Traumatic injuries to the subclavian and axillary arteries: a 13-year review

Ruptured subclavian artery pseudoaneurysm following a shoulder massage on a background of clavicle non-union

We present an unusual case of ruptured subclavian artery pseudoaneurysm following hydrotherapy and shoulder massage session on a background of clavicle non-union.Following a clavicle fracture 16 years ago, which was managed conservatively, a woman in her 30s presents over a decade later with a ruptured subclavian artery pseudoaneurysm.The original midshaft clavicle fracture was sustained 16 years ago. Conservative management was agreed, and she was discharged. Six years ago, she developed a small subclavian artery pseudoaneurysm which was kept under surveillance for 12 months with no active intervention required.Over the following years, she continued to have intermittent shoulder girdle discomfort and neuropathic symptoms. On this presentation, after a sports massage, she presented with rapid-onset supraclavicular and axillary swelling. This was diagnosed as a ruptured subclavian artery pseudoaneurysm and was treated with emergency radiological-guided stenting and subsequent internal fixation of the clavicle non-union.The patient then attended regular orthopaedic and vascular follow-up to ensure her clavicle fracture unites and the graft remains patent.We discuss the case presentation and management of this unusual injury.

Damage control for subclavian artery injury

Mortality from penetrating traumas involving the subclavian vessels can be as high as 60% in pre-hospital settings. Operating room mortality is in the range of 5-30%. This paper presents a case in which a strategy for damage control was employed for a patient with an injury to the origin of the left subclavian artery, using subclavian ligation, with no need for any other intervention, and maintaining viability of the left upper limb via collateral circulation. The authors also review surgical approaches and treatment strategies with a focus on damage control in subclavian vessel injuries.

Malignant meningioma with jugular vein invasion and carotid artery extension: A case report and review of the literature

BACKGROUND

Grade II and III meningiomas [World Health Organization (WHO) classification] rarely have extracranial metastases via the blood circulation; however, we experienced a case with a metaplastic atypical meningioma and local de-differentiation that metastasized to the jugular vein, carotid artery and subclavian artery at the cervicothoracic junction. Such cases have seldom been reported before.

CASE SUMMARY

The patient was a 30-year-old man who developed right neck masses with dysphagia, labored breathing, dizziness, and occasional earaches. Eight months earlier the patient was diagnosed with a right parietal lobe neoplasm and hemorrhage at a local hospital due to the sudden onset of headaches and left limb weakness, and the post-operative pathology was a metaplastic atypical meningioma (WHO grade II) with local de-differentiation (WHO III). Magnetic resonance imaging revealed a calcified mass at the root of the neck on the right and a large cystic mass in the right parapharyngeal space. Head and neck angiography showed that the right common carotid artery was compressed and completely occluded, and the jugular vein was enveloped by the tumor and occluded. A balloon occlusion test showed no perfusion in the right common carotid artery. Tumor resection, carotid artery ligation, and subclavian artery reconstruction were performed. The tumor was a malignant meningioma. Post-operatively, the patient had Horner's syndrome and hoarseness.

CONCLUSION

This case highlights the importance of the link between a large cervical mass and a primary intracranial tumor. Malignant meningioma should not be considered merely as an intracranial metastasis spread through cerebrospinal fluid, it can also be transferred through the circulation to the parapharyngeal space and the cervical great vessels.

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.

[Arterial trauma of the upper limbs: Particularities of the population in Tunisia and risk factors for amputation]

AIM OF THE STUDY

The purpose of our study was to review the population at risk of upper limb arterial injury, to determinate the rate of upper limb salvage and the predictive factors of limb loss.

METHODS

This was a retrospective study, involving 128 patients with upper extremity arterial trauma operated between January first, 2006 and June 30, 2017. Exclusion criteria were arterial ligation, primary limb amputation and arterial iatrogenic injuries. End points were immediate technical success, primary patency and limb salvage rate.

RESULTS

The average age was 27.7 years with a sex ratio M/F=41, causes of trauma were self-inflicted wounds (51%), assaults (23%), road traffic accidents (10%), work accidents (9%) and domestic accidents (7%). Injured arteries were brachial (66.5%) usually because of self-inflicted injuries; arteries of the forearm (31%) and axillery arteries (2.5%). The techniques of arterial repair were vein graft interposition in 52% of cases, end-to-end anastomosis in 23%, primary arterial repair in 21% and venous patch in 4%. Eight reconstructions occluded during the first week (6.25%). Four patients required secondary amputation and limb salvage rate was 96.8%. After a median follow-up time of 62 days, only 21% were followed at 3 months. Mechanism of injury, soft tissue loss and arterial reconstruction thromboses were selected as factors influencing the rate of limb salvage. One death occurred at day 14 secondary to multi-component poly-trauma.

