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The Management of Subclavian Artery Injuries Following Blunt Thoracic Trauma
The Management of Subclavian Artery Injuries Following Blunt Thoracic Trauma James T. Sturm, M.D., James S. Dorsey, M.D., Frederick R. Olson, M.D., and John F. Perry, Jr., M.D. ABSTRACT The records of 15 patients who sustained blunt rupture of the subclavian artery were reviewed. The findings on physical examination included arterial hypotension, unilateral absence of the radial pulse, brachial plexus palsy, and supraclavicular hematoma. The chest roentgenographic findings included wide mediastinums, apical pleural hematomas, and first rib fractures. Fourteen patients survived to undergo angiography and operation. Arterial continuity was restored by primary anastomosis, synthetic grafts, and venous interposition grafts. Ligation of a pseudoaneurysm was carried out in 1 patient with a complete brachial plexus palsy. Amputation of an upper extremity was required in 1 patient. Two patients died postoperatively. We conclude that blunt subclavian artery injuries may be suspected clinically. Absent upper extremity pulses, a wide mediastinum, unrelenting thoracic hemorrhage, and persistent hypotension dictate the necessity for aortography. Relative indications for angiography include brachial plexus palsy, apical pleural hematoma, and a fractured first rib. The complex anatomy of the superior mediastinum and thorax provides a musculoskeletal tunnel of protection for the subclavian vessels. This tunnel of protection makes injury to the subclavian arteries uncommon and at the same time renders the surgical exposure of these structures challenging. The rarity of subclavian artery injuries, and especially blunt subclavian injuries, is evident in both military and civilian practice (1-31. The Vietnam Vascular Registry noted the frequency of subclavian artery injuries to be approximately 1%of all arterial injuries [4]. A large civilian series demonstrated that subclavian arterial disruptions constitute less than 5% of arterial traumas [5]. The majority of reported subclavian artery injuries have occurred as a consequence of penetrating trauma [6]. The present article reviews our experience with 15 patients who incurred subclavian artery disruption after blunt thoracic trauma, and presents a management plan for the diagnosis and treatment of these injuries. From the Departments of Surgery, Emergency Medicine, and Radiology, St. Paul-Ramsey Medical Center, St. Paul, MN. Accepted for publication Jan 20, 1984. Address reprint requests to Dr.Sturm, St. Paul-Ramsey Medical Center, 640 Jackson St, St. Paul, MN 55101.
188
Material and Methods Fifteen patients with blunt disruption of the subclavian artery were treated between 1968 and 1982. There were 12 male and 3 female patients ranging in age from 16 to 43 years (mean & standard deviation 26.2 10.7 years). Six patients were injured as automobile occupants, 4 as motorcycle riders, 2 in crush injuries, and 1each in a fall, as a snowmobile rider, and as a pedestrian. The left subclavian artery was injured in 10 patients and the right subclavian artery, in 5. Severe associated injuries occurred in all patients. The types of injury were as follows: long bone, pelvic, and spinal fractures in 22 patients; other thoracic injuries, 18 patients; brachial plexus palsy, 8; abdominal visceral injuries, 5; closed head injuries, 2; and facial bone fractures, 2. The most common injuries were long bone fractures, brachial plexus palsies, hemopneumothorax, and multiple rib fractures. The Injury Severity Score for each patient was calculated as the sum of the squares of the Abbreviated Injury Codes for the three most severely injured areas of the body [7]. The Injury Severity Scores in this group of patients ranged from 20 to 57 (mean, 32.3 -t 9.96). Accurate records of the number of patients admitted to the hospital for blunt chest trauma are available from 1971 onward. Six patients in this series were seen during the ten-year period from 1971 through 1980, an incidence of 1 patient with subclavian artery disruption for every 187 patients admitted for blunt chest trauma.
