Subclavian Vessel Injuries: Difficult Anatomy and Difficult Territory

Eur J Trauma Emerg Surg (2011) 37:439–449 DOI 10.1007/s00068-011-0133-2

REVIEW ARTICLE

Subclavian vessel injuries: difﬁcult anatomy and difﬁcult territory

J. D. Sciarretta • J. A. Asensio • T. Vu • F. N. Mazzini • J. Chandler • F. Herrerias • J. M. Verde • P. Menendez • J. M. Sanchez • P. Petrone • K. D. Stahl • H. Lieberman • C. Marini

Received: 16 June 2011 / Accepted: 19 June 2011 / Published online: 29 July 2011 Ó Springer-Verlag 2011

Abstract of the mechanism, such injuries can result in significant Introduction Thoracic and thoracic related vascular inju- morbidity and mortality. Subclavian vessel injuries are ries represent complex challenges to the trauma surgeon. generally associated with multiple life-threatening injuries. Subclavian vessel injuries, in particular, are uncommon and Over the years, the overall mortality has continued to highly lethal. Regardless of the mechanism, such injuries improve due to significant advancements in resuscitation, can result in significant morbidity and mortality. emergency medical transport systems, and the increased Materials and methods Systematic review of the litera- development of regionalized systems of trauma. ture, with emphasis on the diagnosis, treatment and outcomes of these injuries, incorporating the authors’ experience. Conclusions These injuries are associated with significant Historical perspective morbidity and mortality. Patients who survive transport are subject to potentially debilitating injury and possibly death. In 1892, Halsted [1] performed the first successful sub- Management of these injuries varies, depending on clavian aneurysmal ligation. Given the infrequent occur- hemodynamic stability, mechanism of injury, and associ- rence of subclavian vessel injuries, surgeons had minimal ated injuries. Despite significant advancements, mortality experience in their management prior to wartime. Com- due to subclavian vessel injury remains high. monly, the general practice was simple ligation. During World War I, the American and British surgeons estimated Keywords Vascular Á Trauma Á Subclavian Á Injury Á that the overall rate of vascular injury ranged from 0.4 to Exposure Á Management 1.3% [8]. In 1919, Makins [2] reported 45 subclavian artery injuries amongst British casualties during World War I [1, 8]. A landmark study from Debakey and Simeone [10]in Introduction 1946 reported an incidence of less than 1%, accounting for 21 patients of 2,471 arterial injuries sustained by American Thoracic and related vascular injuries represent complex soldiers during World War II. During the Korean conflict, challenges for the trauma surgeon. In particular, subclavian Hughes [12], in a study of 304 major arterial vessel inju- vessel injuries are uncommon and highly lethal. Regardless ries, reported only three subclavian artery cases. The relatively few cases throughout the history of war may account for exsanguination on the battle field. Penetrating & J. D. Sciarretta Á J. A. Asensio ( ) Á T. Vu Á subclavian injuries comprised less than 1% of all vascular F. N. Mazzini Á J. Chandler Á F. Herrerias Á J. M. Verde Á P. Menendez Á J. M. Sanchez Á P. Petrone Á injuries reported during the Vietnam conflict [11]. During K. D. Stahl Á H. Lieberman Á C. Marini this time, 48 different surgeons treated this injury; only two Division of Trauma Surgery and Surgical Critical Care, encountered this injury more than once, for a total of 68 Dewitt–Daughtry Family Department of Surgery, Ryder Trauma reported cases. Rich [11] reported a total of 63 subclavian Center, University of Miami, 1800 NW 10 Avenue Suite T-247, Miami, FL 33136-1018, USA artery injuries in the original report of the Vietnam e-mail: [email protected] 123 440 J. D. Sciarretta et al.

