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Subclavian Vessel Injuries: Difficult Anatomy and Difficult Territory

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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 rel- atively 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.
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