*
Clinical Findings Seven patients were seen with arterial hypotension; 4 demonstrated systolic blood pressures of 90 mm Hg or less, and 3 showed systolic pressures of 60 mm Hg or less. One of these 7 patients was receiving cardiopulmonary resuscitation on arrival at the hospital and died in the operating suite before angiography and operation could be carried out. Fourteen of the 15 patients survived to undergo angiography and subsequent surgical repair. The radial pulse was unilaterally absent in 7 patients, present in 4, diminished but present in 2, and not recorded in 1. The radial pulse was indeterminate in the patient receiving cardiopulmonary resuscitation. A brachial plexus palsy on the side of the injured artery occurred in 8 of the 15 patients. A palpable hematoma was observed above the clavicle on the injured side in 4 patients. An ipsilateral fractured first rib was found on chest roentgenogram, at operation, or at autopsy in 7 of the 15 patients. Three of these 7 patients demonstrated
189 Sturm et al: Management of Subclavian Artery Injuries after Blunt Trauma
B Fig 1. (A) The chest roentgenogram demonstrates a markedly widened mediastinal shadow (I1 cm). (B)The angiogram illustrates extravasation of contrast medium from the right subclavian artery as it bifurcates from the innominate artery (arrow).
concomitant fractures of the clavicle. Four other patients showed clavicle fractures without first rib fractures. Three patients sustained scapular fractures and 1, a sternal fracture. On auscultation, no bruits or murmurs were noted in any of the patients. The initial 100 cm anteroposterior supine chest roentgenograms showed a wide mediastinum in 2 patients and an apical pleural radiodensity suggestive of a hematoma in the region of the subclavian artery in 1 patient. Two additional patients demonstrated these radiographic findings (Figs 1, 2). Fourteen of the patients underwent angiography. An absent upper extremity pulse, noted in 7 patients, was the most common indication for angiography. The other indications were a wide mediastinum, 3 patients; persistent arterial hypotension, 2 patients; chest tube hemorrhage, 1 patient; and apical pleural radiodensity, 1. Angiography was performed percutaneously through the femoral artery without any complications.
B Fig 2. (A) The chest roentgenogram shows an apical pleural hematoma on the right. (B)The angiogram demonstrates extravasation of contrast medium from the right subclavian artery just proximal to the internal mammary artery (arrow).
The angiographic and operative findings in 14 patients and the autopsy findings in 1 patient revealed that the left subclavian artery was disrupted in 10 patients and the right subclavian artery in 5 . The site of disruption for the left subclavian artery was near the origin of the vertebral artery in 8 patients, at the junction of the subclavian and axillary arteries in 1patient, and at the origin of the left subclavian artery from the aorta in another. On the right side, the arterial discontinuity occurred about 1 cm distal to the innominate bifurcation in 2 patients and near the origin of the vertebral artery in 3.
190 The Annals of Thoracic Surgery Vol 38 No 3 September 1984
Operative Management For the 10 patients with rupture of the left subclavian artery, several techniques were used. The supraclavicular approach was employed in 5 patients. A trap-door incision was used in 3 patients and an infraclavicular transpectoral incision, in the patient with a distal left subclavian artery tear. A standard posterolateral thoracotomy was employed for the patient in whom the left subclavian artery injury occurred at the origin of that artery hom the aortic arch. For patients with lesions of the right subclavian artery, a trap-door incision was used in 2 and a supraclavicular approach was taken in the 2 others who underwent operation. Primary anastomosis of the injured artery following debridement of devitalized tissue was performed in 7 patients. One of them also underwent reimplantation of an avulsed vertebral artery by end-to-side anastomosis. Arterial continuity was restored with synthetic grafts in 4 patients (two Dacron, two Gore-Tex), and venous interposition grafts were used in 2 patients. Proximal and distal ligation of a pseudoaneurysm was carried out in 1 patient with a complete brachial plexus palsy. The injury occurred in the nondominant extremity, which was flaccid and without function.
Results Successful revascularization was accomplished in 12 of the 14 patients. The patient with a brachial plexus palsy who underwent ligation of a pseudoaneurysm retained a viable, albeit functionless, extremity. One patient required an above-the-elbow amputation because the massive degree of injury precluded restoration of blood flow beyond the brachial artery. This patient was seen with absent arm pulses, a brachial plexus palsy, and profound swelling of the arm. A Gore-Tex interposition graft was placed without difficulty, but the brachial and radial pulses failed to return. Multiple insertions of an embolectomy catheter demonstrated no distal thrombi. Fasciotomies were carried out. Operative angiograms showed that the graft and distal subclavian artery were patent but that no contrast medium flowed beyond the distal brachial artery. Amputation was performed when it became obvious that the flaccid extremity was not viable. Two of the 14 patients who underwent operation died postoperatively (14.3%) of respiratory insufficiency resulting from severe pulmonary contusion. The most common postoperative complications were pulmonary insufficiency and pneumonitis (8 patients). Thrombosis of the axillary vein and arm contractures from palsy occurred in 1 patient each.
