Management of proximal axillary and subclavian artery injuries

Subclavian Artery Injury During Lung Tumor Resection

An open penetrating injury of the subclavian artery is an extremely rare catastrophic situation in thoracic surgery. We experienced a 57-year-old case of iatrogenic subclavian artery injury during the resection of a lung tumor. The injury occurred during the dissection of the adhesion between the stapling site of the previous bullectomy and the chest wall. Systolic blood pressure dropped below 50 mmHg immediately after the injury. Following primary hemostasis achieved with suture closure, the site of injury was sufficiently exposed and successfully repaired.

Angio-Seal Closure for Traumatic Left Subclavian Artery Pseudoaneurysm: A Case Report

Subclavian artery pseudoaneurysms are rare and associated with high morbidity and mortality. Alternative approaches to open surgical repair can include endovascular repair or ultrasound-guided thrombin injection. Here, we describe a safe and novel technique of closure of a subclavian artery pseudoaneurysm with Angio-Seal that was unresponsive to thrombin injection and in a difficult location for open repair.

Endovascular management of traumatic pseudoaneurysm of left subclavian artery: A case report

We present a case report of a 20-year-old male who suffered a stab injury to the left supraclavicular region, resulting in the formation of a pseudoaneurysm of the left subclavian artery. Initial endovascular management with a self-expandable covered stent graft showed promising results, but recurrence with proximal and distal end leaks necessitated further intervention. The patient's financial constraints delayed subsequent treatment, leading to worsening symptoms, including left upper limb paraparesis. Facing technical challenges due to the large size of the aneurysm and proximity to the vertebral artery, a vertebral artery confluence was performed, followed by a longer stent-graft placement to address the pseudoaneurysm successfully. This case highlights the potential advantages of endovascular approaches in complex subclavian artery injuries and emphasizes the importance of timely intervention to avoid complications and improve patient outcomes.

CT angiography of non-aortic thoracic arterial trauma

While aortic injury is the most commonly cited thoracic arterial injury, non-aortic arterial injuries represent an uncommon but significant source of morbidity and mortality in blunt and penetrating thoracic trauma patients. Knowledge of the spectrum of vascular injury and anatomic considerations that dictate patterns of associated thoracic hemorrhage will assist the radiologist in the accurate and efficient diagnosis of these injuries. This article provides a review of anatomy, pertinent clinical exam and CT angiography findings, as well as therapeutic options for non-aortic thoracic arterial trauma.

Ruptured subclavian artery pseudoaneurysm following a shoulder massage on a background of clavicle non-union

We present an unusual case of ruptured subclavian artery pseudoaneurysm following hydrotherapy and shoulder massage session on a background of clavicle non-union.Following a clavicle fracture 16 years ago, which was managed conservatively, a woman in her 30s presents over a decade later with a ruptured subclavian artery pseudoaneurysm.The original midshaft clavicle fracture was sustained 16 years ago. Conservative management was agreed, and she was discharged. Six years ago, she developed a small subclavian artery pseudoaneurysm which was kept under surveillance for 12 months with no active intervention required.Over the following years, she continued to have intermittent shoulder girdle discomfort and neuropathic symptoms. On this presentation, after a sports massage, she presented with rapid-onset supraclavicular and axillary swelling. This was diagnosed as a ruptured subclavian artery pseudoaneurysm and was treated with emergency radiological-guided stenting and subsequent internal fixation of the clavicle non-union.The patient then attended regular orthopaedic and vascular follow-up to ensure her clavicle fracture unites and the graft remains patent.We discuss the case presentation and management of this unusual injury.

Subclavian Artery Pseudoaneurysm in an Eight-Year-Old Boy: A Rare Case Report and Review of Literature

Pseudoaneurysms, also known as fake aneurysms, are balloon-like bulges that develop in the arteries and veins. This can happen due to injury, surgery, infection, or other conditions that damage blood vessels. Pseudoaneurysms are usually asymptomatic but can bleed and be painful. Left untreated, they can lead to severe complications such as thrombus formation and distant embolization. Subclavian pseudoaneurysms are rare, which can lead to potentially life-threatening complications of traumatic or iatrogenic injuries to the subclavian artery, such as catheterization. Prompt diagnosis and management are essential to avoid devastating outcomes. We report the case of a pediatric patient who developed a subclavian pseudoaneurysm after neck trauma and was successfully treated with endovascular embolization. This case highlights the importance of timely management and vigilant monitoring for this rare but potentially life-threatening condition.

Endovascular treatment of axillosubclavian arterial injuries is a safe alternative to open repair

BACKGROUND

Injuries to the axillosubclavian arteries are rare, comprising 5% of all extremity trauma. This study aims to examine contemporary outcomes of traumatic axillosubclavian injuries.

