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Torres IO, Lourenço de Andrade RC, Apoloni R, Simão da Silva E, Puech-Leão P, De Luccia N. Editor's Choice - In Hospital and Long Term Outcomes After Repair of Subclavian and Axillary Artery Injuries. Eur J Vasc Endovasc Surg 2023; 66:840-847. [PMID: 37567338 DOI: 10.1016/j.ejvs.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 07/21/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE To evaluate the in hospital and long term outcomes after open or endovascular repair of subclavian and axillary artery injuries. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Inez Ohashi Torres
- Vascular and Endovascular Surgery Department, São Paulo University Medical School, São Paulo, Brazil.
| | | | - Rafael Apoloni
- Vascular and Endovascular Surgery Department, São Paulo University Medical School, São Paulo, Brazil
| | - Erasmo Simão da Silva
- Vascular and Endovascular Surgery Department, São Paulo University Medical School, São Paulo, Brazil
| | - Pedro Puech-Leão
- Vascular and Endovascular Surgery Department, São Paulo University Medical School, São Paulo, Brazil
| | - Nelson De Luccia
- Vascular and Endovascular Surgery Department, São Paulo University Medical School, São Paulo, Brazil
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Schropp L, de Kleijn RJCMF, Vonken EJ, van Laanen J, Teijink J, Ünlu Ç, Vos FAW, van Hattum ES, Petri BJ, de Borst GJ. Multicenter Case Series and Literature Review on Durability of Stents in the Thoracic Outlet. J Endovasc Ther 2022; 30:355-363. [PMID: 35255758 DOI: 10.1177/15266028221081078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE The aim of this paper was to report our experience with arterial and venous endovascular stent placement in the thoracic outlet (TO) and review available literature. METHODS All patients that underwent arterial or venous stent placement in the TO between 2013 and 2020 in 5 Dutch vascular teaching-hospitals were retrospectively identified. Primary endpoint was symptomatic stent failure due to stenosis, chronic or posture dependent compression, fracture, or occlusion of the stent. Secondary endpoints were symptoms at last follow-up and re-interventions. For the literature review, we searched studies reporting on stenting in the TO. RESULTS Twenty-six patients were included with 11 arterial and 15 venous stents implanted to treat angioplasty resistant stenosis in arterial or venous TO syndrome, iatrogenic or traumatic vascular injury, radiotherapy fibrosis, or arterial dissection. Median follow-up was 19 and 14 months in the arterial and venous-group, respectively. Eight (73%) patients in the arterial, and 9 (60%) in the venous-group suffered symptomatic stent failure. Seven (64%) patients in the arterial, and 9 (60%) in the venous-group required at least 1 re-intervention. When comparing all patients with stent placement after TO decompression (TOD) to patients without, there were substantially more symptomatic stent failures and re-interventions required in the patients without TOD. Six patients (54%) in the arterial-group and 11 (73%) in the venous-group were symptom-free at last follow-up. Five articles describing 51 patients with arterial and 6 articles describing 81 patients with venous stents were included in the literature review. In the arterial-group, no TOD prior to stent placement was performed, while in the venous-group all but 1 article performed TOD prior to stent placement. Results showed comparable rates of symptomatic stent failure (24% vs 30%), and patients requiring re-interventions (29% vs 21%) between groups. CONCLUSION Based on our multicenter series and review, stents in the TO have a considerable risk of failure, both in the venous and the arterial territory. Especially in patients without TOD: the need for re-interventions is high and half the patients eventually undergo TOD. Based on the currently available data, stenting in the TO should be applied cautiously while TOD should be considered.
