Subclavian and axillary vascular injuries

Subclavian arterial rupture due to blunt trauma injury: A case report

RATIONALE

Subclavian arterial injury due to blunt trauma is rare but can have devastating outcomes. Massive hemorrhage or limb ischemia might develop depending on the extent of damage, and open repair might be necessary to salvage the limb. However, life-saving treatments should be prioritized in critically unstable patients.

PATIENT CONCERNS

A 21-year-old male patient who was transferred to our trauma center following a motorcycle accident. Abdominal and chest computed tomography (CT) revealed right renal injury and massive hemothorax with several rib fractures in the right chest.

DIAGNOSIS AND INTERVENTIONS

Right renal injury with multiple extravasations and right 8th intercostal arterial injury were detected during angiography. Emergent exploration with lateral thoracotomy was performed to manage right hemothorax. Pulsating bleeding from the thoracic roof observed in the operative field suggested a subclavian arterial injury. The unstable vital signs did not recover despite massive transfusion, and his right arm had already stiffened. Therefore, endovascular approach was adopted and the second portion of the right subclavian artery was embolized using microcoils and thrombin.

OUTCOMES

Postoperative intensive care unit management performed to resuscitate patient from multiorgan failure included continuous renal replacement therapy (CRRT). After confirming the demarcation lines, transhumeral amputation of the right arm was performed on admission day 12. The patient recovered from multiorgan failure for more than 3 weeks after the accident; however, the patient survived.

LESSONS

Limb salvage, albeit critical for quality of life, is not possible in some cases where life-saving measures require its sacrifice. In these cases, quick decision-making by the surgeon is paramount for patient survival. As illustrated in this case, endovascular approaches should be considered less invasive measures to save the patient's life.

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.

Obesity Does Not Increase Risk for Mortality in Severe Sepsis Trauma Patients

INTRODUCTION

The prevalence of obesity in the United States is up to 40% in adults. Obese patients with severe sepsis have a lower mortality rate compared with normal body mass index (BMI) patients. We hypothesized that trauma patients with severe sepsis and obese BMI will have a decreased mortality risk in comparison with normal BMI patients.

METHODS

The Trauma Quality Improvement Program (2017) was queried for adult trauma patients with documented BMI and severe sepsis. Patients were grouped based on BMI: non-obese trauma patients (nOTP) BMI <30 kg/m2 and obese trauma patients (OTP) ≥30 kg/m2. A multivariable logistic regression model was used for analysis of mortality.

RESULTS

From 1246 trauma patients with severe sepsis, 566 (42.4%) were nOTP and 680 (57.6%) were OTP. OTP had increased length of stay (LOS) (19 vs 21 days, P < .001), intensive care unit (ICU) LOS (13 vs 18 days, P < .001) and ventilator days (10 vs 11 days, P < .001). After adjusting for covariates, when compared to normal BMI patients, patients who were overweight (OR 1.11 CI .875-1.41 P = .390), obese (OR .797 CI .59-1.06 P = .126), severely obese (OR .926 CI .63-1.36 P = .696) and morbidly obese (OR 1.448 CI 1.01-2.07 P = .04) all had a similar associated risk for mortality compared to patients with normal BMI.

CONCLUSION

In adult trauma patients with severe sepsis, this national analysis demonstrated OTP had increased LOS, ICU LOS, and ventilator days compared to nOTP. However, patients with increasing degrees of obesity had similar associated risk of mortality compared to trauma patients with severe sepsis and a normal BMI.

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.

Surgical Management of Delayed Brachial Plexopathy After Clavicle Nonunion

Brachial plexopathy after conservative therapy or surgical treatment of clavicular fractures is an uncommon, yet serious complication that is associated with compression of the brachial plexus or the subclavian artery and vein because they traverse through the thoracic outlet. Surgical decompression of the brachial plexus is the recommended treatment if this condition is to occur. Although there are multiple reports of these cases in the literature, at present, there are no clear guidelines for their management. We are highlighting an institutional management algorithm, illustrated by a small retrospective case series, that uses a multidisciplinary approach in an effort to minimize complications associated with the management of clavicle nonunion.

