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Góes AMDO, Parreira JG, Kleinsorge GHD, Dalio MB, Alves PHF, Gomes FJSDDV, de Araujo WJB, Joviliano EE, de Oliveira JCP. Brazilian guidelines on diagnosis and management of traumatic vascular injuries. J Vasc Bras 2023; 22:e20230042. [PMID: 38021277 PMCID: PMC10647898 DOI: 10.1590/1677-5449.202300422] [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: 03/15/2023] [Accepted: 06/15/2023] [Indexed: 12/01/2023] Open
Abstract
Trauma is a leading cause of death, permanent disability, and health care cost worldwide. The young and economically active are the most affected population. Exsanguination due to noncompressible torso hemorrhage is one of the most frequent causes of early death, posing a significant challenge to trauma and vascular surgeons. The possibility of limb loss due to vascular injuries must also be considered. In recent decades, the approach to vascular injuries has been significantly modified. Angiotomography has become the standard method for diagnosis, endovascular techniques are currently incorporated in treatment, and damage control, such as temporary shunts, is now the preferred approach for the patients sustaining physiological derangement. Despite the importance of this topic, few papers in the Brazilian literature have offered guidelines on vascular trauma. The Brazilian Society of Angiology and Vascular Surgery has developed Projetos Diretrizes (Guideline Projects), which includes this publication on vascular trauma. Since treating trauma patients is a multidisciplinary effort, the Brazilian Trauma Society (SBAIT) was invited to participate in this project. Members of both societies reviewed the literature on vascular trauma management and together wrote these guidelines on vascular injuries of neck, thorax, abdomen, and extremities.
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Affiliation(s)
- Adenauer Marinho de Oliveira Góes
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular - SBAC, São Paulo, SP, Brasil.
- Sociedade Brasileira de Atendimento Integrado ao Traumatizado - SBAIT, São Paulo, SP, Brasil.
- Centro Universitário do Pará - CESUPA, Faculdade de Medicina, Belém, PA, Brasil.
- Universidade Federal do Pará - UFPA, Faculdade de Medicina, Belém, PA, Brasil.
| | - José Gustavo Parreira
- Sociedade Brasileira de Atendimento Integrado ao Traumatizado - SBAIT, São Paulo, SP, Brasil.
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, São Paulo, SP, Brasil.
| | - Gustavo Henrique Dumont Kleinsorge
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular - SBAC, São Paulo, SP, Brasil.
- Sociedade Brasileira de Atendimento Integrado ao Traumatizado - SBAIT, São Paulo, SP, Brasil.
- Fundação Hospitalar do Estado de Minas Gerais - FHEMIG, Clínica de Cirurgia Vascular, Hospital João XXIII, Belo Horizonte, MG, Brasil.
| | - Marcelo Bellini Dalio
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular - SBAC, São Paulo, SP, Brasil.
- Universidade de São Paulo - USP, Divisão de Cirurgia Vascular e Endovascular, Hospital das Clínicas, Ribeirão Preto, SP, Brasil.
| | - Pedro Henrique Ferreira Alves
- Sociedade Brasileira de Atendimento Integrado ao Traumatizado - SBAIT, São Paulo, SP, Brasil.
- Universidade de São Paulo - USP, Faculdade de Medicina, Hospital das Clínicas, III Clínica Cirúrgica, São Paulo, SP, Brasil.
| | - Francisco João Sahagoff de Deus Vieira Gomes
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular - SBAC, São Paulo, SP, Brasil.
- Sociedade Brasileira de Atendimento Integrado ao Traumatizado - SBAIT, São Paulo, SP, Brasil.
- Universidade do Estado do Rio de Janeiro - UERJ, Faculdade de Ciências Médicas, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
- Polícia Militar do Estado do Rio de Janeiro - PMERJ, Rio de Janeiro, RJ, Brasil.
| | - Walter Junior Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular - SBAC, São Paulo, SP, Brasil.
- Universidade Federal do Paraná - UFPR, Hospital das Clínicas, Divisão de Angiorradiologia e Cirurgia Endovascular, Curitiba, PR, Brasil.
| | - Edwaldo Edner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular - SBAC, São Paulo, SP, Brasil.
