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.

The spectrum of computed tomography findings in blunt trauma of the subclavian/axillary artery: a pictorial essay.

Traumatic injuries of the subclavian and axillary arteries are uncommon but have high morbidity and mortality. In contrast to penetrating injuries, which are often lethal, blunt injuries present a wide and heterogeneous spectrum of imaging findings. If a vessel tear or transsection is a life-threatening circumstance, minor injuries might be overlooked in an emergency setting but could cause or aggravate the functional loss of a limb. The aim of this pictorial essay is to acquaint radiologists with the spectrum of imaging findings that could be encountered during the radiological evaluation of the subclavian/axillary artery (SAA) in trauma patients and offer tips and tricks to improve the diagnostic workup of patients with suspected blunt SAA injuries.

Cover with caution: Management of the Left Subclavian Artery in TEVAR for trauma.

BACKGROUND: Elective Thoracic Endovascular Aortic Repair (TEVAR) with left subclavian artery coverage (LSA-C) without revascularization is associated with increased rates of ischemic stroke. In patients with blunt thoracic aortic injury (BTAI) requiring TEVAR, LSA-C is frequently required in over one-third of patients. This study aimed to evaluate outcomes of TEVAR in BTAI patients with and without LSA-C. METHODS: The largest existing international multicenter prospective registry of BTAI, developed and implemented by the Aortic Trauma Foundation, was utilized to evaluate all BTAI patients undergoing TEVAR from March 2016 to January 2021. Patients with uncovered left subclavian artery (LSA-U) were compared with patients who had left subclavian artery coverage with (LSA-R) and without (LSA-NR) revascularization. RESULTS: Of the 364 patients with BTAI who underwent TEVAR, 97 (26.6%) underwent LSA-C without revascularization, 10 (2.7%) underwent LSA-C with revascularization (LSA-R). Late and all ischemic strokes were more common in LSA-NR patients than LSA-U patients ( p = 0.006, p = 0.0007). There was no difference in rate of early, late, or overall incidence of paralysis/paraplegia between LSA-NR and LSA-U. When compiled as composite central nervous system ischemic sequelae, there was an increased rate in early, late, and overall events in LSA-NR compared with LSA-U ( p = 0.04, p = 0.01, p = 0.001). CONCLUSION: While prior studies have suggested the relative safety of LSA-C in BTAI, preliminary multicenter prospective data suggests there is a significant increase in ischemic events when the left subclavian artery is covered and not revascularized. Additional prospective study and more highly powered analysis is necessary. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Usage of a percutaneous closure device to repair an iatrogenic subclavian artery injury.

OBJECTIVES: Inadvertent subclavian artery cannulation during attempted subclavian central venous access is more likely to occur during rushed trauma resuscitations when anatomic landmarks are used for placement. Traditional supraclavicular and infraclavicular approaches for direct repair of the resultant arteriotomy are painful, morbid procedures that should be replaced with more minimally invasive techniques. METHODS: This case report describes the usage of a percutaneous suture-mediated device (Perclose Proglide, Abbott Laboratories) to repair an iatrogenic subclavian artery arteriotomy. RESULTS: Two patients had their injuries successfully repaired using a percutaneous closure device. CONCLUSIONS: The use of a percutaneous closure device to repair iatrogenic subclavian artery injuries is a safe and effective method of repair that precludes a more invasive exposure and repair.

Repair of a Crossbow Bolt Injury of the Subclavian Artery Behind the Mid-clavicle.

The management of a rare midclavicular crossbow bolt injury to the subclavian artery is discussed. Important concepts include the initial clinical diagnosis, operative planning, the surgical approach to the retro-clavicular great vessels, the technical aspects of repair, and postoperative course. A discussion of the reasoning behind an operative vs. endovascular approach is also discussed.

Coverage of the Left Subclavian Artery in Blunt Thoracic Aortic Injury Repair Is Rarely Indicated.