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Affiliation(s)
- Ludo Schropp
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Evert-Jan Vonken
- Department of Interventional Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jorinde van Laanen
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Joep Teijink
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Çagdas Ünlu
- Department of Vascular Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Floris A W Vos
- Department of Vascular Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Eline S van Hattum
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bart-Jeroen Petri
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Potter HA, Alfson DB, Rowe VL, Wadé NB, Weaver FA, Inaba K, O'Banion LA, Siracuse JJ, Magee GA. Endovascular versus open repair of isolated superficial femoral and popliteal artery injuries. J Vasc Surg 2021; 74:814-822.e1. [PMID: 33684481 DOI: 10.1016/j.jvs.2021.02.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 02/23/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Despite the increasing use of endovascular therapy for traumatic arterial injuries, little is known about the outcomes of endovascular repair of superficial femoral artery (SFA) and popliteal artery (PA) injuries. In the present study, we compared the characteristics and outcomes of endovascular vs open repair of traumatic SFA and PA injuries. METHODS We performed a retrospective National Trauma Data Bank analysis of trauma patients with a blunt or penetrating injury of the SFA and/or PA who had undergone endovascular or open repair from 2007 to 2014. Multivariate logistic regression was used to compare the outcomes, with propensity score matching used for sensitivity analysis. RESULTS The incidence of SFA and PA injuries was 0.2%, with an overall increase in the annual use of endovascular stent repair from 3.2% in 2007 to 7.6% in 2014 (P = .002). A total of 2,873 patients with an isolated SFA and/or PA injury were included in the present study, of whom 163 (5.7%) had undergone endovascular repair. SFA injuries were more frequently treated with endovascular repair (70% vs 27%) and PA injuries were more often associated with open repair (41.1% vs 54.7%). Open repair was more frequently associated with a concomitant femur fracture or knee dislocation (30.7% vs 38.8%; P = .039). Endovascular repair was not associated with worse in-hospital amputation-free survival (AFS) compared with open repair on univariate analysis (91.1% vs 89.7%; P = .573) or multivariate logistic regression (odds ratio [OR], 1.053; 95% confidence interval [CI], 0.551-2.012; P = .876). Propensity score matching revealed that in-hospital mortality was higher (OR, 3.69; 95% CI, 1.37-9.82; P = .01) and fasciotomy was lower (OR, 0.23; 95% CI, 0.14-0.37; P < .001) in the endovascular repair group, with no significant differences in AFS (OR, 0.86; 95% CI, 0.48-1.67; P = .65). CONCLUSIONS Endovascular repair of SFA and PA injuries has in-hospital AFS comparable to that for open repair, supporting the increasing use of endovascular repair for traumatic SFA and PA injuries in appropriately selected cases. Given the unexpected finding of increased in-hospital mortality after endovascular repair, further studies are necessary to determine the appropriate patient selection and the durability of endovascular repair.
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Affiliation(s)
- Helen A Potter
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Daniel B Alfson
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif; Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Vincent L Rowe
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Niquelle B Wadé
- Department of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Kenji Inaba
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Los Angeles County+USC Medical Center, University of Southern California, Los Angeles, Calif
| | - Leigh Ann O'Banion
- Vascular Division, Department of Surgery, University of California, San Francisco at Fresno, Fresno, Calif
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif.
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Grillo VTRDS, Jaldin RG, Rosa FD, Secondo MTS, Farres Pimenta RE, Bertanha M, Sobreira ML, Yoshida WB. Tratamento endovascular com endoprótese aórtica para aneurisma de artéria subclávia secundário à fístula arteriovenosa axilo-axilar traumática tardia. J Vasc Bras 2021; 20:e20210016. [PMID: 35096028 PMCID: PMC8759580 DOI: 10.1590/1677-5449.210016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 10/28/2021] [Indexed: 11/24/2022] Open
Abstract
Traumatic arteriovenous fistulas (AVFs) involving the axillary and subclavian vessels are uncommon and account for 5 to 10% of all arterial traumas. The complex anatomy of this region makes treatment of this segment challenging. In this therapeutic challenge, we describe the case of a 73-year-old man, referred for progressive edema and ulceration involving the right upper limb and with a history of gunshot wound to the right infraclavicular region about 50 years previously. Angiotomography was performed and an axillary-axillary AVF was found, associated with tortuosity and aneurysmatic dilation of the subclavian artery downstream. He underwent endovascular intervention and a conical (monoiliac) 26 × 14 × 90 mm Braile® endoprosthesis was used in the aneurysmatic subclavian artery, posterior to the exit of the right vertebral artery and a 16 × 16 × 95mm Excluder® monoiliac endoprosthesis was placed overlapping the first prosthesis, showing a satisfactory result. Therefore, the possibility of successfully using aortic endoprostheses in an unusual and exceptional situation is described.