Treatment Outcome of Traumatic Subclavian Artery Injuries

BACKGROUND

Traumatic subclavian artery injuries are associated with high morbidity and mortality. Thoracic cage and clavicle provide a well protection of the underlying subclavian vessels and nerves and also cause a very limited operation space during open surgery. The endovascular modality is less invasive and alternative to conventional open surgical reconstruction.

PURPOSE

The purpose of this study was to analyze the different therapeutic effects on limb salvage.

METHODS

A retrospective review of patients who presented with blunt or penetrating injuries to the subclavian arteries between March 2012 and March 2021.

RESULTS

Endovascular and open repairs were both effective for traumatic subclavian artery injury. There was no statistical difference in the limb salvage, mortality, procedure-related complication, reintervention rate and in-hospital medical complications. Intraoperative blood loss, red blood cell transfusion requirement and length of hospital stay were significantly lower in the endovascular intervention group.

CONCLUSION

Endovascular treatment represents an attractive alternative to the traditional surgical approach for the treatment of traumatic injuries in the subclavian.

Dissection of Cervical Lymph Node Metastasis With Internal Jugular-Subclavian Venous Junction Invasion Via an Approach Involving Resection of the Margin of the Medial Clavicle

We report here a patient with a massive lymphatic metastasis involving the internal jugular-subclavian venous (IJ-SCV) junction that was safely resected with a new surgical procedure without significant complications. The patient, a 57-year-old man, had advanced hypopharyngeal cancer that had metastasized to the left IJ-SCV junction with a considerable invasion of the vessels, seemingly precluding a conventional surgical intervention. We, therefore, devised a new minimally invasive surgical approach involving resection of the margin of the medial clavicle, which provided an open view of the operation field. This enabled severance of both subclavicular and brachiocephalic veins and removal of the tumor. All procedures were accomplished safely and there were no postoperative circulatory disturbances, including arm edema and compartment syndrome, in the ipsilateral arm. Additionally, postoperative adjuvant chemoradiotherapy was completed uneventfully.

Surgical anatomy of the axillary artery: clinical implications for open shoulder surgery

BACKGROUND

Axillary artery injury is a devastating complication related to anterior shoulder surgery and can result in significant morbidity and/or mortality. The purpose of our study was to evaluate the course of the axillary artery in relation to bony landmarks of the shoulder and identify variations in artery position with humeral external rotation.

MATERIALS AND METHODS

Dissection of 18 shoulders (9 fresh whole-body cadavers) with simulated vessel perfusion using radiopaque dye was performed. The axillary artery position was measured from multiple points including 2 points on the coracoid base (C1 and C2), 3 points on the coracoid tip (C3-C5), 4 points on the glenoid: superior, middle, and inferior glenoid (D1-D4), and 2 points on the lesser tuberosity (L1 and L2). Fluoroscopic measurements were taken and compared at 0° and 90° of external rotation (F1 vs. F1' and F2 vs. F2'). Manual and fluoroscopic measurements were compared with one another using Kendall's τ_b correlation.

RESULTS

There were 6 male and 3 female cadavers with an average age of 67.2 ± 9.3 years (range: 49-77 years). The mean distance from the axillary artery to the coracoid base (C1 and C2) measured 21.1 ± 7.3 and 22.3 ± 7.4 mm, respectively, whereas the mean distance to the coracoid tip (C3, C4, and C5) measured 30.7 ± 9.3, 52.1 ± 20.2, and 46.5 ± 14.3 mm, respectively. Measurements relative to the glenoid face (D1, D2, and D3) showed a progressive decrease in mean distance from superior to inferior, measuring 31.6 ± 10.3, 16.5 ± 7.5, and 10.3 ± 7.3 mm, respectively, whereas D4 (inferior glenoid to axillary artery) measured 17.8 ± 10.7 mm. The minimum distance from the axillary artery to any point on the glenoid was as close as 4.1 mm (D3). There was a statistically significant difference in F1 (0° external rotation) vs. F1' (90° external rotation) (18.5 vs. 13.4 mm, P = .03). Kendall's τ_b correlation showed a strong, positive correlation between manual and fluoroscopic measurements (D4: 16.0 ± 12.5 mm vs. F1: 18.5 ± 10.7 mm) (τ_b = 0.556, P = .037).

