Subclavian artery trauma. Retrospective study of 20 cases
(Portuguese
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Alex
Lederman,1 Flávia Helena Matta de Paiva,2
Glauco Fernandes Saes,3 Ricardo Aun4
1.
Assistant physician, Hospital das Clínicas, Faculdade de Medicina,
Universidade de São Paulo (USP), São Paulo, SP, Brazil.
2. Fourth-year resident, Hospital das Clínicas, Faculdade de
Medicina, USP, São Paulo, SP, Brazil.
3. Ex-resident, Vascular Surgery, Hospital das Clínicas,
Faculdade de Medicina, USP, São Paulo, SP, Brazil.
4. Associate professor, Vascular Surgery Service, USP, São
Paulo, SP, Brazil.
Correspondence:
Ricardo Aun
Av. Albert Einstein, 627/1109
CEP 05659-001 São Paulo, SP, Brazil
Phone: +55 (11) 3742.1365
E-mail: aun@uol.com.br
ABSTRACT
Objective:
Review etiology, associated lesions, treatment, and evolution of
patients with traumatic subclavian artery injuries admitted to the
emergency room of our hospital from January 1997 to December 2001.
Method:
Retrospective review of medical charts at the Hospital das Clínicas
da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP).
Key words: subclavian artery injuries, subclavian artery trauma,
subclavian artery pseudoaneurysm, subclavian arteriovenous fistula.
Results: Of the 77 medical charts analyzed, 20 had subclavian
artery trauma. Seventeen patients were male, with mean age of 29.2
years (12-73). Bullet injuries were the main cause (14/20), followed
by motor vehicle accidents (5/20), and knife wound (1/20). Eleven
patients underwent an arterial bypass surgery with autogenous vein,
one subclavian artery ligation, two primary sutures, four endoluminal
stent grafts, one thrombectomy, and one patient died during surgery.
Associated lesions were: 14 brachial plexus injuries, 10 pulmonary
lesions (only one lobectomy needed), nine venous lesions, seven
thoracic wall lesions, four upper limb fractures, three head traumas,
one carotid artery injury associated to vocal cord paralysis due
to laryngeal nerve injury.
Conclusion: Subclavian artery traumatic lesions are rare and
frequently associated to a great number of lesions. Early and precise
diagnosis plays a major role in the evolution of patients. Arterial
bypass with autogenous vein graft is the most used treatment.
Key-words:
Subclavian artery, trauma, grafts.
J
Vasc Br 2005;4(2):149-54
Subclavian
artery traumatic injuries are rare, severe and present high morbidity
and mortality.1 The diagnosis is not always
clear, and the treatment is complex, since it requires a perfect knowledge
of the anatomy and peculiarities of that region. Surgical access is
complex, due to the surrounding structures (brachial plexus, subclavian
vein, clavicle, and costal arches). An access through thoracotomy or
sternotomy is needed in several cases, in order to obtain adequate hemostasis.2
The presence of associated lesions is extremely frequent, with the involvement
of venous, nervous, bone, mediastinal and cervical structures.3-5
The subclavian
artery lesion should be suspected when there is trauma in the upper
third of the thoracic wall, in the clavicle or supraclavicular fossa
topography associated to absent or reduced pulse in the lower limb,
hemorrhage, local hematoma, shock due to massive hemothorax, machinery
murmur, and first rib fracture.3-5
The clavicle
and chest muscles protect the first rib. In order to be fractured, there
is the need of a high-energy impact, which gives a good idea of the
lesion severity in this region.
The initial
assessment is of great importance, since in unstable cases and in the
hemorrhagic shock the surgical control is the only alternative for the
patient. For hemodynamically stable patients, the use of imaging examinations
is indicated for diagnostic confirmation. Since subclavian artery lesions
are a consequence of high-energy trauma, the investigation of associated
lesions must be done minutely (usually with radiography, tomography,
and ultrasonography).
The aim
of this study was to make a review of cases with subclavian artery injury
admitted to the emergency room of the Hospital das Clínicas da Faculdade
de Medicina da Universidade de São Paulo (USP), in São Paulo, Brazil,
for a 5-year period.
