective studies of REBOA and axillo-subclavian injuries were systematically reviewed.

RESULTS

A total of 7 studies on REBOA and 10 studies on endovascular repair of axillo-subclavian injuries were included. Overall, REBOA was used as an adjunct for hemorrhage control and resuscitation in patients at risk of cardiopulmonary arrest, preventing further cardiovascular collapse successfully. For axillo-subclavian injuries, endovascular stent placement had efficacy comparable to the traditional open repair.

CONCLUSION

REBOA is a safe and effective alternative to open thoracotomy in critically ill trauma patients at risk of death due to torso hemorrhage. Endovascular repair outcomes are comparable to open repair after axillo-subclavian injuries. Long-term results of endovascular repair remain to be defined in this patient population.

Determination of Functional Outcome Following Upper Extremity Arterial Trauma

Upper extremity arterial trauma may lead to significant disability with a poor functional outcome. This study represents a retrospective review of all trauma patients presenting to a university-affiliated medical center. Patients suffering from upper extremity arterial injuries requiring treatment were identified. The injured vessels were identified along with the mechanism of injury and method of repair. The degree of functional disability was evaluated by using a previously validated questionnaire, the Disabilities of the Arm, Shoulder, and Hand (DASH) Outcome Measure. Between September 1999 and December 2004, 17 patients presented with traumatic arterial injury to the upper extremity, with 9 and 8 patients suffering from blunt and penetrating traumas, respectively. One patient required amputation representing a limb salvage rate of 94%. The mean length of hospitalization was significantly shorter for penetrating trauma (5.1 vs 12 days, P = .03), with blunt trauma victims being more prone to coexisting orthopedic injuries ( P = .009). Length of follow-up did not differ between the 2 groups and ranged from 1-60 months. Patients with blunt trauma tended, although not statistically significant, to have higher DASH scores (61.8 vs 22.8, P = .08), indicating a greater degree of disability. By utilizing a validated disability questionnaire, this study confirms that patients suffering from blunt injuries to upper extremity arteries are more likely to have greater degrees of disability affecting everyday activities.

[Endovascular interventions for multiple trauma]

CLINICAL ISSUE

In recent years interventional radiology has significantly changed the management of injured patients with multiple trauma. Currently nearly all vessels can be reached within a reasonably short time with the help of specially preshaped catheters and guide wires to achieve bleeding control of arterial und venous bleeding.

STANDARD TREATMENT/TREATMENT INNOVATIONS

Whereas bleeding control formerly required extensive open surgery, current interventional methods allow temporary vessel occlusion (occlusion balloons), permanent embolization and stenting.

DIAGNOSTIC WORK-UP

In injured patients with multiple trauma preinterventional procedural planning is performed with the help of multidetector computed tomography whenever possible.

PERFORMANCE

Interventional radiology not only allows minimization of therapeutic trauma but also a considerably shorter treatment time.

ACHIEVEMENTS

Interventional bleeding control has developed into a standard method in the management of vascular trauma of the chest and abdomen as well as in vascular injuries of the upper and lower extremities when open surgical access is associated with increased risk. Additionally, pelvic trauma, vascular trauma of the superior thoracic aperture and parenchymal arterial lacerations of organs that can be at least partially preserved are primarily managed by interventional methods.

PRACTICAL RECOMMENDATIONS

In an interdisciplinary setting interventional radiology provides a safe and efficient means of rapid bleeding control in nearly all vascular territories in addition to open surgical access.

Outcome comparison between open and endovascular management of axillosubclavian arterial injuries

BACKGROUND

Endovascular repair (ER) of axillosubclavian arterial injuries is a minimally invasive alternative to open repair (OR). The purpose of this study was to compare the outcomes of ER vs OR.

METHODS

A retrospective study was performed of patients who sustained axillosubclavian arterial injuries admitted to two high-volume academic trauma centers between 2003 and 2013. Patients undergoing ER and OR were matched according to 25 different demographic and clinical variables in a 1:3 ratio using propensity scores. The primary outcome was in-hospital mortality. Secondary outcomes were complications and length of stay.

RESULTS

Among 153 patients (79.7% male; mean age, 32.7 ± 15.9 years) who sustained axillosubclavian arterial injuries, 18 (11.8%) underwent ER and 135 (88.2%) had OR. Matched cases (ER, n = 18) and controls (OR, n = 54) had similar demographic and clinical data, such as age, gender, admission systolic blood pressure and Glasgow Coma Scale score, body Abbreviated Injury Scale scores, Injury Severity Score, and transfusion requirements. Patients undergoing ER had significantly lower in-hospital mortality compared with patients undergoing OR (5.6% vs 27.8%; P = .040; odds ratio, 0.7; 95% confidence interval, 0.6-0.9). Similarly, patients undergoing ER had substantially lower rates of surgical site infections and a trend toward lower rates of sepsis. Outpatient follow-up was available in 88.2% (n = 15) of the patients at a median time of 8 months (1-30 months). Two ER patients required open reintervention for stent-related complications (one for a type Ia endoleak and another for stent thrombosis).