CONCLUSION

Prompt diagnosis, appropriate multidisciplinary management of the upper extremity arterial trauma and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage. Associated soft tissue injury is a poor limb salvage factor.

Ballistic Axillary Vein Transection: A Case Report

Patient: Male, 25-year-old

Final Diagnosis: Axillary vein transection

Symptoms: Shortness of breath

Medication: —

Clinical Procedure: Ligation of the axillary vein

Specialty: Surgery

Subclavian artery occlusion after a clavicle fracture

A 44-year-old man with a 9-day-old left displaced midshaft clavicle fracture was initially treated conservatively. The patient experienced an increase of pain with tickling and cold sensation in the left upper extremity. CT angiography showed left subclavian artery occlusion over 3 cm at the level of the fracture. At surgical repair, a subclavian-brachial bypass was constructed and fracture fixation was done with an eight-hole locking compression plate. Follow-up at 6 months showed full range of motion of the left shoulder, an open bypass and fracture consolidation.

Management and Outcomes of Isolated Axillary Artery Injury: A Five-Year National Trauma Data Bank Analysis

BACKGROUND

The aim of this study is to evaluate recent national trends in the clinical characteristics, management, and outcomes of patients with isolated axillary artery injuries.

METHODS

The National Trauma Data Bank was queried to identify records submitted from 2011 to 2015 that contained an ICD-9-CM diagnosis code for an injury to axillary artery (903.01) and an external cause of injury code indicating blunt or penetrating trauma. Records that contained a diagnosis code for an injury to an additional blood vessel (900.00-903.00, 903.2-904.9), an injury to a nonupper extremity or unclassifiable body region, or whose operative management could not be discerned were excluded. The final study sample included 221 patients with isolated axillary artery injury. The patient's clinical management was the primary outcome of interest. The study sample was stratified by trauma type, and descriptive statistics were performed on all variables.

RESULTS

Seventy-one percent of patients received operative management. Patients with penetrating injury were 24% more likely to be managed operatively than bluntly injured patients (76.9% vs. 62.1%, P = 0.0178). In operatively managed patients, the open repair rate was 82.8% and endovascular repair rate was 10.2%. Graft repair was performed most often (28.0%), followed by placement of a temporary intravenous shunt (17.8%) and surgical occlusion (10.2%). Surgical vessel occlusion was significantly more likely to be performed on patients with penetrating injury than with blunt injury (14.6% vs. 1.9%, P = 0.0124). Patients with penetrating injury had significantly shorter median emergency department length of stay (87.0 min vs. 152.0 min, P < 0.0001), intensive care unit length of stay (2.0 days vs. 3.0 days, P < 0.0388), hospital length of stay (4.0 days vs. 5.0 days, P = 0.0026), and time-to-operative management (1.6 hr vs. 3.9 hr, P < 0.001) compared to bluntly injured patients. Patients with blunt injury had a higher reportable in-hospital complication rate (13.8% vs. 6.0%, P = 0.0477). The overall mortality rate was 3.1% for isolated axillary artery injuries and did not significantly differ by trauma type.

CONCLUSIONS

Axillary artery injury is more often caused by penetrating trauma. Despite introduction of novel endovascular techniques, the majority of patients with isolated axillary artery injury are managed using open repair. Penetrating axillary artery injury is significantly more likely to be managed using open repair and by surgical occlusion. Patients with blunt injury have higher complication rates and longer hospital length of stays. The mortality rate is lower than previously published.

Subclavian artery avulsion following blunt trauma: A case report and literature review

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Subclavian artery injuries are rare, highly fatal, and constitute less than 2% of all vascular injuries.

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Surgical repair of these injuries can be technically challenging due to their anatomic location.

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Therapeutic approaches include surgical repair, endovascular repair, or a hybrid approach depending on the severity of the injury and the patient’s hemodynamic status.

Introduction

Subclavian artery injuries are rare and are associated with a high morbidity and mortality. The majority of patients with blunt trauma to the subclavian artery succumb to their injury before reaching a hospital. In-hospital mortality remains high.

Presentation of case

We report the case of a 30-year-old male who presented with complete traumatic subclavian artery avulsion after a motorcycle collision. He presented in hemorrhagic shock. Temporary hemostatic control was achieved with endovascular balloon occlusion followed by operative intervention.