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Fang G, Fang Y, Xu X, Yang J, Zhu T, Yue J, Fu W, Dong Z. Long-term outcomes of endovascular treatment of isolated subclavian artery aneurysms. Vascular 2020; 29:723-732. [PMID: 33249978 DOI: 10.1177/1708538120975242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of the present study was to review our institutional experience of endovascular treatment for isolated subclavian artery aneurysms and evaluate the long-term outcomes. METHODS A retrospective review of all patients with isolated subclavian artery aneurysms who underwent endovascular treatment between March 2008 and March 2020 was performed. The demographics, aneurysmal characteristics, treatment strategies, and in-hospital and follow-up outcomes were recorded and then analyzed. RESULTS From March 2008 to March 2020, 35 isolated subclavian artery aneurysms were endovascularly treated at our institution. Atherosclerosis was the most common cause of aneurysms in this series. Most aneurysms were intrathoracic (91.4%) and located at the right side (77.1%). There were 26 true aneurysms, seven pseudoaneurysms, and two ruptured isolated subclavian artery aneurysms. Five types of endovascular strategies were performed. Covered stent placement across the aneurysm was the most (54.3%) commonly used method. Technical success was achieved in all patients. The median postoperative in-hospital stay was 4.0 days (range, 1-15 days). One patient died after discharge but within 30 days of surgery due to myocardial infarction. The median follow-up time was 62.0 months (range, 3-132 months). No death, stroke, stent fractures, or severe upper limb ischemia developed during the follow-up period. The cumulative survival rate at five years was 97.1%. The overall complication rate was 25.7% and one-third of complications (8.6%) required reinterventions. CONCLUSIONS Endovascular treatment for isolated subclavian artery aneurysms is safe, effective and technically achievable in most patients. Short- and long-term outcomes are promising. Reasonable and flexible use of covered stents can also get satisfactory outcomes in some complicated lesions such as isolated subclavian artery aneurysms located at the origin of the right subclavian artery, avoiding the huge surgical trauma caused by conventional open repair.
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Affiliation(s)
- Gang Fang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuan Fang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Xu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jue Yang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ting Zhu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianing Yue
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhihui Dong
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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Tadayon N, Yavari N, Zarrintan S, Hosseini SM, Kalantar-Motamedi SMR. Management of traumatic subclavian artery injuries in a high-volume vascular surgery center in Iran. J Cardiovasc Thorac Res 2020; 12:145-149. [PMID: 32626556 PMCID: PMC7321003 DOI: 10.34172/jcvtr.2020.24] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 01/30/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction: Subclavian artery injury is an uncommon vascular trauma with potential morbidity and mortality. Management of subclavian artery trauma requires open and endovascular techniques and timely and efficacious decision is mandatory. We retrospectively reviewed traumatic subclavian artery injuries in a high-volume vascular surgery center in Iran.
Methods: In a retrospective study, we assessed subclavian artery injuries during 6 years in ShohadaTajrish Medical Center. Background characteristics, type of incision, type of operation and outcome of patients were evaluated.
Results: A total of 14 patients had subclavian artery injury (mean age 29.9 ± 13.4 years, 92.9% male). Trauma was in left and right sides in eight (57.1%) and six patients (42.9%) respectively. Arteriorrhaphy, interposition and ligation of injured artery was done in 7 (50.0%), 3 (21.4%) and 4 (28.6%) patients respectively. Associated nerve injury was present in six patients (42.9%). Endovascular proximal control was obtained in six patients (42.9%) prior to vascular exposure. Time of patient referral did not have significant association with shock or type of operation (P > 0.05).