Table 1 Military experiences Conﬂict Author(s) Total arteries Subclavian Incidence (%)

WWI Makins (1919) 1,191 45 3.8 WWII DeBakey & Simeone (1946) 2,471 21 0.9 Korea Hughes (1958) 304 3 1 Vietnam Rich (1970) 1,000 8 0.8 Afghanistan Sherif (1992) 224 Combined with axillary N/A

Vascular Registry for acute arterial vascular injuries during the Vietnam conflict. During the recent conflicts of Iraq and Afghanistan, the overall rate of vascular injury was reported to be greater than in previously reported conflicts [32]. This increase in rate may be related to improved hemorrhage control, shorter evacuation times, and improved survivability [32]. High- velocity-type injuries from explosives and gunshot wounds accounted for the majority of these injuries. Interesting, the incidence of vascular injury was higher in Iraq than Afghanistan (12.5 and 9%, respectively). White et al. [32] identified 1,570 US troops in both Iraq and Afghanistan that presented with wartime-related vascular injuries. Of these, 12% resulted in vascular injuries of the torso, with subclavian vessel injuries accounting for 2.3%. Over a 24-month period, Clouse et al. [33] identified 301 arterial Fig. 1 Anatomy of subclavian vessels vascular injuries, of which 3.7% were due to subclavian– axillary injury. Nevertheless, both the management and The anterior jugular vein is directed lateralward in front of treatment strategies have evolved from the various wars and the artery, but is separated from it by the sternohyoid and battlefields over the course of time (see Table 1). sternothyroid strap muscles. The first portion of the left subclavian artery arises behind the left common carotid, and at the level of the Anatomy fourth thoracic vertebra; it ascends in the superior medi- astinum to the root of the neck and then arches lateralward The subclavian arteries have different origins according to to the medial border of the scalenus anterior. Its anatomic their anatomic location (right versus left). On the right, relations are as follows. In front: the vagus, cardiac, and the subclavian artery arises from the innominate artery phrenic nerves, which lie parallel with it, the left common behind the right sternoclavicular articulation; on the left carotid artery, the left internal jugular and vertebral veins, side it originates directly from the arch of the aorta. The and the commencement of the left innominate vein. It is subclavian artery is divided into three portions. The first covered by the sternothyroid, sternohyoid and sternoclei- portion courses from the origin to the medial border of the domastoid muscles. The second portion of the left sub- scalenus anterior. The second portion lies behind this clavian artery lies behind the scalenus anterior. It is very muscle, while the third portion courses from the lateral short, and forms the highest part of the arch described by border of the scalenus anterior up to the lateral border of the vessel. the first rib (see Fig. 1). On the right side of the neck, the phrenic nerve is sep- The first portion of the right subclavian artery arises arated from the second part of the artery by the scalenus behind the upper part of the right sternoclavicular articu- anterior, while on the left side it crosses the first part of the lation, and passes upward and laterally to the medial artery close to the medial edge of the muscle. Behind margin of the scalenus anterior. It ascends a little above the the vessel are the pleura and the scalenus medi- clavicle, with the extent to which it does this varying in us; above, the brachial plexus of nerves; below, the pleura. different cases. It is crossed by the internal jugular and The subclavian vein lies below and in front of the artery, vertebral veins, by the vagus nerve and the cardiac bran- separated from it by the scalenus anterior. ches of the vagus nerve, and by the subclavian loop of the The third portion of the left subclavian artery runs sympathetic trunk, which forms a ring around the vessel. downward and lateralward from the lateral margin of the