METHODS

A retrospective review was performed on patients admitted with innominate, subclavian, and/or axillary artery injuries to a level 1 trauma center from 2011 to 2021. Patients undergoing endovascular repair were compared to those with open repair.

RESULTS

Thirty two patients met inclusion criteria. Injuries were approached open in 22 (59%) cases and endovascular in 10 (27%). There was no difference in 30-day mortality or hospital length of stay between endovascular and open repair. Endovascular repairs had shorter operative times (1.9 vs 3.1 h, p = 0.009) and lower blood loss (72 vs 1662 mL, p < 0.001).

CONCLUSIONS

Endovascular repair of axillosubclavian arterial injuries demonstrate similar outcomes to open repair. Significantly shorter operative times and lower blood loss suggest potential decreased morbidity.

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.

Case report: Endovascular embolization of the thoracoacromial branch of axillary artery after gunshot trauma at a regional trauma center

Introduction and importance

Penetrating subclavian-axillary artery injury is a rare vascular injury associated with high morbidity and mortality rates traditionally treated with open surgical repair, however endovascular treatments have been utilized in selected cases.

Case presentation

We report a case of a 31-year-old male with a traumatic gunshot injury to the thoracoacromial branch of the left axillary artery successfully managed with endovascular embolization at a regional trauma center.

Clinical discussion

The availability of a hybrid operating suite in severely injured patients is associated with reduced time to intervention, reduced operative duration and improved clinical outcomes. Our experience demonstrates the utility and benefit of a hybrid operating theatre in a regional trauma center. The availability of a hybrid suite allowed rapid diagnostic and therapeutic angiography with a minimally invasive approach and eliminated the need for urgent open surgical management. However, the high costs associated with a hybrid operating theatre remain the major barrier for most regional centers.

Conclusion

The availability of hybrid operating theatre at a regional trauma center allowed early diagnosis and successful management of the injury with a minimally invasive endovascular approach.

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Subclavian-axillary artery injury is rare but carries a high morbidity and mortality.

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Endovascular repairs are effective in selected patients.

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The availability of a hybrid theatre is associated with improved clinical outcomes.

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The costs remain a challenge for most regional centers.

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

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Endovascular repair of traumatic axillosubclavian artery injuries

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

Delayed Onset of Subclavian Artery Pseudoaneurysm With Brachial Plexus Compression Following Gunshot Wound Injury

Early diagnosis of brachial plexus injuries is crucial to prevent long-term morbidity and improve outcomes. We present a unique case of delayed onset of brachial plexus compression two months following a traumatic gunshot injury causing multiple injuries including a T1 vertebral body comminuted fracture and pneumothorax. The patient experienced significant pain and progressive neurological examination changes during follow-up visits, and thus duplex ultrasound and computed tomography (CT) angiography were performed, which demonstrated a left subclavian artery pseudoaneurysm. This was managed operatively by evacuation and interposition bypass. Injuries to the cervical and upper thoracic spine are complex, and when patients present with new-onset neurological findings, axillary swelling, or significant uncontrolled postoperative pain, secondary complications should be suspected. Patients at a high risk of vascular reinjury should be routinely monitored at follow-up to prevent the development of progressive neurological damage to the brachial plexus.

Penetrating angle grinder injury to the neck causing subclavian artery injury

Penetrating injuries to the neck present a unique challenge due to the confined space of the thoracic outlet for haemorrhage control and repair. This results in high mortality rates when the major vascular structures of the neck are transected, as well as potential neurological compromise. We present the case of a penetrating injury to the proximal subclavian artery from a broken angle grinder disc which is a unique mechanism of injury that can have fatal consequences. The patient described in this case underwent an emergent median sternotomy for proximal control of the brachiocephalic trunk and ligation of the right vertebral artery to facilitate a primary repair of the injured vessel segment. Post operatively the patient made a complete recovery with no central or peripheral neurologic deficits and requiring no further interventions. The key points from this case are that angle grinders pose a significant injury burden and early specialised medical attention should be sought, rapid control of the proximal neck vessels can be obtained via a median sternotomy and that the vertebral artery can be ligated in an emergent situation without neurological consequence.

Hybrid repair of proximal subclavian artery transection

Although rare, subclavian artery injuries are associated with significant mortality and morbidity, with almost two-thirds of patients dying before reaching hospital. Recent advances in technology have resulted in increasing use of endovascular therapy in management of these injuries. In this report, we present a case of a successful hybrid repair of traumatic left proximal subclavian artery transection. The employment of an Amplatzer Vascular Plug to control a short proximal subclavian artery stump and subsequent ligation of the distal segment of subclavian artery with its anastomosis to the carotid artery resulted in excellent clinical outcome without performing a sternotomy in a young patient.

