Treatment Outcome of Traumatic Subclavian Artery Injuries

Endovascular Versus Open Repair in Adolescent Patients With Difficult-to-Access Vascular Injuries

INTRODUCTION

Management of subclavian artery injuries (SAI) and iliac artery injuries (IAI) in adolescent trauma patients poses a considerable challenge due to their complex anatomical locations. The aim of our study was to determine the association between the injury mechanism and type of repair with the outcomes of patients with traumatic SAI and IAI.

METHODS

In this retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database2017-2020, adolescent (<18 y) patients with SAI and IAI undergoing either endovascular or open repair were included. Patients were stratified by mechanism (blunt versus penetrating) and type of repair (endovascular [E] versus open [O]) and compared. Outcomes measured were mortality and major complications. Multivariable logistic regression analyses were performed.

RESULTS

Over 4 y, 170 pediatric patients were identified, of which 73 (43%) sustained an SAI and 97 (57%) had IAI. The mean age was 15 and 79% were male. Overall, 39% were managed endovascularly. Both groups had comparable median injury severity score (E: 23 versus O: 25, P = 0.278). For patients with blunt injury (n = 60), the type of repair was neither associated with major complications (E: 39% versus O: 33%, P = 0.694) nor mortality (E: 2.6% versus O: 4.8%, P = 0.651). For patients with penetrating injuries (n = 110), the endovascular repair had significantly lower morbidity (19% versus 41%, P = 0.034) and mortality (3.7% versus 21%, P = 0.041). On multivariable logistic regression, endovascular repair was identified as the only modifiable risk factor associated with reduced mortality (adjusted odds ratio: 0.201, 95% confidence interval [0.14-0.76], P = 0.038).

CONCLUSIONS

Difficult-to-access vascular injuries result in significant morbidity and mortality. Endovascular repair was found to be the only modifiable factor associated with decreased mortality of patients with penetrating injury, whereas the type of repair was not associated with mortality in those with blunt injury.

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

RATIONALE

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

PATIENT CONCERNS

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

DIAGNOSES

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

INTERVENTIONS

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

OUTCOMES

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

LESSONS

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

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.

Life threatening, subclavian artery mycotic aneurysm rupture into a gigantic supraclavicular abscess in an intravenous drug user

Subclavian artery injuries are sporadic, and the most common aetiology is trauma. Self-injury of the vessel in those misusing intravenous drugs is a rare complication, as most reports describe injury to the femoral artery. Thus, erosion and potential rupture of the arterial wall is possible due infection and phlegmon or abscess formation. We present a case of a young, female, hemodynamically unstable intravenous drug user admitted to the emergency department with a life-threatening, purulent haemorrhagic mass located at her right lateral cervical region. The patient admitted an inadvertent arterial puncture 10 days prior and an effort to self-manage the bleeding with the application of self-pressure and antibiotics. Computed tomography arteriogram of the neck revealed a gigantic, multicompartment, thick-walled collection with hyperdense fluid in her right supraclavicular region while active extravasation derived from the right subclavian artery was evident in late arterial phase. The patient was treated with endovascular graft stenting, despite the given presence of infection, as a salvage operation due to time limitation in open surgical repair.

Outcomes of vascular trauma associated with an evolution in the use of endovascular management

BACKGROUND

The availability of endovascular techniques has led to a paradigm shift in the management of vascular injury. While previous reports showed trends towards the increased use of catheter-based techniques, there have been no contemporary studies of practice patterns and how these approaches differ by anatomic distributions of injury. The objective of this study is to provide a temporal assessment of the use of endovascular techniques in the management of torso, junctional (subclavian, axillary, iliac), and extremity injury and to evaluate any association with survival and length of stay.

METHODS

The American Association for the Surgery of Trauma (AAST) Prospective Observational Vascular Injury Treatment registry (PROOVIT) is the only large multicenter database focusing specifically on the management of vascular trauma. Patients in the AAST PROOVIT registry from 2013-2019 with arterial injuries were queried, and radial/ulnar, and tibial artery injuries were excluded. The primary aim was to evaluate the frequency in use of endovascular techniques over time and by body region. A secondary analysis evaluated the trends for junctional injuries and compared the mortality between those treated with open vs. endovascular repair.

RESULTS

Of the 3,249 patients included, 76% were male, and overall treatment type was 42% nonoperative, 44% open, 14% endovascular. Endovascular treatment increased an average of 2% per year from 2013-2019 (Range: 17-35%, R² =.61). The use of endovascular techniques for junctional injuries increased by 5% per year (Range: 33%-63%, R² =.89). Endovascular treatment was more common for thoracic, abdominal, and cerebrovascular injuries, and least likely in upper and lower extremity injuries. Injury severity score (ISS) was higher for patients receiving endovascular repair in every vascular bed except lower extremity. Endovascular repair was associated with significantly lower mortality than open repair for thoracic (5% vs. 46%, p<.001) and abdominal injuries (15% vs 38%, p<.001). For junctional injuries, endovascular repair was associated with a non-statistically significant lower mortality (19% vs. 29%, p=.099), despite higher ISS (25 vs. 21, p=.003) compared to open repair.

CONCLUSION

The reported use of endovascular techniques within the PROOVIT registry increased more than 10% over a 6-year period. This increase was associated with improved survival, especially for patients with junctional vascular injuries. Practices and training programs should account for these changes by providing access to endovascular technologies and instruction in the catheter-based skill sets to optimize outcomes in the future.

Endovascular repair of isolated post-traumatic subclavian artery false-aneurysm (FA) using gore viabahn vbx-balloon-expandable (BE) stent-graft: case report and literature review

True and false aneurysms (FA) of the subclavian artery are at high risk of rupture due to their localization and proximity/closeness to the articular bone structures of the upper thoracic outlet and shoulders. Surgical and endovascular treatments are good options to avoid complications such as aneurysms rupture, thrombosis and distal embolism alone or in combination. Self-expandable (SE) covered stents are the most used devices for the treatment of subclavian artery aneurysms. We report on a case of post traumatic left intra-thoracic subclavian artery FA treated using endovascular technique, highlighting the usefulness of the new covered Gore Viabahn VBX-BE stent-graft that combines the advantages of a high radial strength of a BE stent with the deliverability and conformability of a SE stent.

Torso damage control for ongoing hemorrhage: Tips and tricks

Thoracic injuries are common and occur in combination with other injuries in various compartments representing a significant pattern of injury in any trauma center. Injured patients presenting with exsanguinating hemorrhage from the thoracic cavity are an acute subset of patients that can be extremely challenging to any trauma surgeon as the immediate need to diagnose and intervene is critical. Diagnosis is based on traumatic history pattern and hemodynamics, assisted with plain films, ultra-sound and properly placed chest tubes. The chest should always be considered as a source of unexplained hemodynamic instability with hemorrhage identification by tube thoracostomy, pericardial window or surgical thoracotomy if the patient is already in the OR or if imaging is not available. Various surgical incisions are possible for thoracic traumatic bleeding with various exposure advantages and disadvantages with care and thought prior to incision. Regardless, delay to intervention or trepidation is lethal particularly in these challenging trauma patients.