Conclusion: Although traumatic subclavian artery injuries are rare, its vascular exposures and reconstructions are of potential clinical concern. Endovascular interventions can facilitate proximal control. In addition, endovascular repair by covered stent is an alternative to open surgery.
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Affiliation(s)
- Niki Tadayon
- Division of Vascular & Endovascular Surgery, Department of General & Vascular Surgery, Shohada-Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Iranian Society of Vascular Surgery, Tehran, Iran
| | - Negin Yavari
- Research Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Sina Zarrintan
- Division of Vascular & Endovascular Surgery, Department of General & Vascular Surgery, Shohada-Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Iranian Society of Vascular Surgery, Tehran, Iran.,Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyed Masoud Hosseini
- Division of Vascular & Endovascular Surgery, Department of General & Vascular Surgery, Shohada-Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Iranian Society of Vascular Surgery, Tehran, Iran
| | - Seyed Moahammad Reza Kalantar-Motamedi
- Division of Vascular & Endovascular Surgery, Department of General & Vascular Surgery, Shohada-Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Iranian Society of Vascular Surgery, Tehran, Iran
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Song X, Zheng Y, Zhou M, Chen Y. Total Endovascular Repair of a Juxta-vertebral Subclavian Artery Pseudoaneurysm and Flow Preservation of a Dominant Vertebral Artery Using Parallel Stent Grafts. Ann Vasc Surg 2020; 67:566.e11-566.e15. [PMID: 32335248 DOI: 10.1016/j.avsg.2020.03.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/21/2020] [Accepted: 03/01/2020] [Indexed: 12/01/2022]
Abstract
The endovascular repair of subclavian aneurysms or pseudoaneurysms is now widely adopted. However, controversies still prevail in the management of dominant vertebral arteries originating close to aneurysms, as coverage of the vertebral artery might be complicated by either endoleaks or ischemic events. Here, we present a rare case of multiple aneurysmal lesions involving the right subclavian artery and bilateral internal carotid arteries treated by way of a total endovascular method using parallel stent grafts for the simultaneous exclusion of a subclavian artery pseudoaneurysm and flow preservation of the adjacent vertebral artery. To the best of our knowledge, this is the first study to report the use of this technique for the endovascular repair of juxta-vertebral subclavian artery pseudoaneurysms.
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Affiliation(s)
- Xitao Song
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuehong Zheng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Menxin Zhou
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuexin Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
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Angus LDG, Gerber N, Munnangi S, Wallace R, Singh S, Digiacomo J. Management and Outcomes of Isolated Axillary Artery Injury: A Five-Year National Trauma Data Bank Analysis. Ann Vasc Surg 2019; 65:113-123. [PMID: 31678544 DOI: 10.1016/j.avsg.2019.10.085] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/20/2019] [Accepted: 10/19/2019] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- L D George Angus
- Department of Surgery, Nassau University Medical Center, East Meadow, NY
| | - Noam Gerber
- Department of Surgery, Nassau University Medical Center, East Meadow, NY.
| | - Swapna Munnangi
- Department of Surgery, Nassau University Medical Center, East Meadow, NY
| | - Raina Wallace
- Department of Surgery, Nassau University Medical Center, East Meadow, NY
| | - Shridevi Singh
- Department of Surgery, Nassau University Medical Center, East Meadow, NY
| | - Jody Digiacomo
- Department of Surgery, Nassau University Medical Center, East Meadow, NY
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Elkbuli A, Shaikh S, McKenney M, Boneva D. Successful management with endovascular stent graft repair following gunshot wound to the subclavian artery: Case report and literature review. Int J Surg Case Rep 2019; 64:75-79. [PMID: 31622930 PMCID: PMC6796688 DOI: 10.1016/j.ijscr.2019.09.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/24/2019] [Indexed: 01/17/2023] Open
Abstract
Penetrating injuries to the subclavian artery are usually the result of stab wounds or gunshot wounds. Endovascular stent graft repair of traumatic subclavian artery injuries is a feasible alternative to open surgical approach. Several studies have reported that endovascular approach is associated with a decreased morbidity and mortality compared to open approach.