PATIENTS
AND METHOD
We reviewed
the medical charts from January 1997 to December 2001. Key words used
for sorting out medical charts were subclavian artery lesion, subclavian
artery pseudoaneurysm, arteriovenous fistula of subclavian vessels,
and subclavian artery injuries. Of the 77 medial charts identified,
only 20 presented traumatic lesion of subclavian vessels. We excluded
non-traumatic lesions, iatrogenic, arteritic, atherosclerotic, and chronic
cases.
Analyzed
parameters were Glasgow Coma Scale, blood pressure, respiratory frequency
at admittance. Table 1 and 2 are part of the Revised Trauma Score (RTS).6
 Table
1 - Table and formula used for calculating the Revised Trauma Score
(RTS)6
 |
| Glasgow
Coma Scale (GCS) |
Blood
pressure (BP) |
Respiratory
frequency (RF) |
Value |
|
| 13-15
|
>
89 |
10-29 |
4 |
| 9-12
|
76-89
|
>
29 |
3 |
| 6-8
|
50-75
|
6-9 |
2 |
| 4-5
|
1-49
|
1-5 |
1 |
| 3 |
0 |
0 |
0 |
|
RTS =
0.9368 GCS + 0.7326 BP + 0.2908 RF.
Table
2 - Relation between the Revised Trauma Score (RTS) 6
and survival
|
| RTS
|
Survival
probability |
|
| 0
|
0.027 |
| 1
|
0.071 |
| 2
|
0.172 |
| 3
|
0.361 |
| 4
|
0.605 |
| 5
|
0.807 |
| 6
|
0.919 |
| 7
|
0.969 |
| 7.84
|
0.988 |
|
RESULTS
Of the
20 cases reviewed, 17 were male and three were female. Mean age was
29.2 years (12 to 73 years).
Table
3 shows the cause of lesions.
Table
3 - Etiopathogeny of subclavian artery injuries
|
| Cause
|
n
of patients |
|
| Gunshot
wound |
14 |
| Stab
wound |
1 |
| Running
over |
1 |
| Motor
vehicle and motorcycle accidents |
3 |
| Automobile
passenger |
1 |
| Total
|
20 |
|
Gunshot
wounds were the predominant cause in 14 patients. Traffic accidents
were the cause in five patients: one was run over, three had motorcycle
accidents, and one was an automobile passenger. Only one patient was
a victim of stab wound (cervical thoracic injury).
Main clinical
manifestations at admittance were hemorrhagic shock, in eight patients;
absent pulse in the upper limb, in six patients; local hematoma and
tense hematoma, in four patients; murmur and thrill (arteriovenous fistula
- AVF), in two patients.
The vascular
lesion was clinically suspected in all patients. However, the clinical
examination was enough to define the site and conduct in only 10 patients.
In six cases, the diagnosis was confirmed by ultrasonography, and in
four patients by digital subtraction arteriography via femoral puncture.
All were hemodynamically stable and with the upper limb clinically compensated.
Arteriographies by retrograde injection of contrast in the brachial
artery were not performed, an option chosen by the service.7
The thoracic radiography was performed in 18 patients, being the supra-apical
opacification the most frequently found signal (10/20 patients), followed
by varied degrees of hemothorax (7/20 patients) and first rib fracture
(2/20).
Brachial
plexus lesions were the most frequent associated lesions, present in
55% of cases. No surgical correction of the brachial plexus was performed
at the initial moment. The pulmonary parenchyma lesion was present in
50% of cases, with pulmonary resection (lobectomy) in one case.
Table 4
shows the presence of associated lesions.
Table
4 - Frequency of associated lesions in the 24 cases of subclavian
artery lesion
|
| Associated
lesion |
n
of patients |
|
| Brachial
plexus |
11 |
| Pulmonary
|
10 |
| Venous
lesion |
7 |
| Thorax
(wall/fracture) |
7 |
| Upper
limb fracture |
4 |
| Head
trauma |
3 |
| Carotid
artery lesion |
1 |
| Hoarseness
(vocal cord paralysis) |
1 |
|
We performed
fourteen upper limb revascularizations, being 11 arterial bypass grafts
with autogenous vein (inverted internal bypass vein), two primary sutures,
and thrombectomy in one patient. One patient was submitted to subclavian
artery ligation without reconstruction. One patient with a pseudoaneurysm
and three patients with subclavian artery fistula were submitted to
an endovascular treatment with endoprosthesis insertion. One patient
admitted with hemorrhagic shock died before the lesion could be identified
(initial RTS = 2.98).