CONCLUSION

The axillary artery travels an average of 1-1.8 cm from the inferior glenoid margin, which puts the artery at significant risk. In addition, the artery is significantly closer to the inferior glenoid with humeral external rotation. Surgeons performing anterior shoulder surgery should have a thorough understanding of the axillary artery course and understand changes in the position of the artery with external rotation of the humerus.

Bidirectional endovascular treatment for axillary artery injury secondary to proximal humerus fracture: a case report

Background

Axillary artery injury secondary to proximal humerus fracture is a rare but serious complication. The management of this injury has traditionally involved surgical treatment.

Case summary

A 66-year-old female with gait disturbance slipped and fell off her wheelchair at home. She presented to a local hospital with right shoulder pain and was subsequently urgently transferred to our hospital by helicopter because of suspicion of axillary artery injury. Computed tomography angiography revealed disruption of the right axillary artery. We decided to perform endovascular treatment instead of surgical treatment for axillary artery injury. However, since endovascular treatment via the right femoral artery was impossible, we performed bidirectional (right femoral and right brachial artery approaches) endovascular treatment. We expanded the occluded lesion using a 3.5 mm × 40 mm sized balloon and placed a 5.0 mm × 50 mm stent graft (Gore^® Viabahn^®) across the lesion. The final subclavian injection confirmed that distal flow to the brachial artery was preserved and that there was no leakage of contrast medium from the axillary artery.

Discussion

We performed endovascular treatment for axillary artery injury secondary to proximal humerus fracture. Although surgical repair is typically performed for this kind of injury, our experience suggests that endovascular treatment might be an option in patients with axillary artery injury.

Brachial Plexus Injury Significantly Increases Risk of Axillosubclavian Vessel Injury in Blunt Trauma Patients With Clavicle Fractures

BACKGROUND

A national analysis of clavicle fractures is lacking and the risk of concomitant axillosubclavian vessel injury (ASVI) in patients with clavicle fractures is unknown. A minority of patients may have a combined brachial plexus injury (BPI). We sought to describe risk factors for concomitant ASVI in patients with a clavicle fracture; hypothesizing patients with combined clavicle fracture and BPI has a higher risk of ASVI.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for blunt trauma patients with a clavicle fracture. A multivariable logistic regression model was used to determine risk factors for ASVI. A subset analysis on patients with isolated clavicle fractures was additionally performed.

RESULTS

From 59 198 patients with clavicle fractures, 341 (.6%) had concomitant ASVI. Compared to patients without ASVI, patients with ASVI had a higher median injury severity score (24 vs. 17, P < .001) and rates of pulmonary contusions (43.4% vs. 37.7%, P = .029) and BPI (18.2% vs. .4%, P < .001). After controlling for associated chest wall injuries and humerus fracture, the BPI odds ratio (OR 49.17, 35.59-67.92, P < .001) was independently associated with risk for ASVI. In a subset analysis of isolated clavicle fractures, BPI remained associated with risk of ASVI (OR 60.01, confidence intervals 25.29-142.39, P < .001).

CONCLUSION

The rate of concomitant ASVI in patients with a clavicle fracture is <1%. Patients presenting with a clavicle fracture had a high rate of injuries including pulmonary contusion. Patients with findings suggestive of underlying BPI had a nearly 50 times increased associated risk of ASVI. Thus, a detailed physical exam in this setting including brachial-brachial index appears warranted.

Ballistic Axillary Vein Transection: A Case Report

Patient: Male, 25-year-old

Final Diagnosis: Axillary vein transection

Symptoms: Shortness of breath

Medication: —

Clinical Procedure: Ligation of the axillary vein

Specialty: 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.

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

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.

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.

Management specificities for abdominal, pelvic and vascular penetrating trauma

Management of patients with penetrating trauma of the abdomen, pelvis and their surrounding compartments as well as vascular injuries depends on the patient's hemodynamic status. Multiple associated lesions are the rule. Their severity is directly correlated with initial bleeding, the risk of secondary sepsis, and lastly to sequelae. In patients who are hemodynamically unstable, the goal of management is to rapidly obtain hemostasis. This mandates initial laparotomy for abdominal wounds, extra-peritoneal packing (EPP) and resuscitative endovascular balloon occlusion of the aorta (REBOA) in the emergency room for pelvic wounds, insertion of temporary vascular shunts (TVS) for proximal limb injuries, ligation for distal vascular injuries, and control of exteriorized extremity bleeding with a tourniquet, compressive or hemostatic dressings for bleeding at the junction or borderline between two compartments, as appropriate. Once hemodynamic stability is achieved, preoperative imaging allow more precise diagnosis, particularly for retroperitoneal or thoraco-abdominal injuries that are difficult to explore surgically. The surgical incisions need to be large, in principle, and enlarged as needed, allowing application of damage control principles.