Introduction Penetrating injuries to the subclavian artery are usually the result of gunshot wounds or stab wounds. While subclavian artery injuries are relatively uncommon, vascular injuries due to penetrating trauma are frequently encountered at Trauma Centers. Despite advances in modern medicine, these injuries are associated with a high mortality and can lead to devastating morbidity. Presentation of case We report a case of a 20-year-old male who presented after sustaining multiple gunshot wounds to his left upper and lower extremities. He underwent an emergent repair of a left axillo-subclavian artery injury via an endovascular approach using a covered self-expanding stent and was discharged after less than a week. Discussion Historically, open surgical repair was considered the gold standard in the management of subclavian artery injury. However, rapid technological developments and advances in vascular surgery offer alternative management approaches in traumatic vascular surgery. In a select subset of trauma patients with penetrating vascular injuries, a minimally invasive endovascular approach may be an option. Endovascular repairs are associated with shorter operative times, less blood loss, lower complications and also a reduced mortality rate. Conclusion Endovascular stent graft prostheses offer a minimally invasive treatment modality in the management of traumatic penetrating subclavian artery injuries.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, United States.
| | - Saamia Shaikh
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, United States
| | - Mark McKenney
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, United States; Department of Surgery, University of South Florida, Tampa, FL, United States
| | - Dessy Boneva
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, United States; Department of Surgery, University of South Florida, Tampa, FL, United States
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Full realization of internal mammary artery injury after blunt chest trauma. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 26:504-510. [PMID: 32082790 DOI: 10.5606/tgkdc.dergisi.2018.15302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 01/31/2018] [Indexed: 11/21/2022]
Abstract
Due to the substantial and continual increase in the number of motorized vehicles globally, clinicians are faced with an enormous population at risk for suffering internal mammary artery injuries after blunt chest trauma. Nevertheless, very little attention has been paid to this issue by relevant health practitioners. In addition, there is a scarcity of extant research data, as well as societal guidelines, regarding internal mammary artery injury. In cases with undetected internal mammary artery injury, however, the outcome may be catastrophic or fatal. Thus, investigating and reviewing the anatomy, etiology, diagnostic approaches, and treatment strategies for patients with internal mammary artery injury are urgently needed.
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Buchanan DAS, Owen D, Angliss R, McClure DN. Acute subclavian artery occlusion with associated clavicle fracture managed with bypass graft alone. BMJ Case Rep 2018; 2018:bcr-2018-224719. [PMID: 29954765 DOI: 10.1136/bcr-2018-224719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Subclavian artery injury is a rare consequence of clavicle fracture. It most often results from penetrating trauma but can result from blunt trauma with adjacent bone fragments causing rupture, pseudoaneurysm, dissection or thrombosis of the artery. If flow through the subclavian artery is compromised there is a risk of ipsilateral upper limb ischaemia. Life-threatening haemorrhage may result in cases of laceration, and cerebral infarction may result from dissection. Vascular injury in association with clavicle fracture is typically regarded as an indication for internal fixation of the fracture. We present a case of subclavian artery thrombosis in association with a comminuted midshaft clavicle fracture causing limb ischaemia managed by carotid to brachial artery bypass without internal fracture fixation. The fracture united at 4 weeks and there was no sustained vascular or neurological impairment at follow-up. We advocate urgent vascular intervention in subclavian artery injury. There is little discussion in the literature regarding non-operative management of clavicle fractures with subclavian artery injury. We suggest that select clavicle fractures with subclavian artery injury can be safely managed non-operatively.