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

INTRODUCTION

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

CASE PRESENTATION

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

DISCUSSION

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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Subclavian artery injuries are rare, highly fatal, and constitute less than 2% of all vascular injuries.

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Surgical repair of these injuries can be technically challenging due to their anatomic location.

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Therapeutic approaches include surgical repair, endovascular repair, or a hybrid approach depending on the severity of the injury and the patient’s hemodynamic status.

Introduction

Subclavian artery injuries are rare and are associated with a high morbidity and mortality. The majority of patients with blunt trauma to the subclavian artery succumb to their injury before reaching a hospital. In-hospital mortality remains high.

Presentation of case

We report the case of a 30-year-old male who presented with complete traumatic subclavian artery avulsion after a motorcycle collision. He presented in hemorrhagic shock. Temporary hemostatic control was achieved with endovascular balloon occlusion followed by operative intervention.

Discussion

Prompt diagnosis and meticulous management including early transfusion, when indicated, are necessary to salvage both the patient’s life and limb from such severe injuries. Intra-operative diagnosis of subclavian artery injury is most common due to the hemodynamic instability of most patients with such injuries; however, conventional angiography and computed tomography angiography are useful diagnostic modalities as well. Temporizing measures such as endovascular balloon occlusion to obtain vascular control may serve as a valuable adjunct to surgical repair.

Conclusion

Repair of a subclavian artery injury is challenging for even the most experienced of surgeons. Endovascular techniques can be therapeutic or used as an adjunct to control bleeding ad allow an open repair.

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.

Fatal delayed rupture of the subclavian artery in a patient with first-rib fracture caused by blunt trauma

This case highlights the probable association of significantly displaced posterior first‐rib fracture and jagged edges of the fracture line following blunt chest trauma with delayed ipsilateral subclavian artery rupture. Early angiography and first‐rib repair should promptly be considered under such circumstances.

Diagnosis and management of thoracic and abdominal vascular injuries

Thoracic and abdominal vascular injuries present a formidable challenge to the most experienced surgeon. As prehospital care improves, more patients with these injuries are reaching the hospital alive. Thus, the trauma surgeon must be prepared to deal with them rapidly and precisely. Hemodynamically unstable patients should be transferred directly to the operating room. In stable patients with penetrating thoracic wounds, chest X-ray and arteriography are typically employed to exclude vascular injury. Patients sustaining blunt chest trauma can be screened effectively with CT scanning. Incisions are chosen based on the injured vessel. Hemorrhagic shock is the usual presentation for abdominal vascular trauma. A high index of suspicion is critical in diagnosing occult injuries. This presentation reviews the etiology, diagnosis, and treatment of major thoracic and abdominal vascular injuries.

Penetrating neck injury: a review

Penetrating injury to the neck has inspired considerable controversy with regard to its management, owing to the large number of important, susceptible structures contained in this area. Mandatory exploration of all wounds has generally given way to selective operative management. Clinical assessment has, once again, become the prime diagnostic tool. This review describes the evolution of management and the value of various diagnostic modalities. It concludes with a summary of appropriate operative techniques.

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.

Dual stent migration to the heart and pulmonary artery

The practice of intravascular stenting largely grew out of the concept of stenting the coronaries in acute myocardial infarction. According to the recent United States Renal Data System data registry, there has been a significant increase in endovascular intervention (1.8-fold increase-from 52,380 to 98,148) with a 2.2-fold increase in stent deployment in hemodialysis access (3792-8514). With the increasing use of endovascular stents in the management of dialysis access stenosis, the incidence of stent-related complications has increased significantly. Stent-related complications include stent restenosis, thrombosis (narrowing of the vessel lumen and being a nidus for thombus formation), stent shortening, stent fracture, stent infection, and stent migration. Physiologic variation in the diameter of veins due to respiration, which along with the geometry of the stent, can lead to a shortening lengthening of the stent-resulting in poor wall contact or high-speed impact of shock; in the case of trauma, mechanical bucking can result in tortuous blood vessels thereby resulting in stent migration (however proving this association was not the aim of this article). We report a case of a 44-year-old female with end-stage renal disease on hemodialysis, with stent placement to treat a compromised arteriovenous graft. There have been many cases of stent migration in the past; however, this is the first case of dual stent migration to the heart and pulmonary artery from an unusual (lower extremity) arteriovenous graft location.

