Cervicothoracic arterial injuries: Recommendations for diagnosis and management

Abstract

Management of arterial injuries at the thoracic outlet and neck presents a major challenge to the trauma surgeon: hemorrhagic shock, neurologic deficit, and limb loss are the serious sequelae. Over a 13-year period, 118 patients with injuries to the innominate, carotid, subclavian, and axillary arteries were evaluated. Most injuries were penetrating (78%). Half of the patients were diagnosed by physical examination and half by angiography. Patients were treated by either primary repair (35%), interposition graft (31%), ligation (8%), or anticoagulation (26%). Two patients required amputations (1 digit, 1 above elbow). Overall mortality was 14%, with 5% due to consequences of hemorrhagic shock, 7% due to cerebral ischemia, and 2% due to other causes. Claviculectomy, median sternotomy, and trap door incisions were routinely used for proximal vascular control and repair. We conclude that liberal use of angiography is indicated in stable patients for penetrating wounds near major arteries, and for blunt injuries associated with neurologic deficits unexplained by computed tomography. Patients with obvious arterial injury should have immediate exploration. Extensile exposure is mandatory for appropriate management. Blunt carotid dissections are generally best managed non-operatively with anticoagulation.

Temporary Thoracoscopic Control of the Proximal Left Subclavian Artery for Trauma

“…[2][3][4] Patients fortunate enough to reach surgical intervention have a mortality of 5% to 30% and the mortality is extremely high in those undergoing resuscitative thoracotomy. [5][6][7][8][9] Patients who survive the injury experience considerable morbidity often involving brachial plexus, phrenic nerve, thoracic duct, and occasionally limb loss. 10 -12 These complications are some- Controversies regarding the management of neck injuries date back 4.5 centuries when Ambroise Paré ligated the common carotid and jugular vein and subsequently Flemming ligated the carotid artery with postoperative morbidity and success respectively.…”

Subclavian vessel injuries: difficult anatomy and difficult territory

“…Busy urban trauma centers report admitting between two and four subclavian vascular injuries per year, although some international trauma centers have reported admitting as high as four patients per month [4,5,15,24]. Subclavian artery injury specifically accounts for 1-2% of all acute vascular injuries [3,4,8,9,26,27].…”

“…On the other hand, blunt subclavian artery injuries occur far less frequently. Urban trauma centers report that approximately 1-3% of all traumatic subclavian artery injuries result from blunt trauma [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]. The relatively low incidence of blunt vascular trauma is due to the protected anatomic location of the subclavian vessels.…”

“…A clavicular incision is planned, with the initial incision made in the region of the sternoclavicular junction and extending over the medial half of the clavicle, and, if necessary, continuing onto the deltopectoral groove (see Figs. 2,3,4,5). Adjacent muscle attachments are stripped off the clavicle to better facilitate upward retraction.…”

Emergent Axillary Artery Stent-Graft Placement for Massive Hemorrhage from an Avulsed Subscapular Artery

“…1,2 Surgical management of arterial trauma in the shoulder region is challenging and requires extensive exposure. 3 Over the past decade, stent-graft repair of peripheral arteries has become a viable option in the treatment of vascular disease and injuries. However, little data is available on the use of stent-grafts for emergency treatment of active bleeding in the supra-aortic vessels.…”