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Affiliation(s)
- Dougal A S Buchanan
- Department of Vascular and Endovascular Surgery, Barwon Health, Geelong, Victoria, Australia
| | - David Owen
- Department of Orthopaedic Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Richard Angliss
- Department of Orthopaedic Surgery, Barwon Health, Geelong, Victoria, Australia
| | - David N McClure
- Department of Vascular and Endovascular Surgery, Barwon Health, Geelong, Victoria, Australia
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Stenting of Subclavian Artery True and False Aneurysms: A Systematic Review. Ann Vasc Surg 2018; 47:291-304. [DOI: 10.1016/j.avsg.2017.08.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 08/18/2017] [Accepted: 08/22/2017] [Indexed: 12/12/2022]
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Jiang Z, Yang J, Wang X. Endovascular coil embolization and stenting for the treatment of iatrogenic right internal mammary artery injury: A case report. J Int Med Res 2018; 46:1271-1276. [PMID: 29322817 PMCID: PMC5972256 DOI: 10.1177/0300060517740307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A 54-year-old Chinese woman presented with a 10-year history of repeated paroxysmal palpitations. She was diagnosed with paroxysmal supraventricular tachycardia by 12-lead electrocardiogram and was advised to undergo catheter-based radiofrequency ablation. During the procedure, a rare complication occurred that was diagnosed as a right internal mammary artery penetrating injury. After appropriate emergency treatment with arterial embolization and membrane-covered stent implantation, the patient was out of immediate danger of haemorrhaging. Follow-up computed tomography angiography of the subclavian artery at 3 months after she was discharged from hospital revealed stent-graft patency with no evidence of in-stent thrombosis or stent stenosis. No problems were observed at the 6-month follow-up visit.
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Affiliation(s)
- Zhen Jiang
- 1 Department of Cardiology, First Affiliated Hospital, 26441 School of Medicine, Zhejiang University , Hangzhou, Zhejiang Province, China
| | - JinXiu Yang
- 2 Department of Cardiology, First Affiliated Hospital, 70571 Zhejiang Chinese Medicine University , Hangzhou, Zhejiang Province, China
| | - XingXiang Wang
- 1 Department of Cardiology, First Affiliated Hospital, 26441 School of Medicine, Zhejiang University , Hangzhou, Zhejiang Province, China
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Endovascular solutions for the management of penetrating trauma: an update on REBOA and axillo-subclavian injuries. Eur J Trauma Emerg Surg 2016; 42:687-694. [PMID: 27853843 DOI: 10.1007/s00068-016-0739-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Endovascular procedures continue to gain acceptance as management options for penetrating traumatic injuries. Currently, several areas of potential endovascular application are being investigated. However, the bulk of the literature on this topic is still limited to case series or small retrospective studies. Therefore, we performed a review of the published experience involving the application of endovascular therapy to trauma patients who have sustained penetrating injuries with focus on outcomes of resuscitative endovascular balloon occlusion of the aorta (REBOA) and endovascular repair of axillo-subclavian injuries. METHODS Published case reports, retrospective and prospective studies of REBOA and axillo-subclavian injuries were systematically reviewed. RESULTS A total of 7 studies on REBOA and 10 studies on endovascular repair of axillo-subclavian injuries were included. Overall, REBOA was used as an adjunct for hemorrhage control and resuscitation in patients at risk of cardiopulmonary arrest, preventing further cardiovascular collapse successfully. For axillo-subclavian injuries, endovascular stent placement had efficacy comparable to the traditional open repair. CONCLUSION REBOA is a safe and effective alternative to open thoracotomy in critically ill trauma patients at risk of death due to torso hemorrhage. Endovascular repair outcomes are comparable to open repair after axillo-subclavian injuries. Long-term results of endovascular repair remain to be defined in this patient population.