Delayed Endovascular Stenting of Right Subclavian Artery Pseudoaneurysm Caused by Gunshot Accident in a Syrian Refugee: A Case Report

Sharp penetrating injuries causing right subclavian artery pseudoaneurysm are considered rare. Surgical repair is reportedly associated with a high mortality rate and is considered technically challenging. ¹ In this case report, we report the successful endovascular repair of a delayed pseudoaneurysm of the right subclavian artery caused by a gunshot injury in a 22-year-old Syrian refugee that was associated with significant right brachial panplexopathy. The patient was successfully managed with angioplastic ballooning of the stenotic region of the artery and a covered self-expanding stent. The patient recovered uneventfully, and follow-up evaluation revealed significant improvement in neurological deficit.

Endovascular repair of blunt axillo-subclavian arterial injuries as the first line treatment

AIM

To report and analyse our results regarding the endovascular management of blunt axillo-subclavian arterial injuries as the first line treatment.

METHODS

During an eight-year period, seven patients (mean age 56.4±14.1 years, all males) with blunt traumatic axillo-subclavian arterial injuries were presented to the emergency department. All patients suffered also from concomitant other injuries and had a supraclavicular haematoma along with diminished or absent upper limb peripheral pulses, while computed tomography angiography set the diagnosis.

RESULTS

The endovascular procedure was technically successful in all patients. No procedure-related complication was encountered during the in-hospital stay, while none of the patients died. The median hospital stay was 22 days (range 12-46). During a follow-up period spanning an average of 27 months (range 6-44 months) there was one stent-graft thrombosis at 12 months in an otherwise asymptomatic patient that required no further intervention.

CONCLUSION

Endovascular technique seems to constitute a reliable approach for treating blunt axillo-subclavian arterial injuries in the emergent setting. Despite uncertainties in patient selection and optimal management algorithms, it seems that endovascular approach could be the first line treatment for such injuries. Accumulation of data on larger number of patients with longer follow-up is warranted to further define the value of this therapeutic modality in the trauma setting.

Thoracic venous injuries: an imaging and management overview

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.

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.

Recurrent peripheral embolism following nonunion of the clavicle

Vascular complications in closed clavicular fractures are uncommon, with an incidence of only 0.4%. Subclavian artery injury can present acutely or can have a delayed presentation with arm ischemia. We report the case of an undetected subclavian pseudoaneurysm in a patient with a nonunion fracture clavicle who was referred with persistent ischemia following attempted brachial embolectomy at another center, along with a review of literature to support the hypothesis that in addition to repair of the aneurysm, treatment of the psuedarthrosis by fixation of the clavicle is essential.

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.

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.

Vertebral artery occlusion with Amplatzer vascular plug 4 to prevent subsequent endoleak in stent-graft treatment of subclavian artery gunshot injury

Endovascular treatment options have evolved in many ways and become an important alternative for open surgical repairs in various vascular territories. Herein, we present a case of an 18-year-old man with complex injury to the left subclavian artery and vein caused by a gunshot 4 months ago. After the gunshot, a high-flow fistula between the left subclavian artery and the vein occurred with pseudoaneurysm formation. This fistula led to a significant left subclavian steal phenomenon. A stent-graft was deployed along the injured left subclavian artery after embolization of the left vertebral artery by Amplatzer vascular plug 4 (AVP-4) in order to prevent subsequent endoleak due to the subclavian steal syndrome.

Subclavian vessel injuries: difficult anatomy and difficult territory

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.

Operative exposure and management of axillary vessel injuries

INTRODUCTION

Axillary vessel injuries are uncommon and challenging injuries encountered by trauma surgeons. Proximity of this vessel to other adjacent veins including the axillary vein, brachial plexus and the osseous structures of the shoulder and upper arm account for a large number of associated injuries.

