Subclavian and axillary vascular injuries

doi:10.1016/S0039-6109(01)80012-8

Surgical Clinics of North America

Volume 81, Issue 6, December 2001, Pages 1357-1373

https://doi.org/10.1016/S0039-6109(01)80012-8 Get rights and content

Injuries to the subclavian or axillary vessels are associated with a high mortality rate and only patients with short prehospital periods or contained bleeding survive long enough to be treated. The surgical exposure of these vessels can be difficult and excellent knowledge of the local anatomy is critical. This article describes the anatomy, epidemiology, diagnosis, and surgical exposure of these injuries. Newer diagnostic and therapeutic modalities are discussed also.

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Cited by (71)

Editor's Choice – In Hospital and Long Term Outcomes After Repair of Subclavian and Axillary Artery Injuries
2023, European Journal of Vascular and Endovascular Surgery
To evaluate the in hospital and long term outcomes after open or endovascular repair of subclavian and axillary artery injuries.
This was a retrospective, single centre study. Data were reviewed from patients with subclavian and or axillary injuries who presented to the authors’ centre between January 2009 and December 2022. Outcome data included complications, death, amputations, and re-interventions. A p value < .050 was considered to be statistically significant.
Over the study period, 62 patients with subclavian or axillary trauma were admitted to the study hospital. Patients were young (median age 32.5 years, range 12 – 53) and most were men (85%); 32 patients experienced blunt trauma, and 30 penetrating trauma. The median injury severity score was 18 (interquartile range [IQR] 9, 34), and 47% of patients had a brachial plexus injury. The arterial injury was occlusion in 62% of patients, and the median ischaemia time was 12.5 hours (IQR 7.13, 24). All patients with subclavian injuries (n = 37) and 13 of 25 patients with an axillary injury underwent endovascular repair (stent graft placement). Open repair was performed in 12 patients with axillary injury (axillobrachial bypass in seven patients). At hospital discharge, the amputation free survival rate was 82% vs. 92% (p = .67), the mortality rate was 10% vs. 8% (p = 1.0), and the amputation rate was 10% vs. 0 (p = .57) for endovascular and open repair, respectively. The mean follow up time was 4.1 ± 3.5 years. After the seven year follow up, the stent primary patency was 42%. No re-interventions or amputations were performed after hospital discharge. Disability was related to fractures and soft tissue and brachial plexus injuries.
Endovascular treatment was preferred for patients with subclavian artery injuries. Open repair was preferred for patients with penetrating axillary injuries. In hospital and long term complications were related to fractures and soft tissue and brachial plexus injuries, rather than the treatment of arterial injuries. Measures are needed to reduce ischaemia time and improve brachial plexus injury repair.
Major vascular traumas to the neck, upper limbs, and chest: Clinical presentation, diagnostic approach, and management strategies
2023, Seminars in Vascular Surgery
Major vascular traumas to the neck, upper limbs, and chest may arise from penetrating and/or blunt mechanisms, resulting in a range of clinical scenarios. Lesions to the carotid arteries may also lead to neurologic complications, such as stroke. The increasing use of invasive arterial access for diagnostic and/or interventional purposes has increased the rate of iatrogenic injuries, which usually occur in older and hospitalized patients. Bleeding control and restoration of perfusion represent the two main goals of treatment for vascular traumatic lesions. Open surgery still represents the gold standard for most lesions, although endovascular approaches have increasingly emerged as feasible and effective options, particularly for management of subclavian and aortic injuries. In addition to advanced imaging (including ultrasound, contrast-enhanced cross-sectional imaging, and arteriography) and life support measures, multidisciplinary care is required, particularly in the setting of concomitant injuries to the bones, soft tissues, or other vital organs. Modern vascular surgeons should be familiar with the whole armamentarium of open and endovascular techniques needed to manage major vascular traumas safely and promptly.
Subclavian vessel injuries: Difficult anatomy and difficult territory
2023, Current Therapy of Trauma and Surgical Critical Care
Surgical anatomy of the axillary artery: clinical implications for open shoulder surgery
2021, Journal of Shoulder and Elbow Surgery
Axillary artery injury is a devastating complication related to anterior shoulder surgery and can result in significant morbidity and/or mortality. The purpose of our study was to evaluate the course of the axillary artery in relation to bony landmarks of the shoulder and identify variations in artery position with humeral external rotation.
Dissection of 18 shoulders (9 fresh whole-body cadavers) with simulated vessel perfusion using radiopaque dye was performed. The axillary artery position was measured from multiple points including 2 points on the coracoid base (C1 and C2), 3 points on the coracoid tip (C3-C5), 4 points on the glenoid: superior, middle, and inferior glenoid (D1-D4), and 2 points on the lesser tuberosity (L1 and L2). Fluoroscopic measurements were taken and compared at 0° and 90° of external rotation (F1 vs. F1′ and F2 vs. F2′). Manual and fluoroscopic measurements were compared with one another using Kendall’s τ_b correlation.