Comment . The present investigation illustrates that injury to the subclavian artery should be suspected following blunt thoracic trauma when upper extremity pulses are absent, a brachial plexus palsy is present, or an apical radiodensity or a wide mediastinum is present on the chest roentgenogram. We suggest that absent upper ex-
tremity pulses, a wide mediastinal shadow on chest roentgenogram, unrelenting thoracic hemorrhage, and persistent arterial hypotension following replacement of all obvious blood losses constitute firm indications for angiographic assessment of the aortic arch and its branches. We further suggest that relative indications for thoracic angiography include the presence of a brachial plexus palsy, a localized radiodensity over the apical lung field on the chest roentgenogram, and a fractured first rib. The presence of a brachial pulse should not preclude the diagnosis of subclavian artery injury. Each patient must be individually assessed. The approach toward thoracic aortography should not be timid. Richardson and associates [8] clarified the clinical dictum that a fractured first rib is an indication for thoracic aortography. They studied 55 patients with fractures of the first rib and found that subclavian artery injuries occurred in 3 of them (5.4%). They also reported that a first rib fracture is a hallmark of severe thoracic and extrathoracic trauma. The mortality in this group of patients was 36%. Thoracic injuries occurred in 64% of the series, and abdominal trauma was found in 33% of the patients. The findings of Richardson and co-workers [8] were confirmed by Phillips and colleagues [9]. They reviewed the cases of 45 patients with 49 first rib fractures following blunt thoracic trauma. All of their patients underwent arteriography, subclavian artery injuries were found in 4 (8.9%). Every patient with subclavian artery disruption had clinical evidence of arterial insufficiency. Brachial plexus injury occurred only in association with vascular injuries. Phillips and co-workers suggested that arteriography is indicated after first rib fractures when upper extremity pulses are absent, brachial plexus palsy exists, or first rib fractures (especially posterior fractures) are displaced. Approximately 78% of their first rib fractures could have been managed without arteriography if these principles had been applied. The protective musculoskeletal tunnel surrounding the subclavian arteries makes urgent exposure of these vessels challenging, because the approach used to provide this exposure must allow proximal and distal control of the artery and simultaneously must be expedient. The difficulty of attaining these two goals at the same time is emphasized in the review of Greenough [lo]. It states that by 1929, seventeen different approaches to the subclavian and innominate vessels had been described. The choice of incision depends on the side that is injured and the location of the arterial disruption [3,6, 111. A standard left thoracotomy is useful for approaching left-sided injuries that occur at the origin of the left subclavian artery from the aorta. Control of the proximal left subclavian artery also can be obtained through a small left anterior thoracotomy in the third or fourth intercostal space. The distal subclavian artery can then be approached by the supraclavicular route. If more exposure is required, an upper median sternotomy can be per-
191 Sturm et al: Management of Subclavian Artery Injuries after Blunt Trauma
formed, thereby connecting the incisions to form the socalled trap-door exposure. Reported difficulties with this exposure include loss of time, pleural entry, iatrogenic injury to the innominate and subclavian veins, excessive bleeding, poor exposure secondary to the position of the sternal edges, iatrogenic rib fractures, and difficulty in wound closure [2, 121. Bleeding may occur secondary to inadequate control of the internal mammary artery where the side of the sternum is divided. Left-sided lesions distal to the vertebral artery may be initially approached through a supraclavicular incision. If a large supraclavicular hematoma or persistent thoracic hemorrhage is present, a left anterolateral thoracotomy in the third or fourth intercostal space should be performed initially for proximal control of the subclavian artery. For lesions on the right side, a supraclavicular incision, extended into a median sternotomy when necessary, provides good exposure for injuries near the origin of the right subclavian from the innominate artery. Exposure can be improved by subperiosteal resection of the medial half of the clavicle [13]. Lesions distal to the origin of the vertebral artery may be approached by a supraclavicular incision. If a large supraclavicular hematoma is present, proximal control of the right subclavian artery can be obtained at its origin from the innominate artery through an upper median sternotomy. For lesions on either side, supraclavicular exposure of the subclavian artery is facilitated by placing a sandbag beneath the spine and rotating the chin toward the contralateral shoulder, as in performing Adson’s maneuver. In addition, it is necessary to divide both the sternocleidomastoid and the scalenus anterior muscles when exposing the subclavian artery above the clavicle. The operative mortality of 14.3%in this series parallels that of 11.8% for patients with penetrating subclavian artery injuries [6] and is comparable to that for patients with blunt thoracic trauma in general [14]. The previously noted relationship between mortality and degree of associated injuries [14] was also observed in the present study. Subclavian artery rupture is accompanied by severe associated injuries. The improvements in vascular surgical techniques have made the repair of these vascular lesions straightforward. The total treatment of the patient includes the management of associated injuries and long-term disability. In particular, major nerve injuries that accompany vascular trauma lead to the most severe disabilities. In the case of subclavian artery disruption, brachial plexus palsies occur in approximately half the patients. The palsy may be complete or incomplete and
may be transient or permanent. In most cases of blunt subclavian artery rupture accompanied by brachial plexus palsy, the palsy is virtually complete and almost always permanent. A flaccid and insensible upper extremity is a profound disability, and some patients have requested elective upper extremity amputation and shoulder arthrodesis. Subclavian artery injuries following blunt thoracic trauma have characteristic abnormalities on physical examination or radiological study. An aggressive approach to angiography should avert death from exsanguination when these life-threatening injuries are present.