Discussion

Prompt diagnosis and meticulous management including early transfusion, when indicated, are necessary to salvage both the patient’s life and limb from such severe injuries. Intra-operative diagnosis of subclavian artery injury is most common due to the hemodynamic instability of most patients with such injuries; however, conventional angiography and computed tomography angiography are useful diagnostic modalities as well. Temporizing measures such as endovascular balloon occlusion to obtain vascular control may serve as a valuable adjunct to surgical repair.

Conclusion

Repair of a subclavian artery injury is challenging for even the most experienced of surgeons. Endovascular techniques can be therapeutic or used as an adjunct to control bleeding ad allow an open repair.

Endovascular Repair of Axillary Artery Transection with a Stent Graft following Blunt Trauma

Transection injuries of the axillary artery are rare and typically involve surgical repair. This case describes an emergent endovascular treatment option, using a stent graft, in a patient that was deemed as high risk for open surgery.

Eighteen years' experience of traumatic subclavian vascular injury in a tertiary referral trauma center

Purpose

Traumatic subclavian vascular injury (TSVI) is rare but often fatal. The precise diagnosis of TSVI remains challenging mainly because of its occult nature, less typical presentations, and being overlooked in the presence of polytrauma. Compared to penetrating injuries, it is even more difficult to identify TSVI in patients who have blunt injuries and no visible bleeding. The risk factors associated with TSVI in patients with thoracic trauma are unclear. The aims of this study were to identify risk factors for TSVI in a cohort of patients with thoracic vascular injuries and to report outcomes after clinical treatment.

Methods

From January 2009 to June 2017, 39586 patients were admitted to our hospital (a level I trauma center) due to trauma, and 136 patients with thoracic vascular injury were enrolled in this study. We retrospectively reviewed data from medical records including demographic characteristics, injury scoring systems (RTS, ISS, NISS, TRISS and AIS), management and outcomes. Patients were further divided into the TSVI group (patients with TSVI) and the non-TSVI group (patients with thoracic vascular injuries other than TSVI). Univariate and multivariate analyses were used to identify independent risk factors.

Results

The enrolled 136 patients suffered mostly from blunt trauma (89.0%) and 22 of them had TSVI. When compared to the non-TSVI group, the TSVI group had lower Glasgow Coma Scale (GCS) scores (p = 0.002; especially GCS ≤ 12), less concurrent abdominal injury (p < 0.001), lower Injury Severity Scales (ISS) (p = 0.007) and New Injury Severity Scales (NISS) (p < 0.002) but had higher Abbreviated Injury Scales (AIS) of the head ≥ 3 (p = 0.009) and rates of clavicular or scapular fractures (p = 0.013). No difference was detected between the two groups with regard to age, gender, trauma mechanism, vital signs on arrival, or rate of facial and extremities injury. In multivariate regression analyses, GCS ≤ 12, AIS of the head ≥ 3 and the presence of clavicular or scapular fractures were independent risk factors for TSVI (p = 0.026, p = 0.043 and p = 0.005, respectively) after adjustment for confounding factors. Open and endovascular repair were two surgical procedures utilized for these TSVI patients with an overall mortality rate of 18.2%. No difference was found between these groups with regard to mortality rate and the length of ICU stay, but the patients in the TSVI group had a shorter length of hospital stay.

Conclusions

Our results suggest that GCS ≤ 12, AIS of the head ≥ 3 and the presence of clavicular or scapular fractures were independent risk factors for TSVI in patients with thoracic vascular injuries. For patients with thoracic trauma, TSVI should be considered for prompt management when patients exhibit concurrent injuries to the head, clavicle or scapula.

Endovascular repair of blunt axillo-subclavian arterial injuries as the first line treatment

AIM

To report and analyse our results regarding the endovascular management of blunt axillo-subclavian arterial injuries as the first line treatment.

METHODS

During an eight-year period, seven patients (mean age 56.4±14.1 years, all males) with blunt traumatic axillo-subclavian arterial injuries were presented to the emergency department. All patients suffered also from concomitant other injuries and had a supraclavicular haematoma along with diminished or absent upper limb peripheral pulses, while computed tomography angiography set the diagnosis.

RESULTS

The endovascular procedure was technically successful in all patients. No procedure-related complication was encountered during the in-hospital stay, while none of the patients died. The median hospital stay was 22 days (range 12-46). During a follow-up period spanning an average of 27 months (range 6-44 months) there was one stent-graft thrombosis at 12 months in an otherwise asymptomatic patient that required no further intervention.

