Vascular damage control at the thoracic outlet.

Penetrating injuries to the subclavian artery carry a high mortality rate, especially when the patient presents in shock. Rapid and effective haemorrhage control is challenging due to the anatomical location at the thoracic outlet. Historically, vessel ligation has been used to control bleeding, but this is often performed late, when metabolic exhaustion is established, and is associated with upper-limb ischaemia and limb loss. Rapid proximal control through the chest with temporary intravascular shunting is the damage control technique of choice to temporise blood loss and restore perfusion until the patient is physiologically optimised for a delayed definitive vascular repair. We describe a case of vascular damage control in a patient after gunshot wound.

Brachial Plexus Injury Significantly Increases Risk of Axillosubclavian Vessel Injury in Blunt Trauma Patients With Clavicle Fractures.

BACKGROUND: A national analysis of clavicle fractures is lacking and the risk of concomitant axillosubclavian vessel injury (ASVI) in patients with clavicle fractures is unknown. A minority of patients may have a combined brachial plexus injury (BPI). We sought to describe risk factors for concomitant ASVI in patients with a clavicle fracture; hypothesizing patients with combined clavicle fracture and BPI has a higher risk of ASVI. METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for blunt trauma patients with a clavicle fracture. A multivariable logistic regression model was used to determine risk factors for ASVI. A subset analysis on patients with isolated clavicle fractures was additionally performed. RESULTS: From 59 198 patients with clavicle fractures, 341 (.6%) had concomitant ASVI. Compared to patients without ASVI, patients with ASVI had a higher median injury severity score (24 vs. 17, P < .001) and rates of pulmonary contusions (43.4% vs. 37.7%, P = .029) and BPI (18.2% vs. .4%, P < .001). After controlling for associated chest wall injuries and humerus fracture, the BPI odds ratio (OR 49.17, 35.59-67.92, P < .001) was independently associated with risk for ASVI. In a subset analysis of isolated clavicle fractures, BPI remained associated with risk of ASVI (OR 60.01, confidence intervals 25.29-142.39, P < .001). CONCLUSION: The rate of concomitant ASVI in patients with a clavicle fracture is <1%. Patients presenting with a clavicle fracture had a high rate of injuries including pulmonary contusion. Patients with findings suggestive of underlying BPI had a nearly 50 times increased associated risk of ASVI. Thus, a detailed physical exam in this setting including brachial-brachial index appears warranted.

Plunging Dangerously: A Quantitative Assessment of Drilling the Clavicle.

Bicortical drilling of the clavicle is associated with risk of iatrogenic damage from plunging given the close proximity of neurovascular structures. This study determined plunge depth during superior-to-inferior clavicle drilling using a standard drill vs drill-sensing technology. Two orthopedic surgeons drilled 10 holes in a fresh cadaveric clavicle with drill-sensing technology in freehand mode (functions as standard orthopedic drill) and another 10 holes with drill-sensing technology in bicortical mode (drill motor stops when the second cortex is breached and depth is measured in real time). The drill-measured depths were compared with computed tomography-measured depths. Distances to the neurovascular structures were also measured. The surgeons' plunge depths were compared using an independent t test. With freehand (standard) drilling, the mean plunge depth was 8.8 mm. For surgeon 1, the range was 5.6 to 15.8 mm (mean, 10.9 mm). For surgeon 2, the range was 3.3 to 11.0 mm (mean, 6.4 mm). The surgeons' plunge depths were significantly different. In bicortical mode, the drill motor stopped when the second cortex was penetrated. Drill-measured depths were verified by computed tomography scan, with a mean difference of 0.8 mm. Mean distances from the clavicle to the neurovascular structures were 15.5 mm for the subclavian vein, 18.0 mm for the subclavian artery, and 8.0 mm for the brachial plexus. Plunge depths differed between surgeons. However, both surgeons' plunge depths were greater than distances to the neurovascular structures, indicating a risk of injury due to plunging. Although a nonspinning drill bit may still cause soft tissue damage, drill-sensing technology may decrease the risk of penetrating soft tissue structures due to plunging. [Orthopedics. 2021;44(1):e36-e42.].

Failed angioembolization of a ruptured liver hemangioma complicated by iatrogenic injury of subclavian vein during catheter insertion.