123 Subclavian vessel injuries 441 scalenus anterior to the outer border of the first rib, where it month [4, 5, 15, 24]. Subclavian artery injury specifically becomes the axillary artery. The external jugular vein accounts for 1–2% of all acute vascular injuries [3, 4, 8, 9, crosses its medial part and receives the transverse scapular, 26, 27]. While the majority of these injuries are penetrat- transverse cervical, and anterior jugular veins, which fre- ing, up to 25% are related to a blunt mechanism of injury quently form a plexus in front of the artery. Behind the [14]. The low incidence of subclavian artery injury is pri- veins, the nerve to the subclavius muscle descends in front marily explained by the anatomic location and the pro- of the artery. The terminal part of the artery lies behind the tective barrier provided by the clavicle and thoracic cage. clavicle and the subclavius muscle and is crossed by the In a study combining both prospective and retrospective transverse scapular vessels. The subclavian vein is in front reviews, Demetriades [9] reported that isolated subclavian of and at a slightly lower level than the artery. Behind, it vein injuries were present in 44% of the patients, isolated lies on the lowest trunk of the brachial plexus, which subclavian artery involvement in 39%, and combined intervenes between it and the scalenus medius. Above and injuries in approximately 17% of the cases. On the other to its lateral side are the upper trunks of the brachial plexus hand, Lin et al. [23] reported that 24 of 54 patients pre- and the omohyoid muscle. senting with subclavian artery injuries also sustained The branches of the subclavian artery are the vertebral, associated venous injuries. internal mammary, thyrocervical and costocervical trunks. The subclavian vessels are relatively well protected by On the left side, all four branches generally arise from the the overlying clavicle and first rib, but fractures to these first portion of the vessel; on the right side, the costocer- and other adjacent osseous structures may lead to serious vical trunk usually originates from the second portion of life-threatening injury. In one of the largest series pub- the vessel. On both sides of the neck, the first three bran- lished, Natali reported a total of 10 patients with clavicle ches arise close together at the medial border of the sca- fracture-induced injury [21]. The incidence of clavicular lenus anterior. In the majority of cases, there is a free fractures and associated subclavian vessel injury is esti- interval of 1.25–2.5 cm between the commencement of the mated to be less than 1% [35, 40]. Richardson [19] iden- artery and the origin of the nearest branch. tified the first rib fracture as an useful indicator of severe upper thoracic trauma. In this study, 55 patients with first rib fractures were evaluated, of which 5.5% sustained Incidence associated blunt subclavian artery injuries. A comparable review by Phillips demonstrated similar findings in the Subclavian vessel injuries account for approximately 5% of presence of displaced first rib fractures, with 9% presenting all vascular injuries [3, 4, 28]. Busy urban trauma centers with associated blunt subclavian artery injuries [20]. report admitting between two and four subclavian vascular The majority of subclavian vessel injuries in the civilian injuries per year, although some international trauma cen- population result from penetrating trauma. Over the past ters have reported admitting as high as four patients per several decades, there has been a steady rise in firearm-

Table 2 Civilian subclavian Cities Year Author Injuries artery reports Louisville 1962 Cook 3 Memphis 1964 Pate & Wilson 12 Rochester 1968 Matloff & Morton 3 Chicago 1969 Amato 14 Houston 1970 Bricker 14 Baltimore 1970 Brawley 11 Durban 1978 Robbs 24 Johannesburg 1987 Demetriades 127 Johannesburg 1994 Degiannis 56 Houston 1999 Cox 56 Los Angeles 1999 Demetriades & Asensio 79 Durban 2000 McKinley 260 Atlanta 2000 Kalakuntla 25 Chicago 2003 Lin 54 Istanbul 2004 Aksoy 12 Houston 2008 Carrick 15