This study was supported in part by the St. Paul-Ramsey Hospital Medical Education and Research Foundation.
References 1. DeBakey ME, Simeone FA: Battle injuries in World War 11: an analysis of 2471 cases. Ann Surg 123:534, 1946 2. Brawley RK, Murray GF, Crisler C, Cameron JL: Management of wounds of the innominate, subclavian, and axillary blood vessels. Surg Gynecol Obstet 131:1130, 1970 3. Lim LT, Saletta JD, Flanigan DP: Subclavian and innominate artery trauma: a five-year experience with 17 patients. Surgery 86:890, 1979 4. Rich NM, Baugh JH, Hughes CW: Acute arterial injuries in Vietnam: 1000 cases. J Trauma 10:359, 1970 5. Perry MO, Thal ER, Shires GT: Management of arterial injuries. Ann Surg 173:403, 1971 6. Graham JM, Feliciano DV, Mattox KL, et al: Management of subclavian vascular injuries. J Trauma 20:537, 1980 7. The Abbreviated Injury Scale. 1980 revision. Morton Grove, IL, American Association for Automotive Medicine, 1980 8. Richardson JD, McElvein RB, Trinkle JK: First rib fracture: a hallmark of severe trauma. Ann Surg 181:251, 1975 9. Phillips EH, Rogers WF, Gaspar MR: First rib fractures: incidence of vascular injury and indications for angiography. Surgery 89:42, 1981 10. Greenough J: Operations on innominate artery: report of a successful ligation. Arch Surg 19:1484, 1929 11. Natali J, Maraval M, Kieffer E, Petrovic P: Fractures of the clavicle and injuries of the subclavian artery: report of 10 cases. J Cardiovasc Surg (Torino) 16:541, 1975 12. Imamoglu K, Read RC, Nuebel HC: Cervicomediastinal vascular injury. Surgery 61275, 1977 13. Shumacker HB Jr: Operative exposure of the blood vessels in the superior anterior mediastinum. Ann Surg 127464, 1948 14. Sturm JT, Points BJ, Perry JF Jr: Hemopneumothorax following blunt trauma of the thorax. Surg Gynecol Obstet 141:539, 1975
188
Material and Methods Fifteen patients with blunt disruption of the subclavian artery were treated between 1968 and 1982. There were 12 male and 3 female patients ranging in age from 16 to 43 years (mean & standard deviation 26.2 10.7 years). Six patients were injured as automobile occupants, 4 as motorcycle riders, 2 in crush injuries, and 1each in a fall, as a snowmobile rider, and as a pedestrian. The left subclavian artery was injured in 10 patients and the right subclavian artery, in 5. Severe associated injuries occurred in all patients. The types of injury were as follows: long bone, pelvic, and spinal fractures in 22 patients; other thoracic injuries, 18 patients; brachial plexus palsy, 8; abdominal visceral injuries, 5; closed head injuries, 2; and facial bone fractures, 2. The most common injuries were long bone fractures, brachial plexus palsies, hemopneumothorax, and multiple rib fractures. The Injury Severity Score for each patient was calculated as the sum of the squares of the Abbreviated Injury Codes for the three most severely injured areas of the body [7]. The Injury Severity Scores in this group of patients ranged from 20 to 57 (mean, 32.3 -t 9.96). Accurate records of the number of patients admitted to the hospital for blunt chest trauma are available from 1971 onward. Six patients in this series were seen during the ten-year period from 1971 through 1980, an incidence of 1 patient with subclavian artery disruption for every 187 patients admitted for blunt chest trauma.