Axillary Arterial Thrombosis Secondary to Re-Fracture of the Humerus

In the presented case report, we evaluated mechanism of axillary artery thrombosis in cases of repeated fracture of the shoulder. A 73-year-old female fell down on an outstretched hand. Radiographs demonstrated a Neer’s 2-part displaced fracture of the proximal humerus and open fracture of the acromion. Forty years ago, in a car accident, fractures of the same proximal humerus and clavicle occurred and were surgically treated. Two hours after fixation with Kirschner wires, thrombosis of the axillary artery was quickly diagnosed and rapid treatment allowed revascularisation of the arm without any consequences.

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.

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.

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.

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.

Experience and technique for the endovascular management of iatrogenic subclavian artery injury

BACKGROUND

Inadvertent subclavian artery catheterization during attempted central venous access is a well-known complication. Historically, these patients are managed with an open operative approach and repair under direct vision via an infraclavicular and/or supraclavicular incision. We describe our experience and technique for endovascular management of these injuries.

METHODS

Twenty patients were identified with inadvertent iatrogenic subclavian artery cannulation. All cases were managed via an endovascular technique under local anesthesia. After correcting any coagulopathy, a 4-French glide catheter was percutaneously inserted into the ipsilateral brachial artery and placed in the proximal subclavian artery. Following an arteriogram and localization of the subclavian arterial insertion site, the subclavian catheter was removed and bimanual compression was performed on both sides of the clavicle around the puncture site for 20 min. A second angiogram was performed, and if there was any extravasation, pressure was held for an additional 20 min. If hemostasis was still not obtained, a stent graft was placed via the brachial access site to repair the arterial defect and control the bleeding.

RESULTS

Two of the 20 patients required a stent graft for continued bleeding after compression. Both patients were well excluded after endovascular graft placement. Hemostasis was successfully obtained with bimanual compression over the puncture site in the remaining 18 patients. There were no resultant complications at either the subclavian or the brachial puncture site.

CONCLUSION

This minimally invasive endovascular approach to iatrogenic subclavian artery injury is a safe alternative to blind removal with manual compression or direct open repair.

Management of upper extremity vascular injury: outcome related to the Mangled Extremity Severity Score

BACKGROUND

The Mangled Extremity Severity Score (MESS) is an objective criterion for amputation prediction after lower extremity injury as well as for amputation prediction after upper extremity injury. A MESS of >or=7 has been utilized as a cutoff point for amputation prediction. In this study, we examined the result of upper extremity vascular injurty (UEVI) management in terms of the amputation rate as related to the MESS.

METHODS

During January 2002 to July 2007, we reviewed patients with UEVIs at our institution. Data collections included demographic data, mechanism of injuries, injury severity score (ISS), ischemic time, MESS, pathology of UEVI, operative management, and amputation rate. Decisions to amputate the injured limbs at our institution were made individually by clinically assessing limb viability (i.e., color and capillary refill of skin; color, consistency, and contractility of muscles) regardless of the MESS. The outcome was analyzed in terms of the amputation rate related to the MESS.

RESULTS

There were 52 patients with UEVIs in this study: 25 (48%) suffered blunt injuries and 27 (52%) suffered penetrating injuries. The age ranged from 15 to 59 years (mean 28.7 years). The mean ischemia time was 10.07 h. The mean ISS was 17.52. There were 12 patients (23%) with subclavian artery injuries, 3 patients (5.76%) with axillary artery injuries, 18 patients (34.61%) with brachial artery injuries, and 19 patients (36.54%) with radial artery and/or ulnar artery injuries. Primary repairs were performed in 45 patients (86.54%), with ligations in 3 patients (5.77%). An endovascular stent-graft was used in one patient (1.92%). Primary amputations were performed in three patients (5.77%). Secondary amputations (amputation after primary operation) were done in 4 of 49 patients (secondary amputation rate 8.16%). All amputation patients suffered blunt injuries and had a MESS of >or=7 (range 7-11). The overall amputation rate in this study was 13.46% (7/52 patients). Multivariate analysis revealed that the only factor significantly associated with amputation was the MESS. There were no amputations in 33 patients who had a MESS of <7. We could avoid amputation in 12 of 19 patients who had a MESS>or=7. There were no mortalities among 52 UEVI patients.

CONCLUSIONS

MESS, an outcome score used to grade the severity of extremity injuries, correlates well with the risk of amputation. Nevertheless, a MESS of >or=7 does not always mandate amputation. On the other hand, the MESS is a better predictor for patients who do not require amputation when the score is <7. The decisions to amputate in patients should be made individually based on clinical signs and an intraoperative finding of irreversible limb ischemia.

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.