123 442 J. D. Sciarretta et al. related injuries in the US as a result of increased civilian compression. When possible, manual compression should use of weaponry. Several published series observed a be continued until primary vascular control in the operating similarly low incidence of blunt versus a relatively high room is achieved. In cases of penetrating retroclavicular incidence of penetrating injury across the globe [5–47]. injuries, direct pressure may not be effective, and thus Graham [4], who studied the largest civilian series, repor- balloon tamponade may be a life-saving option [39]. In a ted that 93 patients sustained subclavian artery injuries combined retrospective and prospective study, Demetri- over a 24-year period. Of these, only two resulted from a ades [9] reported active bleeding from the wound in 65% of nonpenetrating injury. Over a period of 10 years, a retro- the patients upon initial evaluation, along with findings of spective review by Lin [23] identified 54 patients with shock in 72%. More than 20% of patients with subclavian penetrating subclavian artery injuries, of which 85% or axillary vascular injuries reach the hospital with no vital resulted from gunshot wounds. Conversely, McKinley [24] signs or with imminent cardiac arrest as a result of exan- reported that 82% of subclavian artery injuries resulted guinating blood loss [39]. Of note, associated intrathoracic from stab wounds and 10% from low-velocity gunshot injuries are also found in about 28% of these patients [39]. wounds, a trend not appreciated in US regional trauma Once the airway is secured, these patients should undergo centers (see Table 2). immediate Emergency Department thoracotomy (EDT) on On the other hand, blunt subclavian artery injuries occur the side of injury; if necessary, the incision may be far less frequently. Urban trauma centers report that extended to the opposite side. approximately 1–3% of all traumatic subclavian artery McKinley et al. [24] reported a prospective study of 260 injuries result from blunt trauma [4–21]. The relatively low patients, among whom approximately 25% with subclavian incidence of blunt vascular trauma is due to the protected artery injuries had minimal symptoms and delayed com- anatomic location of the subclavian vessels. Both rapid plications, prompting the patients to seek medical advice. deceleration injury and bony fractures are responsible for In a series reported by Lim et al. [15], only 24% of the blunt injury of this artery. Not uncommonly, however, the patients had a pulse deficit. Apparent soft tissue ecchy- injury remains unrecognized secondary to normal physical mosis and hematoma at the base of neck and upper chest examination findings. In other cases, patients experience a can be a diagnostic clue during physical examination. delay in symptoms after their initial injury, thereby post- Other characteristic findings of brachial plexus palsy, arm poning treatment. swelling, pulsatile hematomas or bruit may indicate traumatic arteriovenous fistula.

Clinical presentation Diagnosis Patients sustaining penetrating thoracic inlet injuries presenting with hemodynamically instability should undergo Early diagnosis of a subclavian vessel injury is essential. early intubation, judicious fluid resuscitation, and imme- Physical examination findings of a subclavian arterial diate treatment of life-threatening injuries upon presenta- injury may be more subtle than obvious pulsatile bleeding tion. Contralateral upper extremity or lower extremity as seen with penetrating wounds. Other concomitant inju- intravenous access and orotracheal intubation should be ries adjacent to the subclavian vessels are highly suspicious carried out in cases where cervical and/or mediastinal for a neurovascular injury. Neurologic deficits of the upper swelling are present, resulting from expanding hematomas extremity, overlying bruits, decreased or absent pulses in caused by subclavian vessel injury [13]. the brachial, radial or ulnar arteries, and ipsilateral clavicle In a retrospective study of subclavian vessel injury, or rib fracture are diagnostic clues. The clinical diagnosis DeGiannis [31] reported that 50% of the patients in their may be obvious, with a comprehensive vascular exam series presented with an initial systolic blood pressure revealing a cool, pulseless, and pale upper extremity. of \100 mmHg. Several published series confirm similar Specific signs of subclavian artery injury may also include hemodynamic findings consistent with hypovolemic shock expanding or pulsatile hematomas in the supraclavicular upon presentation [18, 24, 30]. In the experience of space or the axilla, as the hematoma dissects along the Agarwal [18], profound shock was present in 80% of those neurovascular sheath. Brachial plexopathy can also be a who sustained injury to both the subclavian artery and vein. reliable predictor of underlying subclavian injury [34]. The unstable patient in hypovolemic shock who is unre- Radiographic investigations should only be performed sponsive to resuscitation should be transported immedi- in hemodynamically stable patients. In these cases, an ately to the operating room. initial plain chest X-ray is completed without delay. Gra- Any penetrating injury to the subclavian artery with ham [4] reported that 16% of their 93 patients with pene- pulsatile bleeding should be controlled with direct external trating subclavian injuries had radiographic evidence of 123 Subclavian vessel injuries 443 mediastinal widening. Injuries to the proximal portions of the subclavian vessels may present with massive hemothorax and mediastinal widening on chest X-ray. Other diagnostic investigations include obtaining a simple ankle brachial index (ABI) in patients that are hemodynamically stable; an ABI of less than 0.9 is considered abnormal and believed diagnostic or suspicious for underlying arterial injury. However, normal ABI indices may result even in the presence of a subclavian arterial injury, due to the rich collateral circulation from this vessel. Color flow Doppler (CFD) studies are an additional noninvasive technique for assessing subclavian vessel injury. Unfortunately, CFD studies can be suboptimal in those with a large body habitus, and are also limited in their views of the aortic arch, innominate vessels, and left subclavian artery. Readily available spiral CT scans with Fig. 2 Clavicular incision with clavicle removal to expose sub- intravenous contrast have become a favorable option in clavian vessels for a gunshot wound identifying vascular injuries. CT angiography is a potential alternative in selected cases, avoiding conventional angiography in 85% of the cases [46]. The value of emergent angiography is restricted and should only be entertained for hemodynamically stable patients after appropriate resuscitation. Ideally, the surgeon should accompany the patient to the angiography suite. If acute decompensation occurs, the angiogram should be aborted, and the patient transferred to the operating room. Positive studies without clinical exam findings may war- rant surgical exploration of the affected segment, as in cases of intimal dissection, pseuodoaneurysm, and/or contained transection. Many advocate the routine use of angiography with subclavian artery injuries. Precise surgical planning and the identification of additional arterial injuries support these views. In Graham’s series [4], 20% of concomitant arterial injures were identified by angiography. Nevertheless, color Fig. 3 Thrombosed right subclavian artery post gunshot wound flow Doppler and CT angiography are now more frequently utilized than conventional angiography. Angiography, however, remains the ‘‘gold standard,’’ and should be reserved for those without any evidence of hemodynamic compromise.