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Matsagkas M, Kouvelos G, Peroulis M, Xanthopoulos D, Bouris V, Arnaoutoglou E. Endovascular repair of blunt axillo-subclavian arterial injuries as the first line treatment. Injury 2016; 47:1051-6. [PMID: 26905594 DOI: 10.1016/j.injury.2016.02.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 01/25/2016] [Accepted: 02/05/2016] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Miltiadis Matsagkas
- Department of Surgery - Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece.
| | - George Kouvelos
- Department of Surgery - Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Michalis Peroulis
- Department of Surgery - Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Dimitrios Xanthopoulos
- Department of Surgery - Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Vasilios Bouris
- Department of Surgery - Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Eleni Arnaoutoglou
- Department of Anesthesiology, School of Medicine, University of Ioannina, Ioannina, Greece
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Kalish J, Nguyen T, Hamburg N, Eberhardt R, Rybin D, Doros G, Farber A. Associated venous injury significantly complicates presentation, management, and outcomes of axillosubclavian arterial trauma. Int J Angiol 2013; 21:217-22. [PMID: 24293980 DOI: 10.1055/s-0032-1330969] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
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.
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Affiliation(s)
- Jeffrey Kalish
- Division of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, Massachusetts
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DuBose JJ, Rajani R, Gilani R, Arthurs ZA, Morrison JJ, Clouse WD, Rasmussen TE. Endovascular management of axillo-subclavian arterial injury: a review of published experience. Injury 2012; 43:1785-92. [PMID: 22921384 DOI: 10.1016/j.injury.2012.08.028] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 08/03/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND The role of endovascular treatment for vascular trauma, including injury to the subclavian and axillary arteries, continues to evolve. Despite growing experience with the utilization of these techniques in the setting of artherosclerotic and aneurysmal disease, published reports in traumatic subclavian and axillary arterial injuries remain confined to sporadic case reports and case series. METHODS We conducted a review of the medical literature from 1990 to 2012 using Pubmed and OVID Medline databases to search for all reports documenting the use of endovascular stenting for the treatment of subclavian or axillary artery injuries. Thirty-two published reports were identified. Individual manuscripts were analysed to abstract data regarding mechanism, location and type of injury, endovascular technique and endograft type utilized, follow-up, and radiographic and clinical outcomes. RESULTS The use of endovascular stenting for the treatment of subclavian (150) or axillary (10) artery injuries was adequately described for only 160 patients from 1996 to the present. Endovascular treatment was employed after penetrating injury (56.3%; 29 GSW; 61 SW), blunt trauma (21.3%), iatrogenic catheter-related injury (21.8%) and surgical injury (0.6%). Injuries treated included pseudoaneurysm (77), AV fistula (27), occlusion (16), transection (8), perforation (22), dissection (6), or other injuries otherwise not fully described (4). Initial endovascular stent placement was successful in 96.9% of patients. Radiographic and clinical follow-up periods ranging from hospital discharge to 70 months revealed a follow-up patency of 84.4%. No mortalities related to endovascular intervention were reported. New neurologic deficits after the use of endovascular modalities were reported in only one patient. CONCLUSION Endovascular treatment of traumatic subclavian and axillary artery injuries continues to evolve. Early results are promising, but experience with this modality and data on late follow-up remain limited. Additional multicenter prospective study and capture of data for these patients is warranted to further define the role of this treatment modality in the setting of trauma.
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Affiliation(s)
- Joseph J DuBose
- University of Maryland Medical System, R Adams Cowley Shock Trauma Center, United States Air Force Baltimore Center for the Sustainment of Trauma and Readiness Skills, United States:
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Endovascular management of axillosubclavian artery injuries: report of three cases. Surg Today 2012; 43:918-22. [DOI: 10.1007/s00595-012-0330-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2011] [Accepted: 03/21/2012] [Indexed: 10/27/2022]
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Repair of Blunt Thoracic Outlet Arterial Injuries: An Evolution From Open to Endovascular Approach. ACTA ACUST UNITED AC 2011; 71:E114-21. [DOI: 10.1097/ta.0b013e31822cf359] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Weger N, Klaassen Z, Sturt C, Hertz S. Endovascular Treatment of a Pseudoaneurysm After an Iatrogenic Axillary Artery Injury. Ann Vasc Surg 2010; 24:826.e9-12. [PMID: 20471203 DOI: 10.1016/j.avsg.2009.12.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 10/31/2009] [Accepted: 12/20/2009] [Indexed: 11/24/2022]
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