BACKGROUND: Thoracic endovascular repair has become the standard treatment for blunt thoracic aortic injury (BTAI). Occlusion of the left subclavian artery (LSA) is generally required for an adequate landing zone (ALZ). We propose that coverage of the LSA is not necessary for BTAI even with a short landing zone (SLZ). METHODS: Retrospective review of BTAI patients, who were treated from January 2008 to December 2020, was analyzed. BTAI was categorized into 2 cohorts, SLZ <20 mm and ALZ >20 mm. Demographic data, trauma scores, grade of BTAI, procedure-related data, and clinical outcomes were analyzed. t-Test and chi-squared tests were used for statistical analysis. RESULTS: Thoracic endovascular repair was performed in 59 BTAI patients (mean age of 38.9 ± 14 years, mean Injury Severity Score of 40.4 ± 9.3). Two cohorts were identified: 49 patients had an SLZ, and 10 patients had an ALZ (14 ± 3.1 mm vs. 25 ± 4.1 mm, P = 0.03). The procedures were performed successfully with 59 patients (86.4%) deploying in zone 3. In-hospital mortality (SLZ group: 4.1% vs. ALZ group: 0, P = 0.318), endoleak (SLZ group: 4.1% vs. ALZ group: 20%, P = 0.45), stroke (SLZ group: 0 vs. ALZ group: 0, P = 1), spinal cord ischemia (SLZ group: 2% vs. ALZ group: 0, P = 1), left arm ischemia (SLZ group: 0 vs. ALZ group: 0, P =1), and reintervention rate (SLZ group: 0 vs. ALZ group: 0, P = 1) were not statistically different between cohorts. CONCLUSIONS: BTAI repair with an SLZ can be treated successfully without covering the LSA, analyzing technical success and in-hospital complications. Mid- and long-term data are necessary to confirm the durability of this technique.

Ministernotomy repair of inadvertent proximal right subclavian artery injury following right internal jugular central venous catheter insertion.

A man in his 60s was referred for urgent coronary artery bypass grafting (CABG) procedure following acute coronary syndrome. After induction of general anaesthesia, right jugular venous catheterisation under two-dimensional ultrasound guidance was planned as part of perioperative management. While obtaining vascular access, the pulsatile flow was noted once the dilator was inserted, having to abandon the procedure and immediately apply manual pressure. CT angiogram showed proximal right subclavian artery injury with active contrast extravasation and resultant large haematoma in the neck. The patient underwent urgent exploration of the injured vessel through a J-shaped ministernotomy, and primary repair of the artery was performed. The patient recovered from the procedure without any complications. He continued to stay in the hospital for a few days, afterwards, he underwent the initially planned CABG surgery. He was discharged home on day 5 after surgery without further concerns.

Impact of Endovascular Stenting on Outcomes in Patients with Traumatic Subclavian Artery Injury.

BACKGROUND: Traumatic subclavian artery injury (SAI) remains uncommon but can lead to significant morbidity and mortality. Although open and endovascular repair offer excellent limb salvage rates, their role in blunt and penetrating injuries is not well defined. The goal of this study was to examine the effect of mechanism of injury and type of repair on outcomes in patients with traumatic SAI. STUDY DESIGN: Patients undergoing procedures for traumatic SAI were identified from the Trauma Quality Improvement Program database between 2015 and 2018. Demographics, severity of injury and shock, type of subclavian repair (open vs endovascular), morbidity, and mortality were recorded. Patients with SAI were stratified by mechanism and type of repair and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality. RESULTS: Seven hundred thirty-seven patients undergoing procedures for SAI were identified. Of these, 39% were penetrating. The majority were male (80%) with a median age and Injury Severity Score (ISS) of 37 and 21, respectively. 58% of patients were managed endovascularly. For patients with blunt injury, the type of repair affected neither morbidity (25% vs 19%, p = 0.116) nor mortality (11% vs 10%, p = 0.70). For patients with penetrating injuries, endovascular repair had significantly lower morbidity (12% vs 22%, p = 0.028) and mortality (6% vs 21%, p = 0.001). MLR identified endovascular repair as the only modifiable risk factor associated with reduced mortality (odds ratio, 0.35; 95% confidence interval, 0.14 to 0.87, p = 0.02). CONCLUSIONS: SAI results in significant morbidity and mortality regardless of mechanism. Although the type of repair did not affect mortality in patients with blunt injury, endovascular repair was identified as the only modifiable predictor of reduced mortality in patients with penetrating injuries.

Analysis of Traumatic Axillo-Subclavian Vessel Injuries: Endovascular Management is a Viable Option to Open Surgical Reconstruction.