Surgical management

The operative approach for subclavian vessel injury requires great familiarity with the local anatomy. The basic vascular surgical principles of proximal and distal control are imperative. Historically, a variety of classical operative exposures have been described for the management of subclavian artery injuries. The surgical approach is dictated by the clinical presentation and site of injury. The patient is initially placed in the supine position, with the ipsilateral arm abducted at 30° and the head turned away from injury. Fig. 4 Polytetraﬂuoroethylene (PTFE) 8 mm graft 123 444 J. D. Sciarretta et al.

Fig. 5 Doppler probe being utilized to ascertain ﬂow and velocity Fig. 7 Young female that sustained a stab wound to the left thoracic postrepair inlet. Arrived in cardiopulmonary arrest. Required left anterolateral thoracotomy and open CPR. In the OR she required median sternotomy and supraclavicular incision to control a left subclavian arterial injury. Clamps are providing proximal and distal control

Fig. 6 Henly subclavian clamps (arrows)

A clavicular incision is planned, with the initial incision Fig. 8 Partial transection of the left subclavian artery in the previous made in the region of the sternoclavicular junction and patient. Required resection and interposition graft with autogenous extending over the medial half of the clavicle, and, if reversed saphenous vein graft necessary, continuing onto the deltopectoral groove (see Figs. 2, 3, 4, 5). Adjacent muscle attachments are stripped off the clavicle to better facilitate upward retraction. Cla- and an anterolateral thoracotomy. This exposure is vicular resection and disarticulation of the sternoclavicular advantageous only for left subclavian injuries, not right, joint are surgical techniques that offer additional exposure because of the vessel’s posterior location. These described to proximal injuries. Henly subclavian clamps are useful surgical approaches are individually selected on a case-by- for providing proximal and distal control (see Fig. 6). case basis and according to each surgeon’s overall A median sternotomy with cervical extension also experience. provides optimal control of proximal right subclavian Traditionally, the operative management of subclavian injuries [39]. Well described, but not recommended nor artery injury includes ligation, primary repair, or interpo- used often nowadays, is the ‘‘trapdoor’’ incision, which sition graft. The vascular repair chosen is inﬂuenced by the allows for exposure to the ﬁrst and second parts of the left degree and level of injury. Ligation should be reserved for subclavian artery. The components of this approach those who are unstable with multiple life-threatening include a clavicular incision, limited median sternotomy, associated injuries, extensive shoulder trauma, or infected

