Case Report: Urgent endovascular treatment of subclavian artery injury after blunt trauma

Abstract

Subclavian arterial injury is rare and potentially life-threatening, particularly when it leads to arterial occlusion, causing limb ischemia, retrograde thromboembolization and cerebral infarction within hours after injury. Here we report a blunt trauma case with subclavian arterial injury, upper extremity ischemia, and the need for urgent treatment to salvage the limb and prevent cerebral infarction. A 41-year-old man had a left, open, mid-shaft clavicle fracture and left subclavian artery injury accompanied by a weak pulse in the left radial artery, decreased blood pressure of the left arm compared to the right, and left hand numbness. Urgent debridement and irrigation of the open clavicle fracture was followed by angiography for the subclavian artery injury. The left distal subclavian artery had a segmental dissection with a thrombus. Urgent endovascular treatment using a self-expanding nitinol stent successfully restored the blood flow and blood pressure to the left upper extremity. Endovascular treatment is a viable option for cases of subclavian artery injury where there is a risk of extremity ischemia and cerebral infarction.

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

“…Furthermore, these reports suggest endovascular control prior to open repair results in minimal active haemorrhage during the repair, in turn reducing intraoperative blood loss, improving the surgical field, reducing the risk of iatrogenic neurovascular injury and improving the accuracy of the repair itself. 10 We found this to be true in our case, even in the previously unreported context of acute subclavian artery trauma secondary to clavicle fracture.…”

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

“…67 Dissections, including dissections that result in occlusion, can be treated with bare metal stents such as the WALLSTENT (Boston Scientific) 48,65 and Smartstent (Cordis). 57…”

“…52 Concern for brachial injury if washout is not performed may not bear out-in one study where all 8 patients were managed with stents despite hemodynamic instability or hematoma, only 1 required a washout. 52 Lesions treated within the literature include occlusions, 54 dissections, 48,52,[55][56][57] pseudoaneurysm, 48,58,59 and arteriovenous (AV) fistulas 49,60 due to trauma. There are multiple reports of trauma secondary to iatrogenesis as well, which can present as AV fistulas and pseudoaneurysms.…”

“…67 Dissections, including dissections that result in occlusion, can be treated with bare metal stents such as the WALLSTENT (Boston Scientific) 48,65 and Smartstent (Cordis). 57 In most reports, femoral access is used. Multiple cases describe the use of brachial access in addition to femoral access if the lesion is difficult to cross, 54,68 such as in the case of a complete transection.…”

Delayed subclavian artery rupture secondary to a traumatic first rib fracture

“…Endovascular repair with the use of a covered stent graft is a less invasive method of repair and allows the area of injury to be accessed from a remote site which is preferable if there is an area of surrounding traumatised tissue. Endovascular approaches are particularly useful when there is a high risk of ischaemia to the limb or cerebral infarction [ 6 ].…”