CONCLUSION

Endovascular technique seems to constitute a reliable approach for treating blunt axillo-subclavian arterial injuries in the emergent setting. Despite uncertainties in patient selection and optimal management algorithms, it seems that endovascular approach could be the first line treatment for such injuries. Accumulation of data on larger number of patients with longer follow-up is warranted to further define the value of this therapeutic modality in the trauma setting.

Percutaneous Transluminal Angioplasty for Axillary Artery Dissection After Open Reduction of Shoulder Fracture-Dislocation: A Case Report

CASE

Injury of the axillary artery after shoulder-joint fracture or dislocation is uncommon. We describe the clinical outcome of an elderly patient with a dissecting aneurysm of the axillary artery following open reduction of a fracture-dislocation of the shoulder. The arterial dissection was successfully managed with percutaneous transluminal balloon angioplasty.

CONCLUSION

This case report highlights the need for careful vascular examination of all elderly patients with a fracture or dislocation of the shoulder and the possible use of percutaneous transluminal angioplasty for the management of arterial dissection prior to proceeding with surgical exploration.

[Wound of the left subclavian artery by a screwdriver: about a case]

Nous rapportons le cas d'un patient présentant une plaie de l'artère sous-clavière gauche suite à un traumatisme par un tournevis. Il s'agit d'une lésion rare mais grave, qui entraine souvent des complications neurologiques et respiratoires pouvant être mortelles. Dans les pays en voie de développement, la chirurgie classique à ciel ouvert reste de premier recours.

Associated venous injury significantly complicates presentation, management, and outcomes of axillosubclavian arterial trauma

Axillosubclavian vessel injury (ASVI) is associated with high morbidity and mortality. Most studies are single-center experiences of small numbers of patients with penetrating injury. We assessed 21st-century presentation and management of ASVI and focused on outcomes of combined arterial/venous injury. We reviewed the National Trauma Data Bank for patients with isolated arterial ASVI (group 1) and combined arterial/venous ASVI (group 2). Demographics, injury severity parameters, interventions, complications, and outcomes were compared. We identified 581 patients with ASVI (mean age 35.1; 88.1% male), with 466 isolated arterial injuries and 115 combined arterial/venous injuries. Group 2 had lower presenting systolic blood pressure and Glasgow Coma Scale, and had higher rates of operative repair (55.7 vs. 43.1%, p = 0.016) and higher mortality (33.9 vs. 13.9%, p < 0.001). There were no differences in amputation (5.2 vs. 2.4%, p = 0.121), compartment syndrome (2.6 vs. 1.9%, p = 0.713), and deep vein thrombosis (0.9 vs. 0.2%, p = 0.357). When separated by mechanism of injury, combined injuries from blunt trauma did increase amputation rates (27.8 vs. 4.2%, p = 0.002). Multivariate analysis revealed that combined arterial/venous injury significantly increased risk of death (odds ratio [OR], 2.99; confidence interval [CI], 1.73 to 5.17; p = 0.0001). Penetrating injury had higher odds of death than blunt injury (OR, 1.96; CI, 1.03 to 3.73; p = 0.041). ASVI is rare but extremely lethal. Concomitant venous and arterial injury is not associated with worse limb-related outcomes, except in blunt injuries and resultant amputations, but is associated with a threefold increase in mortality rates compared with isolated arterial injury.

Isolated axillary artery injury due to blunt trauma in ice hockey

We report the first case of a purely isolated axillary artery dissection because of focal blunt trauma to the axilla. A 42-year-old man presented to our outpatient orthopedic clinic 7 days after a fall during a hockey game whereby another player's skate blade struck the patient directly in the axilla without disrupting the skin. The patient denied having any symptoms of shoulder dislocation but experienced some pain and numbness, which subsided rapidly. Then he developed a cool hand with exertional claudication. Physical examination revealed absent radial and brachial pulses. Computed tomographic angiography demonstrated dissection of the distal axillary artery extending to the middle two-thirds of the brachial artery. Following urgent consultation with vascular surgery, the patient was treated operatively with reverse saphenous interpositional grafting and embolectomy. This case illustrates the need to have a heightened index of suspicion to all injuries to the axilla and the importance of performing careful soft tissue and neurovascular examinations in hockey players presenting with shoulder complaints, even when bony injury is not present.