123 Subclavian vessel injuries 445

Fig. 9 Gunshot wound: right infraclavicular area Fig. 11 Repaired with an autogenous reverse saphenous vein graft

Fig. 12 Gunshot wound: right subclavian artery. Vessel debridement and resection

Fig. 10 Segmental resection of the injured right subclavian artery or ruptured aneurysm [14, 24]. Anatomically, extensive collateral flow through the thyrocervical trunk permits the safe ligation of the subclavian arteries [36]. Arterial reconstruction should, however, be attempted whenever feasible. Occasionally, temporary shunting can be used with the intention of arterial repair at a later stage. Stab wounds can sometimes be managed appropriately with debridement and repair (see Figs. 7, 8). Simple lateral arteriorrhaphy is the preferred technique in the appropriate setting, but this method can only be used 20% of the time (see Figs. 9, 10, 11)[3]. Ligating multiple arterial branches may provide additional length during primary repair, but considerable mobilization should be performed cautiously, as these branches provide an extensive collateral network Fig. 13 6 mm polytetrafluoroethylene (PTFE) graft inserted to the upper extremity. On the other hand, gunshot wounds generally cause significant blast injury and usually require anastomosis following debridement is one of the conven- an interposition graft (see Figs. 12, 13). Autogenous tional methods utilized with arterial injury. Prosthetic reverse saphenous vein or prosthetic grafts with end-to-end grafts can be safely used with acceptable outcomes due to

123 446 J. D. Sciarretta et al.

Fig. 14 Blunt injury to right subclavian artery (A) at take-off of Fig. 16 8 mm polytetraﬂuoroethylene (PTFE) interposition graft brachiocephalic trunk (B). C Origin of the right common carotid from the origin of the right subclavian artery (A). B Brachiocephalic artery trunk

Fig. 17 Lacerated left subclavian vein

Fig. 15 Resected segment of the subclavian artery. Intimal flap is seen arteriovenous fistulas, may be managed with catheter-based stent grafts by interventional services. Definitive catheter- based repairs by stent grafts are, unfortunately, not without their reported low incidence of graft infection (see consequence. At this time, however, endovascular repair Figs. 14, 15, 16)[37, 38]. At the same time, prosthetic does not appear to be superior to traditional surgical ther- grafts offer expedient repair compared to the delay asso- apy, although it does remain an alternative option for very ciated with autologous vein harvesting. Lateral venorrha- carefully selected patients. Similarly, there are no reported phy should be attempted for subclavian venous injuries if it data on their long-term outcome (see Table 3). does not cause significant luminal narrowing (see Fig. 17). If it is not feasible, simple ligation is acceptable with little morbidity [3, 39]. Morbidity Recent advancements in endovascular techniques have provided another viable option to those who are poor sur- Delay in diagnosis, complicated operative exposure, and gical candidates and those who meet strict select criteria. associated injuries are all contributing factors influencing Minimally invasive approaches to subclavian artery injuries the patient’s overall morbidity at the time of admission. are well documented and are promising alternatives in the Hemodynamic compromise on arrival to the hospital also management of these injuries. Carefully selected patients, corresponds to higher morbidity and longer hospitaliza- such as those with arterial stenosis, false aneurysms or tions, as demonstrated in Kalakuntla’s [30] 6-year