In this study, we report a case of failed angioembolization of a ruptured liver hemangioma complicated by iatrogenic injury of the subclavian vein during catheter insertion. A 30-year-old woman experienced blunt trauma upon falling from her bed. Laceration of a seemingly preexisting hepatic hemangioma was diagnosed. No other injury was detected during a preoperative diagnostic workup. Subclavian vein catheterization was performed, followed by angioembolization to control bleeding due to the ruptured hemangioma. After angioembolization, the patient's systolic blood pressure and hemoglobin levels were 70 mmHg and 5.3 g/dL, respectively. She underwent emergency laparotomy. During the surgery, a large volume of blood in the abdominal cavity due to profuse bleeding from the ruptured hemangioma was observed. Because of a hemothorax found on chest radiography, we performed thoracoscopy, which revealed a large volume of blood in the right thoracic cavity and perforation of the subclavian vein by the catheter. After the damage-control surgery, the patient recovered safely. In this case, ruptured liver hemangioma complicated by subclavian vein catheter-related injury was treated safely using damage-control surgery. The catheter-related injury could be identified and treated using thoracoscopy.

Side-by-Side Stenting Repair of a Traumatic Pseudoaneurysm at a Venous Confluence.

OBJECTIVES: The incidence and prevalence of iatrogenic vascular trauma in the United States is staggering. This has led to the advent and implementation of more efficient and effective vascular repair methods. Although open surgical repair may still be considered gold standard, new endovascular solutions have emerged as other viable options. When using an endovascular approach, proper stent sizing is vital to a successful repair. METHODS: We present a case of a traumatic injury and pseudoaneurysm formation at the confluence of the right internal jugular and right subclavian veins during a central line placement. This iatrogenic pseudoaneurysm was treated with endovascular placement of side-by-side stents. A mathematical formula, which we have designated "Matteo's law," was utilized to select properly sized stent grafts to reconstruct the confluence and prevent infolding and endoleaks. RESULTS: After deployment of kissing stents at the confluence of the right internal jugular and right subclavian veins, a venogram was performed, which demonstrated successful exclusion of the pseudoaneurysm and no endoleaks. Clinical follow-up confirms continued wide open flow through the reconstructed venous confluence at 8 months post-procedure. CONCLUSION: In reconstruction of a venous confluence, selection of properly sized stent grafts is paramount to preventing infolding and endoleaks. Matteo's law states that the circumference of the native receiving vessel must equal the sum of the circumferences of both kissing stent grafts, subtracting the redundant material where the 2 stents interface.

Anatomic Site-Specific Complication Rates for Central Venous Catheter Insertions.

BACKGROUND: Central venous catheter (CVC) complication rates reflecting the application of modern insertion techniques to a clinically heterogeneous patient populations are needed to better understand procedural risk attributable to the 3 common anatomic insertion sites: internal jugular, subclavian, and femoral veins. We sought to define site-specific mechanical and duration-associated CVC complication rates across all hospital inpatients. METHODS: A retrospective chart review was conducted over 9 months at Georgetown University Hospital and Washington Hospital Center. Peripherally inserted central catheters and tunneled or fluoroscopically placed CVC's were excluded. Mechanical complications (retained guidewire, arterial injury, and pneumothorax) and duration-associated complications (deep vein thrombosis or pulmonary embolism, and central line-associated bloodstream infections) were identified. RESULTS: In all, 1179 CVC insertions in 801 adult patients were analyzed. Approximately 32% of patients had multiple lines placed. Of 1179 CVCs, 73 total complications were recorded, giving a total rate of one or more complications occurring per CVC of 5.9%. There was no statistically significant difference between site-specific complications. A total of 19 mechanical complications were documented, with a 1.5% complication rate of one or more mechanical complications occurring. A total of 54 delayed complications were documented, with a 4.4% complication rate of 1 or more delayed complications occurring. There were no statistically significant differences between anatomic sites for either total mechanical or total delayed complications. CONCLUSIONS: These results suggest that site-specific CVC complication rates may be less common than previously reported. These data further inform on the safety of modern CVC insertion techniques across all patient populations and clinical settings.

Controle de danos para lesão de artéria subclávia / Damage control for subclavian artery injury

Resumo Os traumas penetrantes de vasos subclávios atingem mortalidade de até 60% em um cenário pré-hospitalar. A mortalidade no intraoperatório varia de 5-30%. Apresenta-se um caso de estratégia de controle de danos para um paciente com lesão na origem da artéria subclávia esquerda, através de ligadura, sem necessidade de outra intervenção, mantendo a viabilidade do membro superior esquerdo por meio de circulação colateral. Os autores fazem uma revisão sobre vias de acesso e estratégias de tratamento com ênfase em controle de danos para lesões de vasos subclávios.