[Surgical accesses to the major mediastinal vessels in thoracic trauma]

Trauma is the most common cause of death in the economically active population and thoracic trauma is directly or indirectly responsible for one quarter of these deaths. Lesions to the large thoracic vessels are associated with immediate or early death in the hospital setting. Patients admitted alive can be classified as stable or unstable. The access route to be elected for management of these veins will depend on this status, as well as on the anatomical particularities of the patient, which may require combined incisions for adequate access. This article provides a review and discussion of lesions to these structures as well as access routes to them.

Chest computed tomography for penetrating thoracic trauma after normal screening chest roentgenogram

BACKGROUND

Chest computed tomography (CCT) is a method of screening for intrathoracic injuries in hemodynamically stable patients with penetrating thoracic trauma. The objective of this study was to examine the changes in utilization of CCT over time and evaluate its contribution to guiding therapeutic intervention.

METHODS

A level 1 trauma center registry was queried between 2006 and 2011. Patients undergoing CCT in the emergency department after penetrating thoracic trauma as well as patients undergoing thoracic operations for penetrating thoracic trauma were identified. Patient demographics, operative indications, use of CCT, injuries, and hospital admissions were analyzed.

RESULTS

In all, 617 patients had CCTs performed, of whom 61.1% (371 of 617) had a normal screening plain chest radiograph (CXR). In 14.0% (51 of 371) of these cases, the CCT revealed findings not detected on screening CXR. The majority of these injuries were occult pneumothoraces or hemothoraces (84.3%; 43 of 51), of which 27 (62.8%) underwent tube thoracostomy. In only 0.5% (2 of 371), did the results of CCT alone lead to an operative indication: exploration for hemopericardium. The use of CCT in our patients significantly increased overall (28.8% to 71.4%) as well as after a normal screening CXR (23.3% to 74.6%) over the study period.

CONCLUSIONS

The use of CCT for penetrating thoracic trauma increased 3.5-fold during the study period with a concurrent increase in findings of uncertain clinical significance. Patients with a normal screening CXR should be triaged with 3-hour delayed CXR, serial physical examinations, and focused assessment with sonography for trauma; and CCT should only be used selectively as a diagnostic modality.

Operative exposure and management of axillary vessel injuries

INTRODUCTION

Axillary vessel injuries are uncommon and challenging injuries encountered by trauma surgeons. Proximity of this vessel to other adjacent veins including the axillary vein, brachial plexus and the osseous structures of the shoulder and upper arm account for a large number of associated injuries.

MATERIALS AND METHODS

Systematic review of the literature, with emphasis on the diagnosis, treatment and outcomes of these injuries, incorporating the authors' experience.

CONCLUSIONS

Although uncommon, axillary arterial injuries can result in significant morbidity, limb loss and mortality. Early diagnosis and timely repair of the artery leads to good outcomes.

Axillary artery dissection after scapular fracture

Blunt shoulder trauma rarely causes damage to either arteries or nerves. Neurovascular structures are covered by muscles and protected by the surrounding bones deep in the axilla. We report a case of a 34-year-old male motorbike driver referred to us 5 hours after injury. Standard X-ray of the left shoulder revealed multipart fracture of the left scapula, and angiography showed that the first segment of the left axillary artery was dissected proximal to the minor pectoral muscle. Urgent diagnosis using imaging techniques and restoration of blood flow using open or endovascular repair are crucial for optimal outcome. Damage to the nerves predicts the final functional outcome regardless of prompt revascularization.

Penetrating thoracic great vessel injury: impact of admission hemodynamics and preoperative imaging

BACKGROUND

The management of penetrating great vessel (PGV) injury is challenging. Patients in shock require rapid evaluation, whereas in stable patients, imaging studies may optimize the surgical approach. We reviewed our experience with PGV injury to determine the impact of admission blood pressure and accuracy of imaging studies, both angiography and computed tomographic angiography (CTA).

METHODS

Retrospective review of the trauma registry from 2001 to 2007 identifying patients with PGV injury. Demographics, admission systolic blood pressure, imaging studies, specific injuries, incision, methods of repair, hospital and intensive care length of stay, complications, and mortality were recorded. Shock was defined as systolic blood pressure <90 mm Hg.