BACKGROUND: In traumatic axillo-subclavian vessel injuries, endovascular repair has been increasingly described, despite ongoing questions regarding infection risk and long-term durability. We sought to compare the clinical and safety outcomes between endovascular and surgical treatment of traumatic axillo-subclavian vessel injuries. METHOD: A search query of the prospectively maintained PROOVIT registry for patients older than 18 years of age with a diagnosis of axillary or subclavian vessel injury between 2014-2019 was performed at a Level 1 Trauma Center. Patient demographics, severity of injury, Mangled Extremity Severity Score (MESS), Injury Severity Score (ISS), procedural interventions, complications, and patency outcomes were collected and analyzed. RESULTS: Twenty-three patients with traumatic axillo-subclavian vessel injuries were included. There were similar rates of penetrating and blunt injuries (48% vs. 52%, respectively). Eighteen patients (78%) underwent intervention: 11 underwent endovascular stenting or diagnostic angiography; 7 underwent open surgical repair. There was similar severity of arterial injuries between the endovascular and open surgical groups: transection (30% vs. 40%, respectively), occlusion (30% vs. 40%, respectively). The open surgical group had worse initial clinical comorbidities: higher ISS scores (17.0 vs 13.5, p = 0.034), higher median MESS scores (6 vs. 3.5, P = 0.001). The technical success for the endovascular group was 100%. The endovascular group had a lower estimated procedural blood loss (27.5 mL vs. 624 mL, P = 0.03). The endovascular arterial group trended toward a shorter length of hospital stay (5.6 days vs. 27.6 days, P = 0.09) and slightly reduced procedural time (191.0 min vs. 223.5 min, P = 0.165). Regarding imaging follow up (average of 60 days post-discharge), 7 patients (54%) underwent surveillance imaging (5 with duplex ultrasound, 2 with computed tomography angiography CTA) that demonstrated 100% patency. Regardless of ISS or MESS scores, at long term clinical follow up (average of 214 days), there were no limb losses, graft infections or vascular complications in either the endovascular or open surgical group. CONCLUSIONS: Endovascular treatment is a viable option for axillo-subclavian vessel injuries. Preliminary results demonstrate that endovascular treatment, when compared to open surgical repair, can have similar rates of technical success and long-term outcomes in patency, infection and vascular complications.

Surgical Management of Subclavian and Proximal Axillary Artery Injuries.

Subclavian and proximal axillary arterial injuries are rare and difficult to manage. Eight patients were managed from January 2008 to December 2018 at The Aga Khan University Hospital, Karachi, Pakistan with mean age of 36.13 ± 14.48 years. All patients had penetrating injuries, from gunshot in 5 (62.5%), bomb blast in 2 (25%), and stab wound in 1 (12.5%) case. Six (75%) patients presented in haemodynamically stable condition. The mean time between the injury and patient presentation was 28 ± 8.39 hours. The injuries were approached via supraclavicular incision in 3 (37.5%) patients, infraclavicular incisions in 2 (25%) patients and median sternotomy in 2 (25%) patients. Three (37.5%) patients had false aneurysm, while 5 (62.5%) had transected artery. Primary repair was performed in 2 (25%) cases, while 6 (75%) patients were treated with interposition graft with polytetrafluoroethylene (PTFE). All patients have salvaged limbs with good functional outcomes.  Key Words: Subclavian artery, Penetrating injury, Vascular trauma, Vascular repair.

Treatment Outcome of Traumatic Subclavian Artery Injuries.

BACKGROUND: Traumatic subclavian artery injuries are associated with high morbidity and mortality. Thoracic cage and clavicle provide a well protection of the underlying subclavian vessels and nerves and also cause a very limited operation space during open surgery. The endovascular modality is less invasive and alternative to conventional open surgical reconstruction. PURPOSE: The purpose of this study was to analyze the different therapeutic effects on limb salvage. METHODS: A retrospective review of patients who presented with blunt or penetrating injuries to the subclavian arteries between March 2012 and March 2021. RESULTS: Endovascular and open repairs were both effective for traumatic subclavian artery injury. There was no statistical difference in the limb salvage, mortality, procedure-related complication, reintervention rate and in-hospital medical complications. Intraoperative blood loss, red blood cell transfusion requirement and length of hospital stay were significantly lower in the endovascular intervention group. CONCLUSION: Endovascular treatment represents an attractive alternative to the traditional surgical approach for the treatment of traumatic injuries in the subclavian.