Table
5 shows the surgical approaches.
Table
5 - Approaches used in the treatment of traumatic lesions of the
subclavian artery
* Death
with no lesion approach.
In a 5-year
follow-up, there was a preservation of the upper limb in 18 patients.
Of these, nine presented some level of neurological deficit, due to
the brachial plexus lesion. Two patients were submitted to plexus reconstruction
and progressed well in the weeks after the primary surgery.
One patient,
who was ran over by a truck and had the left hemithorax and the left
upper limb crushed, progressed with occlusion of the subclavian-axillary
graft, limb and thoracic wall gangrene. He was submitted to external-clavicular-scapulohumeral
disarticulation. His current condition is good, but the recovery is
compromised due to the upper limb disarticulation.
Operative
mortality was 20% (4/20). One patient died before the lesion could be
controlled; another patient died soon after the end of the surgery -
artery and subclavian vein ligation by external cervical thoracotomy
(initial RTS = 2.98). The patient who presented a cervical thoracic
bullet injury with lesion and subclavian, carotid, and vertebral artery
ligation died on the second postoperative day (RTS = 3.92). One patient
who, despite the revascularization being patent and functional, progressed
with pulmonary complications died on the 38th postoperative
day (RTS = 4.92). The RTS of patients who died varied from 2.92 to 3.92,
and of those who survived varied from 6.2 to 7.4 (means of 7.05 and
3.92, respectively).
DISCUSSION
The traumatic
lesion of subclavian vessels presents high morbidity and mortality,
reaching 66% if deaths at the site of the trauma are included,8
and between 14.8 to 15.5% of cases that are admitted to the surgical
center alive.8,9 In our series, we only
analyzed cases of patients who were admitted alive at the hospital,
and in 70% of cases with penetrating lesion (14/20). The presence of
several associated lesions indicates the severity of the initial lesion.
Brachial plexus lesion was the most frequent 14/20 (70%), above the
average reported in the literature,10 with
a high level of neurological sequel (12/14), which is probably due to
the exclusion of iatrogenic cases from the casuistics, since they tend
to cause damage to a smaller extent of the artery. The severity of lesions
in cases reported here is coherent with the types of traumatic agents
verified, that is, penetrating trauma due to high-speed bullet injury
and in blunt trauma or with intense deceleration. In these cases the
traumatic avulsions of the plexus roots are common.
Venous
lesions, whose incidence in the literature is 20%,9
were 9/20 (45%) in our series. The reason for this high number of venous
lesions is the same reported for the occurrence of brachial plexus lesions.
In both
situations, the anatomical proximity was also a major factor for the
presence of associated lesions. The use of auxiliary diagnostic methods
is often not possible, due to the hemodynamic instability presented
by the patients. Performing advanced imaging examinations, such as the
duplex scanning, computed tomography (CT), and arteriography is justified
for stable patients. These imaging methods locate the wound and define
the approach more clearly. As a general rule, however, thoracic radiographies
should be made as frequent as possible. We do not make it only in exceptionally
emergent cases that need immediate surgery. Predominant radiological
signs in the literature5,8 are the presence
of supra-apical opacification (which, in our series, was the predominant
radiological sign, found in 10/20 patients), widening of the superior
mediastinum, blurring of the aortic knob, deviation of the trachea,
pneumothorax and hemothorax, besides fracture of the costal arches.
The fracture of the first costal arch is particularly highly indicated
in closed thoracic trauma of the subclavian artery lesion (2/20 cases).
A clavicle fracture was also found. In these patients, the occurrence
of trauma of the cervical and thoracic vertebrae is also possible. In
hemodynamically stable patients ultrasonography (duplex scanning) and
CT are performed, when it does not imply therapeutic delay, to locate
the vascular lesion and establish the operative strategy.2,5,8
CT plays a major role in the identification and staging of associated
lesions. Arteriography is a method of actual importance and therapeutic
convenience. However, as a method of isolated identification of the
arterial lesion it is rarely performed. Retrograde humeral arteriography,
although not used in our service, is a simple, fast, and efficient diagnostic
method, which could be performed even in emergency rooms with conventional
x-ray device. It offers high accuracy, which allows readiness and promptness
in the patient's treatment, as showed by Aerts et al.'s7
experiment in our environment. Endoluminal treatment methods of subclavian
artery injuries have been used more often. In these cases, arteriography
serves four purposes: identification, location, planning, and execution
of the treatment.