Abstract Mortality from penetrating traumas involving the subclavian vessels can be as high as 60% in pre-hospital settings. Operating room mortality is in the range of 5-30%. This paper presents a case in which a strategy for damage control was employed for a patient with an injury to the origin of the left subclavian artery, using subclavian ligation, with no need for any other intervention, and maintaining viability of the left upper limb via collateral circulation. The authors also review surgical approaches and treatment strategies with a focus on damage control in subclavian vessel injuries.

Twiddler's Syndrome Combined With Subclavian Crush Syndrome: A Case of ICD Lead Failure and Potential Challenging Lead Extraction.

Our report demonstrates how Twiddler's syndrome associated with subclavian crush syndrome may result in a challenging transvenous lead extraction. Thus, it should be performed in centers with experience with the appropriate tools.

Transvenous lead extraction with laser reduces need for femoral approach during the procedure.

INTRODUCTION: Cardiac implantable electronic device (CIED) trans venous lead extraction (TLE) is technically challenging. Whether the use of a laser sheath reduces complications and improves outcomes is still in debate. We therefore aimed at comparing our experience with and without laser in a large referral center. METHODS: Information of all patients undergoing TLE was collected prospectively. We retrospectively compared procedural outcomes prior to the introduction of the laser sheath lead extraction technique to use of laser sheath. RESULTS: During the years 2007-2017, there were 850 attempted lead removals in 407 pts. Of them, 339 (83%) were extracted due to infection, device upgrade/lead malfunction in 42 (10%) cases, and other (7%). Complete removal (radiological success) of all leads was achieved in (88%). Partial removal was achieved in another 6% of the patients. Comparison of cases prior to and after laser technique introduction, showed that with laser, a significantly smaller proportion of cases required conversion to femoral approach [31/275 (6%) laser vs. 40/132 (15%) non-laser; p<0.001]. However, success rates of removal [259/275 (94%) vs. 124/132 (94%) respectively; p = 0.83] and total complication rates [35 (13%) vs. 19 (14%) respectively; p = 0.86] did not differ prior to and after laser use. In multivariate analysis, laser-assisted extraction was an independent predictor for no need for femoral extraction (OR = 0.39; 95% CI 0.23-0.69; p = 0.01). CONCLUSION: Introduction of laser lead removal resulted in decreased need to convert to femoral approach, albeit without improving success rates or preventing major complications.

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.

Redefining the morphometry of subclavian vessels for clavicle fracture treatments.

PURPOSE: Clavicle fractures are common injuries in adults and children. Although neurovascular damage is rarely seen, acute subclavian artery pseudoaneurysms and injuries to subclavian vessels were reported for closed fractures of the clavicle. The aim of this study was to identify the morphological details of the subclavian vessels and their relation to the sternoclavicular joint and body of the clavicle. METHODS: 127 patients (66 females and 61 males) were evaluated using reconstructed three-dimensional computed tomographic angiographies. The point at which the subclavian artery crossed posterior to the clavicle was detected as a landmark. The medio-lateral distance between the sternal end of the clavicle, landmark, antero-posterior distance between the clavicle and the subclavian artery, diameter of the artery and vein, angle between the subclavian artery and vein, distance of the subclavian vein to the subclavian artery and the clavicle at the landmark were measured. Measurements were compared according to gender and right and left sides, and age correlation was determined. RESULTS: Morphometric relationship between the subclavian vessels and clavicle presented differences between genders. We measured the antero-posterior distance between the subclavian artery and the clavicle to be less than 1 cm (0.91 cm). CONCLUSION: The subclavian artery travelled longer distances in men than women to reach the point that it crossed the clavicle. Our results demonstrated that the subclavian artery does not pass from the inferior margin of the clavicle, thus, superior plate osteosynthesis does not have any risk to injury against the subclavian vessels during the management of the clavicle fractures.

Early-BYRD: alternative early pacing and defibrillation lead replacement avoiding venous puncture.

BACKGROUND: In cases of lead failure after implantation of pacemakers (PM) or implantable cardioverter defibrillators (ICD) early lead replacement may be challenging. Puncture of the subclavian vein bears possible complications such as pneumothorax, hematothorax, and damage of leads to be left in place. To avoid venous puncture PM or ICD leads were replaced using a flexible polypropylene sheath (Byrd-sheath). METHOD: From January 2010 through December 2017, 55 patients underwent early lead exchange avoiding venous puncture. Early lead exchange for this study was defined as a reintervention within 14 days after the initial lead implantation. The connector of the malfunctioning lead was cut off, and stabilized by a stiff stylet. After having cut off the plastic knob of the stylet, the lead was passed through the polypropylene sheath and the latter advanced into the subclavian vein with gentle rotational movements to gain access to the subclavian vein. After lead removal the polypropylene sheath was replaced by a peel away sheath a new lead inserted. RESULTS: Overall, 23 defibrillation leads and 34 pacing leads (16 right atrial leads, 17 right ventricular leads, and 1 left ventricular lead) were successfully explanted. Access to the subclavian vein was uneventful, and blood loss minimal. Radiation exposure and fluoroscopy time were also negligible. CONCLUSION: The Byrd-sheath technique proved to be safe and successful in providing vein access within 2 weeks after initial lead implantation using the previously implanted lead and thus avoiding puncture of the subclavian vein.