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.

Reparación endovascular de las lesiones traumáticas de la arteria subclavia / Endovascular repair of traumatic subclavian artery injuries

Resumen Introducción: La reparación convencional de la arteria subclavia es desafiante, con una morbilidad del 24% y mortalidad del 5% al 25%; las técnicas endovasculares permiten la reparación arterial subclavia desde un acceso distal, reduciendo la elevada morbimortalidad asociada. Objetivo: Evaluar los resultados a largo plazo del tratamiento endovascular de las lesiones traumáticas de la arteria subclavia. Materiales y Método: Estudio descriptivo, observacional (revisión de serie de casos unicéntrica) de pacientes sometidos a la reparación endovascular de la arteria subclavia, debido a lesiones traumáticas, utilizando dos técnicas (stent balón expandible y oclusión endovascular con balón) durante un período de 12 años (2007-2019) en el Hospital Dr. Eduardo Pereira de Valparaíso, Chile. Resultados: Se realizaron 15 procedimientos consecutivos, electivos (86,67%), urgencias (13,33%), sexo masculino (66,67%), femenino (33,33%), edad promedio de 55,8 años (rango 26-69), abordaje utilizado: arteria femoral común (93,33%) y arteria braquial (6,67%), etiología de las lesiones: iatrogenia (66,67%) y trauma (33,33%), reparación mediante stent balón expandible (66,67%), oclusión endovascular con balón (33,33%), tasa de éxito técnico (100%), tasa de permeabilidad primaria a 1, 5, 10 años del 100%, 93,33% y 86,66% respectivamente, seguimiento medio (61,4 meses), estancia hospitalaria promedio (3,3 días), tiempo quirúrgico promedio (75 min), no hubo morbilidad cardiovascular, neurológica central o mortalidad relacionada al procedimiento. Discusión: La técnica endovascular elimina la necesidad de disección quirúrgica, disminuyendo el riesgo de lesión de estructuras adyacentes, especialmente en pacientes politraumatizados. Conclusión: En pacientes adecuadamente seleccionados, la técnica endovascular representa una excelente estrategia terapéutica de reparación de las lesiones subclavias.

Introduction: Conventional subclavian artery repair is challenging, with 24% morbidity and 5% to 25% mortality. Endovascular techniques allow subclavian repair from a distal artery, reducing the associated high morbidity and mortality. Aim: To evaluate the long-term results of endovascular treatment of traumatic lesions of the subclavian artery. Materials and Method: Descriptive, observational study (single-center case series review) of patients undergoing endovascular repair of the subclavian artery due to traumatic injuries, using two techniques (expandable balloon stent and endovascular balloon occlusion), during a period of 12 years (2007-2019), at the Dr. Eduardo Pereira Hospital in Valparaíso, Chile. Results: 15 consecutive procedures were performed, elective (86.67%), emergencies (13.33%), male sex (66.67%), female (33.33%), average age of 55.8 years (range 26-69), approach used: common femoral artery (93.33%) and brachial artery (6.67%), etiology of the lesions: iatrogenesis (66.67%) and trauma (33.33%), repair by expandable balloon stent (66.67%), balloon occlusion (33.33%), technical success rate (100%), primary patency rate at 1, 5, 10 years of 100%, 93.33% and 86.66% respectively, mean follow-up (61.4 months), average hospital stay (3.3 days), average surgical time (75 min), there was no cardiovascular, central neurological morbidity or mortality related to the procedure. Discussion: Endovascular techniques eliminate the need for surgical dissection, reducing the risk of injury to adjacent structures, especially in multiple trauma patients. Conclusion: In properly selected patients, the endovascular technique represents an excellent therapeutic strategy for the repair of subclavian artery lesions.

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

Subclavian artery injury is a rare complication of clavicle fracture. The fractured clavicle can lacerate the underlying subclavian artery. Life-threatening haemorrhage can occur secondary to arterial laceration, and if distal blood flow is impaired, upper limb ischaemia can develop. There is little discussion in the literature regarding combined (or 'hybrid') endovascular and open surgical management of acute subclavian injuries secondary to clavicle fracture. We report a case of subclavian artery laceration secondary to clavicle fracture, managed with a combined endovascular and open surgical approach. An endovascular balloon was used for proximal arterial control, while surgical exposure and primary repair of the subclavian artery was completed, followed by fixation of the clavicle. There was no sustained vascular or neurological impairment at follow-up. We suggest that select traumatic injuries of the subclavian artery can be safely and successfully managed with a combined endovascular and open surgical approach.