*
Clinical Findings Seven patients were seen with arterial hypotension; 4 demonstrated systolic blood pressures of 90 mm Hg or less, and 3 showed systolic pressures of 60 mm Hg or less. One of these 7 patients was receiving cardiopulmonary resuscitation on arrival at the hospital and died in the operating suite before angiography and operation could be carried out. Fourteen of the 15 patients survived to undergo angiography and subsequent surgical repair. The radial pulse was unilaterally absent in 7 patients, present in 4, diminished but present in 2, and not recorded in 1. The radial pulse was indeterminate in the patient receiving cardiopulmonary resuscitation. A brachial plexus palsy on the side of the injured artery occurred in 8 of the 15 patients. A palpable hematoma was observed above the clavicle on the injured side in 4 patients. An ipsilateral fractured first rib was found on chest roentgenogram, at operation, or at autopsy in 7 of the 15 patients. Three of these 7 patients demonstrated
189 Sturm et al: Management of Subclavian Artery Injuries after Blunt Trauma
B Fig 1. (A) The chest roentgenogram demonstrates a markedly widened mediastinal shadow (I1 cm). (B)The angiogram illustrates extravasation of contrast medium from the right subclavian artery as it bifurcates from the innominate artery (arrow).
concomitant fractures of the clavicle. Four other patients showed clavicle fractures without first rib fractures. Three patients sustained scapular fractures and 1, a sternal fracture. On auscultation, no bruits or murmurs were noted in any of the patients. The initial 100 cm anteroposterior supine chest roentgenograms showed a wide mediastinum in 2 patients and an apical pleural radiodensity suggestive of a hematoma in the region of the subclavian artery in 1 patient. Two additional patients demonstrated these radiographic findings (Figs 1, 2). Fourteen of the patients underwent angiography. An absent upper extremity pulse, noted in 7 patients, was the most common indication for angiography. The other indications were a wide mediastinum, 3 patients; persistent arterial hypotension, 2 patients; chest tube hemorrhage, 1 patient; and apical pleural radiodensity, 1. Angiography was performed percutaneously through the femoral artery without any complications.
B Fig 2. (A) The chest roentgenogram shows an apical pleural hematoma on the right. (B)The angiogram demonstrates extravasation of contrast medium from the right subclavian artery just proximal to the internal mammary artery (arrow).
The angiographic and operative findings in 14 patients and the autopsy findings in 1 patient revealed that the left subclavian artery was disrupted in 10 patients and the right subclavian artery in 5 . The site of disruption for the left subclavian artery was near the origin of the vertebral artery in 8 patients, at the junction of the subclavian and axillary arteries in 1patient, and at the origin of the left subclavian artery from the aorta in another. On the right side, the arterial discontinuity occurred about 1 cm distal to the innominate bifurcation in 2 patients and near the origin of the vertebral artery in 3.
190 The Annals of Thoracic Surgery Vol 38 No 3 September 1984
Operative Management For the 10 patients with rupture of the left subclavian artery, several techniques were used. The supraclavicular approach was employed in 5 patients. A trap-door incision was used in 3 patients and an infraclavicular transpectoral incision, in the patient with a distal left subclavian artery tear. A standard posterolateral thoracotomy was employed for the patient in whom the left subclavian artery injury occurred at the origin of that artery hom the aortic arch. For patients with lesions of the right subclavian artery, a trap-door incision was used in 2 and a supraclavicular approach was taken in the 2 others who underwent operation. Primary anastomosis of the injured artery following debridement of devitalized tissue was performed in 7 patients. One of them also underwent reimplantation of an avulsed vertebral artery by end-to-side anastomosis. Arterial continuity was restored with synthetic grafts in 4 patients (two Dacron, two Gore-Tex), and venous interposition grafts were used in 2 patients. Proximal and distal ligation of a pseudoaneurysm was carried out in 1 patient with a complete brachial plexus palsy. The injury occurred in the nondominant extremity, which was flaccid and without function.