MATERIALS AND METHODS

Systematic review of the literature, with emphasis on the diagnosis, treatment and outcomes of these injuries, incorporating the authors' experience.

CONCLUSIONS

Although uncommon, axillary arterial injuries can result in significant morbidity, limb loss and mortality. Early diagnosis and timely repair of the artery leads to good outcomes.

[Injury to the subclavian and vertebral arteries in childhood following blunt force trauma]

Injuries of great vessels, such as the subclavian or vertebral arteries in childhood are rare. More frequent and therefore better described are dissections of the vertebral artery, which frequently occur following low energy trauma. The combination of dissection of the vertebral and subclavian arteries described in this case study led to sensory affections of the left arm. Therapeutic anticoagulation is the therapy of choice to avoid possible ischemic insults. The therapeutic approach of injuries to the subclavian artery remains unclear and is in the focus of discussions.

Penetrating thoracic great vessel injury: impact of admission hemodynamics and preoperative imaging

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.

Vascular injuries after blunt chest trauma: diagnosis and management

Background

Although relatively rare, blunt injury to thoracic great vessels is the second most common cause of trauma related death after head injury. Over the last twenty years, the paradigm for management of these devastating injuries has changed drastically. The goal of this review is to update the reader on current concepts of diagnosis and management of blunt thoracic vascular trauma.

Methods

A review of the medical literature was performed to obtain articles pertaining to both blunt injuries of the thoracic aorta and of the non-aortic great vessels in the chest. Articles were chosen based on authors' preference and clinical expertise.

Discussion

Blunt thoracic vascular injury remains highly lethal, with most victims dying prior to reaching a hospital. Those arriving in extremis require immediate intervention, which may include treatment of other associated life threatening injuries. More stable injuries can often be medically temporized in order to optimize definitive management. Endovascular techniques are being employed with increasing frequency and can often significantly simplify management in otherwise very complex patient scenarios.

[Operative management of penetrating injuries to the subclavian artery. Technical tutorial]

Penetrating injury to the subclavian arteries is one of the most taxing arterial injuries a trauma surgeon can encounter. Operative access for repair is difficult, crossing two separate anatomical areas-superior mediastinum and base of the neck. The artery runs well protected behind sternum and clavicle and tears easily if clamped. Physiologically unstable patients must be rushed to theatre in an attempt to control exanguinating haemorrhage and to repair the injury. In the rare circumastance of being confronted with it, it is imperative for the occasional trauma surgeon to have a practical operative concept for dealing with this type of injury. This tutorial describes a practical approach for penetrating subclavian injuries, and it discusses alternative surgical strategies when supraclavicular expanding hematomas deny straightforward access.

Long-term results of stent graft treatment of subclavian artery injuries: management of choice for stable patients?

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.

Management of Subclavian and Axillary Artery Injuries: Spanning the Range of Current Therapy

Injuries of the subclavian and proximal axillary arteries are potentially devastating but account for a minority of vascular injuries presenting to trauma centers in the United States. We have reviewed our recent experience with management of subclavian and axillary artery injuries in a state-designated level 1 academic trauma center and report four cases that illustrate the typical arterial injury patterns and the entire therapeutic armamentarium in its current iteration. Sub-clavian and proximal axillary artery injuries present as interesting surgical problems. A high index of suspicion for vascular injuries should be maintained given the mechanism and proximity to major vasculature. Consideration should always be given to the least invasive treatment options in stable patients. Awareness of multiple therapeutic modalities and indications for each should be an integral part of every surgeon's armamentarium. As with all vascular intervention, eventual failure is the rule rather than the exception; therefore, plans for longitudinal surveillance should be made independent of the technique used to treat the injury.

Axillary vein perforation by the medial cutaneous nerve of the forearm

Variation in the venous pattern in the arm is common. In this study, a rare variant of the axillary vein and its association with the median cutaneous nerve of the forearm is described. In the axilla, the medial cutaneous nerve of the forearm penetrated the axillary vein, thereby creating two narrow venous channels at the site of passage. Such variations are important because a large number of diagnostic and therapeutic invasive procedures are carried out on veins. A possible mode of origin and the clinical importance of this variation are discussed.