There were 6 male and 3 female cadavers with an average age of 67.2 ± 9.3 years (range: 49-77 years). The mean distance from the axillary artery to the coracoid base (C1 and C2) measured 21.1 ± 7.3 and 22.3 ± 7.4 mm, respectively, whereas the mean distance to the coracoid tip (C3, C4, and C5) measured 30.7 ± 9.3, 52.1 ± 20.2, and 46.5 ± 14.3 mm, respectively. Measurements relative to the glenoid face (D1, D2, and D3) showed a progressive decrease in mean distance from superior to inferior, measuring 31.6 ± 10.3, 16.5 ± 7.5, and 10.3 ± 7.3 mm, respectively, whereas D4 (inferior glenoid to axillary artery) measured 17.8 ± 10.7 mm. The minimum distance from the axillary artery to any point on the glenoid was as close as 4.1 mm (D3). There was a statistically significant difference in F1 (0° external rotation) vs. F1′ (90° external rotation) (18.5 vs. 13.4 mm, P = .03). Kendall’s τ_b correlation showed a strong, positive correlation between manual and fluoroscopic measurements (D4: 16.0 ± 12.5 mm vs. F1: 18.5 ± 10.7 mm) (τ_b = 0.556, P = .037).
The axillary artery travels an average of 1-1.8 cm from the inferior glenoid margin, which puts the artery at significant risk. In addition, the artery is significantly closer to the inferior glenoid with humeral external rotation. Surgeons performing anterior shoulder surgery should have a thorough understanding of the axillary artery course and understand changes in the position of the artery with external rotation of the humerus.
Neck and Thoracic Outlet
2021, Rich’s Vascular Trauma
The neck and thoracic outlet contain numerous vital structures in a compact space, so trauma to this region often results in catastrophic hemorrhage, neurological deficit, and death. Consequently, the clinician must approach these patients with a high index of suspicion. The spectrum of vascular injuries ranges from exsanguinating hemorrhage to subtle imaging findings with a seemingly innocuous physical examination that can lead to delayed hemispheric stroke. Vascular injuries to the neck require utilization of multiple imaging modalities, comprehensive planning, and advanced operative skills. A knowledge of anatomy and vascular exposures along with keen surgical judgment are crucial, especially in the unstable patient in whom immediate surgical intervention is required. Improvements in the speed and sensitivity of computed tomography has led to its widespread use in screening patients for inconspicuous injuries. This has led to earlier recognition of blunt cerebrovascular injuries with associated improvements in prognosis. Endovascular treatment of injuries in the neck and thoracic outlet can reduce operative complexity and the morbidity of difficult surgical exposures. Although endovascular skills and technology have improved at a rapid pace, they have not been disseminated to the care of severely injured patients at the same rate. As endovascular capabilities for trauma become more routine, they will dramatically change treatment paradigms and improve outcomes.
Stent-Grafts, Coils, and Plugs
2021, Rich’s Vascular Trauma
Historically, angiography has been the gold standard for diagnosis of vascular trauma. Use of multidetector computed tomography in trauma patients has significantly decreased the need for diagnostic angiography in this population. What was once the main diagnostic modality for vascular trauma is now a platform for catheter-directed interventions for the acutely bleeding patient. Endovascular techniques are now widely accepted in the emergency management of many traumatic injuries. It has also become the preferred route of management for pseudoaneurysms and arterial venous fistulas that occur after solid organ injury. Catheter-based techniques for control of hemorrhage include occlusive embolization or reconstructive options using stent-grafting. Resuscitative endovascular techniques and management of traumatic aortic injury will be discussed elsewhere in this textbook. This chapter will focus on endovascular techniques for junctional vascular trauma, solid organ injury, pelvic injury, and iatrogenic injury as well as postoperative care. Although there has been an expansion of endovascular hemorrhage control, patient selection remains of paramount importance. Management of a hemodynamically unstable trauma patient continues to mandate immediate open operative intervention. Patients with solid organ or vascular injury who remain hemodynamically normal or respond appropriately to resuscitation may benefit from the decreased morbidity associated with endovascular interventions versus open exposure. Literature has shown high rates of success and decreased morbidity with endovascular hemorrhage control. Long-term outcomes continue to be investigated as this is an expanding therapy choice with increased use yearly.

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¹: From the Trauma and Surgical Intensive Care Unit, University of Southern California and the Los Angeles County and University of Southern California Medical Center, Los Angeles, California

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Subclavian and axillary vascular injuries

Chest

J Am Coll Surg

Injury

Penetrating injuries of the axillary artery

Aust NZ J Surg

Penetrating injuries to the thoracic great vessels

J Card Surg

Subclavian vascular injuries

Br J Surg

Evaluation of penetrating injuries of the neck. A prospective study of 223 patients

World J Surg

Penetrating injuries of the neck in stable patients. Physical examination, angiography, or color flow Doppler

Arch Surg

Noncovered stent placement in a blunt traumatic injury of the right subclavian artery

Cardiovasc Intervent Radiol