123 Subclavian vessel injuries 447

Table 3 Results of subclavian Author Year Injuries Repairs Complications Amputations Deaths artery repair Amato 1969 14 13 0 0 0 Bricker 1970 14 11 0 0 3 Rich 1970 8 7 1 0 0 Drapanas 1970 16 0 0 1 4 Perry 1971 23 0 0 0 1 retrospective review of managing subclavian artery inju- injury that results from high-energy trauma. A constellation ries. The morbidity and mortality with subclavian artery of injuries includes clavicular fracture or dislocation, injuries is greatly influenced by the number of concomitant avulsed shoulder muscles, and neurovascular damage. In injuries. In penetrating wounds, the severity of the injury cases of absent brachial plexus function, vascular recon- correlates with the location, and for cases of gunshot struction should not be attempted, and the arm should be wounds, the velocity of the missile. Neighboring structures, amputated below the shoulder [40]. particularly the subclavian vein, brachial plexus, lung, clavicle and first rib, are most susceptible to injury. Generally, the long-term morbidity of subclavian artery Outcomes and mortality injury is closely linked to the presence of associated brachial plexus injuries. Brachial plexus symptoms have Both penetrating trauma and occasionally blunt trauma to resulted in debilitating ipsilateral neurosensory deficits the subclavian vessels can result in significant blood loss from contusion or crush (direct trauma) and traction injury. and hemorrhagic shock prior to presentation. Select In Graham’s [47] series of 65 patients, associated brachial patients that have short transport times and hemorrhage plexus injuries were observed in 35% of the patients. A control by contained hematoma or thrombosis experience similar finding of 43% was reported by Johnson [34]. In improved hemodynamic status upon arrival and thus have this series, they identified 83% of partial brachial plexus better survival rates. In-hospital mortality ranges from 5 to injuries on follow-up, demonstrating some functional 35% with penetrating injuries, which is higher than for improvement, indicating that neuropraxia was the initial blunt trauma [4, 6, 7]. The reported overall mortality ran- deficit. Unfortunately, cases of complete brachial plexus ges from 39 to 80%, with the majority succumbing prior to transection and secondary nerve repair may only return arrival at the hospital [9, 14, 23, 24]. This unfortunate minimal functional improvement and render the patient statistic is directly related to exsanguination or associated with permanent functional disability. head trauma in cases of blunt injury [9, 14]. The series of Known vascular complications such as thrombosis, graft McKinley et al. [24] confirms these findings, and also infection, and aneurysm formation are familiar postopera- details a post mortem evaluation of violent deaths over tive drawbacks. At the same time, postponement of medi- 4 years, documenting 135 deaths resulting from isolated cal attention following injury with symptoms of arm injury to the subclavian artery and exsanguination. paralysis may occur due to a large false aneurysm com- The reported operative mortality in published civilian pressing the brachial plexus. These patients met with poor series ranges from 4.7 to 30% [4, 9, 15, 28, 30, 44], with outcomes despite intervention [24, 42]. In the cases of higher mortality rates seen for combined subclavian artery venous ligation, Demetriades and Asensio [39] observed and vein injuries. In a large series of 228 penetrating transient swelling of the upper extremity, but no significant subclavian vessel injuries, 61% of the patients were dead venous-related complication. Elevation of the affected on arrival [9]. In these series, venous injuries led to a extremity over a course of several days results in consid- higher mortality rate than arterial injuries: 82 and 60%, erable improvement. Clavicular division also has the respectively. Similar findings were found in another pub- potential for debilitating consequences such as osseous lished series of 20 patients, where isolated subclavian vein malunion, pseudoarthrosis, and osteomyelitis [24]. injuries resulted in a mortality rate of 50% [39]. This may Other complications in the management of subclavian be due to possible venous embolus or ongoing bleeding vessel injury may predispose the patient to local surgical from venous injury without the vasoconstrictive effects of wound infections, coagulopathy, massive transfusions, arterial injuries [39]. thoracic duct injury, and air embolism. The risk of pros- The morbidity and mortality associated with subclavian thetic graft infection also exists, but remains low, with long- artery injuries is greatly influenced by the number of term graft patency rates of 94% [38]. Scapulothoracic dis- associated injuries. Lin [23] reported that patients with sociation, although rare, is without question a devastating three or more associated injuries incurred a mortality rate

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