CONCLUSIONS

In our experience with axillosubclavian arterial injuries, ER was associated with improved mortality and lower complication rates. Patient follow-up demonstrates an acceptable reintervention rate after ER. Further multicenter prospective evaluation is warranted to determine long-term outcomes.

Surgical management of axillosubclavian vascular injuries

Objective:

Complex surgical exposures to upper extremity injuries required for conventional surgery correlate with a high morbidity and mortality. We present our results with conventional surgery following injuries of the subclavian and axillary vessels.

Methods:

Between November 2007 and March 2012, 29 cases with subclavian-axillary vascular injury were operated. Diagnostic and treatment methods, associated organ injury, morbidity and mortality rates in these cases were respectively reviewed.

Results:

The causes of injuries were stab wounds in 11 cases (37.9%), gunshot wounds in 9 cases (31%), iatrogenic injuries in 5 cases (17.2%) and blunt trauma 4 cases (13.7%). Eight patients (27.5%) had isolated arterial injury while 21 patients (72.4%) had coexisting organ injury (vein, bone, soft tissue, nerve). Primary repair and usage of saphenous vein were the most common surgical methods. One patient died due to myocardial infarction. (Mortality 3.4%)

Conclusions:

Vascular injuries of axillosubclavian are frequently associated with neurogenic, osseous and soft tissue injuries and should have early intervention. Conventional surgery remains the choice of treatment in patients with poor status and urgency.

Risk of continuing planned surgery after endovascular repair of subclavian artery injury: a case report

Endovascular repair with covered stents has been widely used to treat subclavian and axillary artery injuries and has produced promising early results. The possibility of a thromboembolism occurring in cerebral arteries during an endovascular procedure should be a cause for concern. In the case of endovascular management of arterial traumas, a prompt and sufficient period for check-up of the patient's neurological signs is needed, even if it requires postponing elective intervention for the patient's safety. We report a rare case of liver transplantation immediately after endovascular repair of an iatrogenic subclavian arterial injury to describe the risk of continuing planned surgery without neurologic assessment.

Associated venous injury significantly complicates presentation, management, and outcomes of axillosubclavian arterial trauma

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.

Axillary artery transection after shoulder dislocation

Axillary artery transection after shoulder dislocation without bone fracture is extremely rare. Early diagnosis, use of the occlusion balloon for proximal control of axillary artery bleeding, and surgical treatment are important to avoid morbidity and mortality. A 74-year old man presented with a complete transection of axillary artery associated with anterior dislocation of the shoulder without bone fracture. Left axillary artery transection was seen on angiography. An angioplasty balloon was used to prevent bleeding from the subclavian artery. The brachial plexus was compressed by a hematoma. Axillary artery repair was performed with an autologous reversed saphenous vein graft interposition. The patient had palpable distal pulses postoperatively. Motor function was significantly improved but still impaired in the postoperative period. Follow-up at 3 months showed good function of the left arm.Successful management of axillary artery injuries requires prompt diagnosis and surgical treatment. Neurologic injury may affect the functional outcome of the limb.

Penetrating neck injury to the superior thoracic artery managed by video-assisted thoracoscopic surgery

Penetrating trauma to the axillary artery and its branches is uncommon and associated with high morbidity and mortality. Open exploration is mandated in hemodynamically unstable patients, but surgical exposure can be difficult due to the concentration of vital structures and complex anatomy in this region. Computed tomographic angiography is a potential diagnostic modality in hemodynamically stable patients. In these patients, endovascular therapies may provide a feasible means of controlling hemorrhage while minimizing surgical complications. A high incidence of concomitant intrathoracic injury has resulted in an expanding role for video-assisted thoracoscopic surgery. In this paper, we present a case of penetrating injury to the superior thoracic artery that was not amenable to endovascular therapy and was ultimately managed with thoracoscopic surgery.

Endovascular management of axillo-subclavian arterial injury: a review of published experience

BACKGROUND

The role of endovascular treatment for vascular trauma, including injury to the subclavian and axillary arteries, continues to evolve. Despite growing experience with the utilization of these techniques in the setting of artherosclerotic and aneurysmal disease, published reports in traumatic subclavian and axillary arterial injuries remain confined to sporadic case reports and case series.

METHODS

We conducted a review of the medical literature from 1990 to 2012 using Pubmed and OVID Medline databases to search for all reports documenting the use of endovascular stenting for the treatment of subclavian or axillary artery injuries. Thirty-two published reports were identified. Individual manuscripts were analysed to abstract data regarding mechanism, location and type of injury, endovascular technique and endograft type utilized, follow-up, and radiographic and clinical outcomes.