Results Successful revascularization was accomplished in 12 of the 14 patients. The patient with a brachial plexus palsy who underwent ligation of a pseudoaneurysm retained a viable, albeit functionless, extremity. One patient required an above-the-elbow amputation because the massive degree of injury precluded restoration of blood flow beyond the brachial artery. This patient was seen with absent arm pulses, a brachial plexus palsy, and profound swelling of the arm. A Gore-Tex interposition graft was placed without difficulty, but the brachial and radial pulses failed to return. Multiple insertions of an embolectomy catheter demonstrated no distal thrombi. Fasciotomies were carried out. Operative angiograms showed that the graft and distal subclavian artery were patent but that no contrast medium flowed beyond the distal brachial artery. Amputation was performed when it became obvious that the flaccid extremity was not viable. Two of the 14 patients who underwent operation died postoperatively (14.3%) of respiratory insufficiency resulting from severe pulmonary contusion. The most common postoperative complications were pulmonary insufficiency and pneumonitis (8 patients). Thrombosis of the axillary vein and arm contractures from palsy occurred in 1 patient each.
Comment . The present investigation illustrates that injury to the subclavian artery should be suspected following blunt thoracic trauma when upper extremity pulses are absent, a brachial plexus palsy is present, or an apical radiodensity or a wide mediastinum is present on the chest roentgenogram. We suggest that absent upper ex-
tremity pulses, a wide mediastinal shadow on chest roentgenogram, unrelenting thoracic hemorrhage, and persistent arterial hypotension following replacement of all obvious blood losses constitute firm indications for angiographic assessment of the aortic arch and its branches. We further suggest that relative indications for thoracic angiography include the presence of a brachial plexus palsy, a localized radiodensity over the apical lung field on the chest roentgenogram, and a fractured first rib. The presence of a brachial pulse should not preclude the diagnosis of subclavian artery injury. Each patient must be individually assessed. The approach toward thoracic aortography should not be timid. Richardson and associates [8] clarified the clinical dictum that a fractured first rib is an indication for thoracic aortography. They studied 55 patients with fractures of the first rib and found that subclavian artery injuries occurred in 3 of them (5.4%). They also reported that a first rib fracture is a hallmark of severe thoracic and extrathoracic trauma. The mortality in this group of patients was 36%. Thoracic injuries occurred in 64% of the series, and abdominal trauma was found in 33% of the patients. The findings of Richardson and co-workers [8] were confirmed by Phillips and colleagues [9]. They reviewed the cases of 45 patients with 49 first rib fractures following blunt thoracic trauma. All of their patients underwent arteriography, subclavian artery injuries were found in 4 (8.9%). Every patient with subclavian artery disruption had clinical evidence of arterial insufficiency. Brachial plexus injury occurred only in association with vascular injuries. Phillips and co-workers suggested that arteriography is indicated after first rib fractures when upper extremity pulses are absent, brachial plexus palsy exists, or first rib fractures (especially posterior fractures) are displaced. Approximately 78% of their first rib fractures could have been managed without arteriography if these principles had been applied. The protective musculoskeletal tunnel surrounding the subclavian arteries makes urgent exposure of these vessels challenging, because the approach used to provide this exposure must allow proximal and distal control of the artery and simultaneously must be expedient. The difficulty of attaining these two goals at the same time is emphasized in the review of Greenough [lo]. It states that by 1929, seventeen different approaches to the subclavian and innominate vessels had been described. The choice of incision depends on the side that is injured and the location of the arterial disruption [3,6, 111. A standard left thoracotomy is useful for approaching left-sided injuries that occur at the origin of the left subclavian artery from the aorta. Control of the proximal left subclavian artery also can be obtained through a small left anterior thoracotomy in the third or fourth intercostal space. The distal subclavian artery can then be approached by the supraclavicular route. If more exposure is required, an upper median sternotomy can be per-
191 Sturm et al: Management of Subclavian Artery Injuries after Blunt Trauma