When there
is hemodynamic instability, the patient is then submitted to approaches
according to clinical suspicion of bleeding or hematoma location. In
this series there was hemodynamic instability in six patients. In two
patients, there was no suspicion of the injured artery, which made impossible
any examination besides a simple radiography. At hospitals prepared
for giving medical care to these patients, ultrasound, CT and even pre-operative
arteriography can be performed, particularly on patients in whom the
endoluminal treatment is intended, occurring in four cases of this series.
As to the
approach, we used combined approaches, aiming at obtaining access to
the longitudinal axis of the vessel, as established by Schumaker,2
with a few modifications and adaptions.11
Whenever possible, we established a proximal repair for the clamping
before approaching the lesion site. Isolated median sternotomy (10/20
cases) or associated to another approach was the most used approach,
once the hemostasis of the lesion is more efficiently obtained with
the proximal control of the brachiocephalic trunk and the left carotid
artery. To approach the left subclavian artery origin, the left thoracotomy
at the third or fourth space is needed. However, the exposed segment
of this artery through such approach is limited to 2 or 3 cm, hence
the need for sternotomy and supraclavicular fossa.11
Concerning
lesions of the distal segment of the subclavian artery, two aspects
should always be taken into consideration by the surgeon. First, the
supraclavicular approach and the anatomical relations of the artery
with the brachial plexus and the subclavian artery. Second, still considering
the objective of having access to the longitudinal axis of the vessel,
is the conduct towards the clavicle. In this series, whenever needed,
the middle third of the clavicle was resected to allow a wider exposure
of the subclavian vessels and branches of the plexus (three cases with
no important sequels).
Arterial
repair through bypass with an inverted saphenous vein is the choice
method.12 Debridement and primary anastomosis
are also accepted techniques. There are cases in which the use of synthetic
material, like PTFE,13 is justified. In
this series, of the 14 surgical revascularizations performed, inverted
bypass vein was used in 11, two primary sutures were performed and thrombectomy
in only one patient. Arterial ligation was performed in one patient,
who progressed to death in the early postoperative period.
The endovascular
treatment with endoprosthesis insertion was performed in four patients,
who were admitted hemodynamically stable and with no signs of upper
limb ischemia. In these patients (4/20) we found local hematoma with
murmur and thrill in two cases. Preoperative arteriography was only
performed in these four patients. However, as a choice of our service,
the endoluminal treatment was performed at the surgical center, once
there is always the possibility for operative conversion. Endoprostheses,
when inserted into the subclavian artery, may present an occlusion rate
of 60% until 18 months after insertion. Nevertheless, as it occurs slowly
and progressively, there is no development of ischemia symptoms.14
None of the patients submitted to the endoprosthesis insertion died,
which makes its use attractive when there is no ischemia or hemodynamic
decompensation.
Regarding
the extremity preservation, one patient had to be submitted to amputation.
Besides the vascular lesion, there was a great crushing of soft tissue
that was infected, forcing the interscapulo-humeral disarticulation
on the fifth postoperative day, despite the functionality of the reconstruction.
Despite the severe case of infection and thoracic trauma associated,
this patient survived.
There were
four deaths, one in the preoperative period and before hemostasis was
obtained, and the other three in the postoperative period, due to systemic
complications of the trauma and hemorrhage, well characterized by the
RTS assessment, which, in this series, was 3.8 among those who died,
and 7.05 among those who survived. Mortality (20%) is compatible with
the literature.9,10,12
RTS6
has been accepted by several services as a determiner of the severity
and the death risk of traumatized patients. Although originally accepted
as a screening tool, it now has a wider use and can currently predict
death risk of a certain patient with a determined trauma, according
to Table 2.
In this
series, patients who died presented RTS between 2.98 and 3.02, with
survival probability between 17.2 and 36.1%. Among patients who survived,
RTS was between 6.2 and 7.4, with 91.9 and 98.8%, respectively.
We conclude
that subclavian artery traumatic lesions are rare and often associated
to a great number of lesions. Early and precise diagnosis plays a major
role in the evolution of patients. Arterial bypass with autogenous vein
graft is the most used treatment. In the long term most limitations
are a consequence of brachial plexus lesion sequels.
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