Pericardial Tamponade Caused by Perforation of Marshall Vein During Left Jugular Central Venous Catheterization.

BACKGROUND The persistence of a vein of Marshall (VoM) from the left subclavian vein to the coronary sinus is a rare cardiac anomaly known as a persistent left superior vena cava (PLVC). This anatomical variant is usually asymptomatic but can lead to serious complications during catheterization via the left subclavian or internal jugular vein, as described here. In our case, the patent vein of Marshall directly connected the coronary sinus with the left subclavian vein discovered in a cardiac arrest patient because of pericardial effusion during the insertion of a central venous catheter (CVC). CASE REPORT A 62-year-old patient required a central line insertion through a left internal jugular vein. The patient immediately went into cardiac arrest after CVC insertion with a pericardial effusion. The patient was successfully resuscitated with the drainage of a pericardial effusion. A chest X-ray revealed that the central venous catheter (CVC) was located along the left border of the mediastinum rather than the right border. It was evident that the central venous catheter was inadvertently placed into the pericardial space, resulting in tamponade. This complication occurred through inadvertent access of a small persistent vein of Marshall. CONCLUSIONS This case illustrates the importance of knowledge of anatomical variants of the persistent vein of Marshall to prevent or correctly interpret and manage procedural complications.

Blunt traumatic scapular fractures are associated with great vessel injuries in children.

BACKGROUND: Patients with stable blunt great vessel injury (GVI) can have poor outcomes if the injury is not identified early. With current pediatric trauma radiation reduction efforts, these injuries may be missed. As a known association between scapular fracture and GVI exists in adult blunt trauma patients, we examined whether that same association existed in pediatric blunt trauma patients. METHODS: Bluntly injured patients younger than 18 years old were identified from 2012 to 2014 in the National Trauma Data Bank. Great vessel injury included all major thoracic vessels and carotid/jugular. Demographics of patients with and without scapular fracture were compared with descriptive statistics. The χ test was used to examine this association using SAS Version 9.4 (SAS Institute, Inc, Cary, NC). RESULTS: We found a significant association between pediatric scapular fracture and GVI. Of 291,632 children identified, 1,960 had scapular fractures. Children with scapular fracture were 10 times more likely to have GVI (1.2%) compared to those without (0.12%, p < 0.0001). Most common GVI seen were carotid artery, thoracic aorta, and brachiocephalic or subclavian artery or vein. Children with both scapular fracture and GVI were most commonly injured by motor vehicles (57% collision, 26% struck). CONCLUSIONS: Injured children with blunt scapular fracture have a 10-fold greater risk of having a GVI when compared to children without scapular fracture. Presence of blunt traumatic scapular fracture should have appropriate index of suspicion for a significant GVI in pediatric trauma patients. LEVEL OF EVIDENCE: Epidemiologic and prognostic study, level III; Therapeutic, level IV.

The Selective Non-operative Management of Penetrating Cervical Venous Trauma is Safe and Effective.

BACKGROUND: This paper reviews our experience with penetrating cervical venous trauma and aims to validate the selective non-operative management (SNOM) of these injuries. METHODS: This was a retrospective review of a prospectively maintained registry. All patients presenting alive with an injury to the internal jugular vein, subclavian vein or innominate vein following a PNI were reviewed for a 6-year period. RESULTS: Among 817 patients admitted for the management of PNI, 76 (9.3%) had a venous injury. Of these, 37 (48.7%) patients were managed non-surgically, 20 (26.3%) required immediate surgical exploration, seven of whom had an associated arterial injury, and 19 (25%) underwent surgery following a diagnostic CTA, 16 of whom had an associated arterial or aero-digestive injury. In total, only 16 (21.1%) of the 76 patients required exploration for venous injury alone. The majority (63.2%) of patients had a history of severe bleeding or hemodynamic instability prior to arrival, but only 20 (26.3%) required immediate exploration. Two (2.6%) patients died as a result of venous injury. No patients developed complications related to the venous injury. CONCLUSIONS: SNOM is applicable to a well-defined subset of patients with isolated penetrating cervical venous trauma to the IJV and SCV identified on CTA.