Endovascular Stent Graft Repair for True and Post-Traumatic False Aneurysms of the Subclavian Artery.

OBJECTIVE: Subclavian artery aneurysms (SAAs) are uncommon but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for SAAs. METHODS: The clinical data of 18 SAA patients who underwent endovascular repair at 3 hospitals from January 2009 to December 2019 were retrospectively collected and analyzed. RESULTS: Eighteen patients (12 men and 6 women) with a mean age of 61 years were included. Six patients (33.3%) had a history of hypertension, and 5 (27.8%) had a history of chest trauma. Five patients (27.8%) were asymptomatic. Thirteen (72.2%) SAAs were true aneurysms, and the others (27.8%) were posttraumatic false aneurysms. Endovascular stent graft repair was performed in all patients without conversion to open surgery. The immediate technique success rate was 94.4%, with no postoperative death and only one case (5.6%) of endoleak that was observed on intraoperative angiography and later resolved spontaneously. All patients survived over a median follow-up time of 57 months. Follow-up imaging showed that all stent grafts remained patent, with no endoleak. CONCLUSIONS: Endovascular stent graft repair is feasible, safe, and effective for true and posttraumatic false SAAs and represents a promising treatment option for these SAAs.

Iatrogenic jugulo-subclavian fistula.

Iatrogenic arteriovenous fistula of major neck vessels is a rare complication but can occur after central venous catheterization. Symptoms can range from nothing to severe heart failure and management can be particularly complex. We report a case that we treated recently in our department.

A systematic review and individual patient data meta-analysis of heart failure as a rare complication of traumatic arteriovenous fistulas.

OBJECTIVE: Traumatic arteriovenous fistulas (AVFs) are rare. The vast majority occur secondary to penetrating injuries. High-output cardiac failure is a well-recognized serious complication of AVFs, associated with high morbidity and mortality. The objective of the present study was to identify predictors of heart failure (HF) in patients with traumatic AVF. METHODS: Both PubMed/MEDLINE (Ovid) and CINAHL were searched (up to June 2019) for studies reporting individual patient data on the clinical and demographic characteristics of patients with AVF secondary to penetrating trauma. Exclusion criteria were age <18 years, no specification of symptoms, a cranial, spinal, or cardiac AVF location, and an iatrogenic mechanism of injury. The present study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. RESULTS: A total of 274 AVF patients from 15 case series and 177 case reports were included. The median age at presentation was 32 years (interquartile range, 24-43 years), 90% were men. The most frequent mechanisms of injury were stab wounds (43%) and gunshot wounds (32%). The AVF location was the abdomen (n = 86; 31%), lower limb (n = 79; 29%), neck (n = 61; 22%), thorax (n = 38; 14%), and upper limb (n = 10; 4%). Of the 274 patients, 35 (13%) had presented with HF and 239 (87%) with other symptoms. The risk of HF increased with an increased feeding artery diameter (P < .001). On univariate analysis, HF was significantly associated with a longer median time from injury to presentation with AVF (11.2 years vs 0.1 years; P < .001), older median age at presentation (43 years vs 31 years; P = .002), involvement of a large feeding artery (ie, aorta, pulmonary artery, subclavian artery, external iliac artery; 40% vs 13%; P < .001), shrapnel injuries (11% vs 2%; P = .011), and injuries to the trunk or lower limb (94% vs 71%; P = .004). After adjusting for clinical and demographic patient characteristics, involvement of a large feeding artery (odds ratio, 3.25; 95% confidence interval, 1.26-8.42; P = .015) and every 6 years of delay to presentation (odds ratio, 1.30; 95% confidence interval, 1.03-1.63; P = .026) remained independent predictors for HF. CONCLUSIONS: HF occurs in a small but important fraction of traumatic AVF patients and develops after highly variable latency periods. Large feeding arteries and delayed presentation independently predicted HF in this cohort.

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.