RESULTS

Thirty-six consecutive patients were identified, average age was 28 (+/-10) years, of whom 20 (56%) presented in shock. Those in shock had more combined arterial-venous injuries (60% vs. 25%), concomitant thoracic injuries requiring resection (45% vs. 19%), and units of packed red blood cells (5.8 +/- 2 vs. 2.7 +/- 1.5), p < 0.01. For those in shock, the mean time to the operating room was 27 minutes +/- 9 minutes and 75% had sternotomy. Among stable patients, 56% had a periclavicular approach and 31% partial sternotomy. All 16 stable patients had imaging; angiography in 3 patients and CTA in 7 patients. In six patients who had both angiography and CTA, the results were concordant; therefore, CTA accurately diagnosed arterial injury in all 13 patients. Imaging changed the choice of incision in 4 (25%). Intensive care length of stay was significantly longer in the shock group 3.1 (+/-2.1) days versus 1.4 (+/-1.6) days (p = 0.01). There were 5 (14%) complications and no deaths.

CONCLUSION

Patients in shock require rapid evaluation. Sternotomy affords excellent exposure to all PGV injuries, and partial sternotomy is useful in stable patients. In stable patients, CTA can be valuable in defining the injury and may influence the surgical approach. Surgical results are surprisingly good, even in unstable patients and may be related to rapid transport and operation.

Vascular injuries after blunt chest trauma: diagnosis and management

Background

Although relatively rare, blunt injury to thoracic great vessels is the second most common cause of trauma related death after head injury. Over the last twenty years, the paradigm for management of these devastating injuries has changed drastically. The goal of this review is to update the reader on current concepts of diagnosis and management of blunt thoracic vascular trauma.

Methods

A review of the medical literature was performed to obtain articles pertaining to both blunt injuries of the thoracic aorta and of the non-aortic great vessels in the chest. Articles were chosen based on authors' preference and clinical expertise.

Discussion

Blunt thoracic vascular injury remains highly lethal, with most victims dying prior to reaching a hospital. Those arriving in extremis require immediate intervention, which may include treatment of other associated life threatening injuries. More stable injuries can often be medically temporized in order to optimize definitive management. Endovascular techniques are being employed with increasing frequency and can often significantly simplify management in otherwise very complex patient scenarios.

Management of upper extremity vascular injury: outcome related to the Mangled Extremity Severity Score

BACKGROUND

The Mangled Extremity Severity Score (MESS) is an objective criterion for amputation prediction after lower extremity injury as well as for amputation prediction after upper extremity injury. A MESS of >or=7 has been utilized as a cutoff point for amputation prediction. In this study, we examined the result of upper extremity vascular injurty (UEVI) management in terms of the amputation rate as related to the MESS.

METHODS

During January 2002 to July 2007, we reviewed patients with UEVIs at our institution. Data collections included demographic data, mechanism of injuries, injury severity score (ISS), ischemic time, MESS, pathology of UEVI, operative management, and amputation rate. Decisions to amputate the injured limbs at our institution were made individually by clinically assessing limb viability (i.e., color and capillary refill of skin; color, consistency, and contractility of muscles) regardless of the MESS. The outcome was analyzed in terms of the amputation rate related to the MESS.

RESULTS

There were 52 patients with UEVIs in this study: 25 (48%) suffered blunt injuries and 27 (52%) suffered penetrating injuries. The age ranged from 15 to 59 years (mean 28.7 years). The mean ischemia time was 10.07 h. The mean ISS was 17.52. There were 12 patients (23%) with subclavian artery injuries, 3 patients (5.76%) with axillary artery injuries, 18 patients (34.61%) with brachial artery injuries, and 19 patients (36.54%) with radial artery and/or ulnar artery injuries. Primary repairs were performed in 45 patients (86.54%), with ligations in 3 patients (5.77%). An endovascular stent-graft was used in one patient (1.92%). Primary amputations were performed in three patients (5.77%). Secondary amputations (amputation after primary operation) were done in 4 of 49 patients (secondary amputation rate 8.16%). All amputation patients suffered blunt injuries and had a MESS of >or=7 (range 7-11). The overall amputation rate in this study was 13.46% (7/52 patients). Multivariate analysis revealed that the only factor significantly associated with amputation was the MESS. There were no amputations in 33 patients who had a MESS of <7. We could avoid amputation in 12 of 19 patients who had a MESS>or=7. There were no mortalities among 52 UEVI patients.

CONCLUSIONS

MESS, an outcome score used to grade the severity of extremity injuries, correlates well with the risk of amputation. Nevertheless, a MESS of >or=7 does not always mandate amputation. On the other hand, the MESS is a better predictor for patients who do not require amputation when the score is <7. The decisions to amputate in patients should be made individually based on clinical signs and an intraoperative finding of irreversible limb ischemia.