formed, thereby connecting the incisions to form the socalled trap-door exposure. Reported difficulties with this exposure include loss of time, pleural entry, iatrogenic injury to the innominate and subclavian veins, excessive bleeding, poor exposure secondary to the position of the sternal edges, iatrogenic rib fractures, and difficulty in wound closure [2, 121. Bleeding may occur secondary to inadequate control of the internal mammary artery where the side of the sternum is divided. Left-sided lesions distal to the vertebral artery may be initially approached through a supraclavicular incision. If a large supraclavicular hematoma or persistent thoracic hemorrhage is present, a left anterolateral thoracotomy in the third or fourth intercostal space should be performed initially for proximal control of the subclavian artery. For lesions on the right side, a supraclavicular incision, extended into a median sternotomy when necessary, provides good exposure for injuries near the origin of the right subclavian from the innominate artery. Exposure can be improved by subperiosteal resection of the medial half of the clavicle [13]. Lesions distal to the origin of the vertebral artery may be approached by a supraclavicular incision. If a large supraclavicular hematoma is present, proximal control of the right subclavian artery can be obtained at its origin from the innominate artery through an upper median sternotomy. For lesions on either side, supraclavicular exposure of the subclavian artery is facilitated by placing a sandbag beneath the spine and rotating the chin toward the contralateral shoulder, as in performing Adson’s maneuver. In addition, it is necessary to divide both the sternocleidomastoid and the scalenus anterior muscles when exposing the subclavian artery above the clavicle. The operative mortality of 14.3%in this series parallels that of 11.8% for patients with penetrating subclavian artery injuries [6] and is comparable to that for patients with blunt thoracic trauma in general [14]. The previously noted relationship between mortality and degree of associated injuries [14] was also observed in the present study. Subclavian artery rupture is accompanied by severe associated injuries. The improvements in vascular surgical techniques have made the repair of these vascular lesions straightforward. The total treatment of the patient includes the management of associated injuries and long-term disability. In particular, major nerve injuries that accompany vascular trauma lead to the most severe disabilities. In the case of subclavian artery disruption, brachial plexus palsies occur in approximately half the patients. The palsy may be complete or incomplete and
may be transient or permanent. In most cases of blunt subclavian artery rupture accompanied by brachial plexus palsy, the palsy is virtually complete and almost always permanent. A flaccid and insensible upper extremity is a profound disability, and some patients have requested elective upper extremity amputation and shoulder arthrodesis. Subclavian artery injuries following blunt thoracic trauma have characteristic abnormalities on physical examination or radiological study. An aggressive approach to angiography should avert death from exsanguination when these life-threatening injuries are present.
This study was supported in part by the St. Paul-Ramsey Hospital Medical Education and Research Foundation.
References 1. DeBakey ME, Simeone FA: Battle injuries in World War 11: an analysis of 2471 cases. Ann Surg 123:534, 1946 2. Brawley RK, Murray GF, Crisler C, Cameron JL: Management of wounds of the innominate, subclavian, and axillary blood vessels. Surg Gynecol Obstet 131:1130, 1970 3. Lim LT, Saletta JD, Flanigan DP: Subclavian and innominate artery trauma: a five-year experience with 17 patients. Surgery 86:890, 1979 4. Rich NM, Baugh JH, Hughes CW: Acute arterial injuries in Vietnam: 1000 cases. J Trauma 10:359, 1970 5. Perry MO, Thal ER, Shires GT: Management of arterial injuries. Ann Surg 173:403, 1971 6. Graham JM, Feliciano DV, Mattox KL, et al: Management of subclavian vascular injuries. J Trauma 20:537, 1980 7. The Abbreviated Injury Scale. 1980 revision. Morton Grove, IL, American Association for Automotive Medicine, 1980 8. Richardson JD, McElvein RB, Trinkle JK: First rib fracture: a hallmark of severe trauma. Ann Surg 181:251, 1975 9. Phillips EH, Rogers WF, Gaspar MR: First rib fractures: incidence of vascular injury and indications for angiography. Surgery 89:42, 1981 10. Greenough J: Operations on innominate artery: report of a successful ligation. Arch Surg 19:1484, 1929 11. Natali J, Maraval M, Kieffer E, Petrovic P: Fractures of the clavicle and injuries of the subclavian artery: report of 10 cases. J Cardiovasc Surg (Torino) 16:541, 1975 12. Imamoglu K, Read RC, Nuebel HC: Cervicomediastinal vascular injury. Surgery 61275, 1977 13. Shumacker HB Jr: Operative exposure of the blood vessels in the superior anterior mediastinum. Ann Surg 127464, 1948 14. Sturm JT, Points BJ, Perry JF Jr: Hemopneumothorax following blunt trauma of the thorax. Surg Gynecol Obstet 141:539, 1975