RESULTS

The use of endovascular stenting for the treatment of subclavian (150) or axillary (10) artery injuries was adequately described for only 160 patients from 1996 to the present. Endovascular treatment was employed after penetrating injury (56.3%; 29 GSW; 61 SW), blunt trauma (21.3%), iatrogenic catheter-related injury (21.8%) and surgical injury (0.6%). Injuries treated included pseudoaneurysm (77), AV fistula (27), occlusion (16), transection (8), perforation (22), dissection (6), or other injuries otherwise not fully described (4). Initial endovascular stent placement was successful in 96.9% of patients. Radiographic and clinical follow-up periods ranging from hospital discharge to 70 months revealed a follow-up patency of 84.4%. No mortalities related to endovascular intervention were reported. New neurologic deficits after the use of endovascular modalities were reported in only one patient.

CONCLUSION

Endovascular treatment of traumatic subclavian and axillary artery injuries continues to evolve. Early results are promising, but experience with this modality and data on late follow-up remain limited. Additional multicenter prospective study and capture of data for these patients is warranted to further define the role of this treatment modality in the setting of trauma.

[Surgical accesses to the major mediastinal vessels in thoracic trauma]

Trauma is the most common cause of death in the economically active population and thoracic trauma is directly or indirectly responsible for one quarter of these deaths. Lesions to the large thoracic vessels are associated with immediate or early death in the hospital setting. Patients admitted alive can be classified as stable or unstable. The access route to be elected for management of these veins will depend on this status, as well as on the anatomical particularities of the patient, which may require combined incisions for adequate access. This article provides a review and discussion of lesions to these structures as well as access routes to them.

Traumatic subclavian arterial rupture: a case report and review of literature

Subclavian artery injuries represent an uncommon complication of blunt chest trauma, this structure being protected by subclavius muscle, the clavicle, the first rib, and the deep cervical fascia as well as the costo-coracoid ligament, a clavi-coraco-axillary fascia portion. Subclavian artery injury appears early after trauma, and arterial rupture may cause life-treatening haemorrages, pseudo-aneurysm formation and compression of brachial plexus. These clinical eveniences must be carefully worked out by accurate physical examination of the upper limb: skin color, temperature, sensation as well as radial pulse and hand motility represent the key points of physical examination in this setting. The presence of large hematomas and pulsatile palpable mass in supraclavicular region should raise the suspicion of serious vascular injury. Since the first reports of endovascular treatment for traumatic vascular injuries in the 90’s, an increasing number of vascular lesions have been treated this way. We report a case of traumatic subclavian arterial rupture after blunt chest trauma due to a 4 meters fall, treated by endovascular stent grafting, providing a complete review of the past twenty years’ literature.

Endovascular management of peripheral vascular trauma

Endovascular interventions (EVIs) are an important adjunct to open surgical management of peripheral vascular injuries. In appropriate situations, EVIs decrease operative time, estimated blood loss, and iatrogenic complications when compared with similar surgical cohorts by limiting surgical dissection in traumatized operative fields. In situations where definitive repair is not possible with EVIs, endovascular techniques permit control of hemorrhage or damage and facilitate open surgical repair. EVIs for peripheral vascular injury have proven effective in three anatomic regions: the neck, subclavian, and lower-extremity regions. The interventional radiologist should become familiar with the physical and personnel resources in the area preferred by the consulting trauma team to minimize unnecessary delays when acute intervention or angiography is requested. Clinical and radiographic surveillance for patency and compliance with antiplatelet or anticoagulation therapy is essential but has historically been poor in trauma patients.

Percutaneous treatment of traumatic upper-extremity arterial injuries: a single-center experience

PURPOSE

To assess the feasibility and effectiveness of emergency percutaneous treatment of traumatic injuries of upper-extremity arteries.

MATERIALS AND METHODS

Between January 2000 and December 2007, 11 patients (mean age, 49.9 years) with traumatic injuries of upper-extremity arteries were observed: three had pseudoaneurysms, four had dissections, three had transections, and one had mural hematoma. Lesions involved the axillary (n = 6), subclavian (n = 3), or brachial artery (n = 2). Pseudoaneurysms and transections were treated with stent grafts, (n = 6) and dissections and mural hematomas were treated with bare stents (n = 2) or angioplasty (n = 3). Follow-up (mean, 45.1 months; range, 12-84 months) was performed with color Doppler ultrasonography at 1, 3, 6, and 12 months and then, yearly.

RESULTS

Immediate technical success was obtained in all cases. No major complications occurred; there was one asymptomatic occlusion of the interosseous artery and one case of incomplete thrombosis of the radial artery (with recanalization after 1 month with systemic medical therapy). During a mean follow-up of 45.1 months, one stent-graft occlusion occurred, which was treated with intraarterial pharmacologic thrombolysis (urokinase 60,000 IU/h for 12 hours). Overall primary clinical success rate was 95.2% and secondary clinical success rate was 100%.

CONCLUSIONS

Percutaneous treatment is a feasible and safe tool for injuries of upper-extremity arteries because it can provide a fast and definitive termination of bleeding or a resolution of acute ischemia. This approach, with its low invasiveness, can be proposed as first-line treatment in patients with traumatic lesions of upper-extremity arteries.