- Universidade de São Paulo - USP, Divisão de Cirurgia Vascular e Endovascular, Hospital das Clínicas, Ribeirão Preto, SP, Brasil.
| | - Julio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular - SBAC, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro - UNIRIO, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
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Hazra D, Kota AA, Raj SP, Premkumar P, Selvaraj AD, Agarwal S, Thomas BP. Does endovascular repair of post-traumatic thoracic vascular injury of the subclavian/axillary arteries followed by brachial plexus injury improve outcome? Indian J Thorac Cardiovasc Surg 2021; 38:294-299. [PMID: 35528997 PMCID: PMC9023618 DOI: 10.1007/s12055-021-01278-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 11/25/2022] Open
Abstract
Traumatic injuries to the axillary artery or subclavian artery along with a brachial plexus injury are infrequent. Although the traditional management has been conservative because of robust collaterals, the functional improvement of the limb depends on the degree of brachial plexus injury and on the revascularization status. We report three cases of endovascular repair post-traumatic axillo-subclavian artery injuries followed by brachial plexus injury with good functional outcomes. Endovascular repair of post-traumatic subclavian and axillary artery injuries followed by brachial plexus injury is safe and feasible, and improves limb outcomes.
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Affiliation(s)
- Darpanarayan Hazra
- Department of Vascular Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| | - Albert Abhinay Kota
- Department of Vascular Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| | - Sam Pon Raj
- Department of Vascular Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| | - Prabhu Premkumar
- Department of Vascular Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| | - Andrew Dheepak Selvaraj
- Department of Vascular Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| | - Sunil Agarwal
- Department of Vascular Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| | - Binu Prathap Thomas
- Department of Hand and Leprosy Reconstructive Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
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Staniszewska A, Anwar M, Hamady M, Nott D. Hybrid repair of proximal subclavian artery transection. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408620934364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although rare, subclavian artery injuries are associated with significant mortality and morbidity, with almost two-thirds of patients dying before reaching hospital. Recent advances in technology have resulted in increasing use of endovascular therapy in management of these injuries. In this report, we present a case of a successful hybrid repair of traumatic left proximal subclavian artery transection. The employment of an Amplatzer Vascular Plug to control a short proximal subclavian artery stump and subsequent ligation of the distal segment of subclavian artery with its anastomosis to the carotid artery resulted in excellent clinical outcome without performing a sternotomy in a young patient.
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Affiliation(s)
- Aleksandra Staniszewska
- Department of Vascular Surgery, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Muzaffar Anwar
- Department of Vascular Surgery, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mohamad Hamady
- Department of Interventional Radiology, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - David Nott
- Department of Vascular Surgery, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
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González Canga C, Busto Suárez S, Camblor Santervás LA, Vega García F, Zanabili Al-Sibbai A, Álvarez Marcos F, Alonso Pérez M. Endovascular Treatment of a Traumatic Axillary Artery Rupture Using the Dual Bull's-Eye Technique. Ann Vasc Surg 2020; 69:447.e17-447.e21. [PMID: 32474146 DOI: 10.1016/j.avsg.2020.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/01/2020] [Accepted: 05/06/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Our purpose is to report a case of an axillary artery rupture treated by endovascular means using the dual bull's-eye technique. An 83-year-old woman with multiple comorbidities was diagnosed with axillary artery rupture after the reduction of a shoulder dislocation. METHODS An endovascular repair attempt was made, but, despite the use of a double approach (antegrade and retrograde), reconnecting both ends of the severed artery was deemed not possible. 5-mm Amplatz GooseNeck snares were advanced from each access and superposed in a perpendicular plane. A percutaneous infraclavicular puncture with a lumbar needle was made through both snares, and a V14 guidewire was subsequently introduced. The guidewire was recovered through femoral and brachial accesses, and a 7 × 100 mm covered self-expandable stent was deployed. RESULTS The final angiographic control did not show further hemorrhage, and the patient recovered radial pulse. Follow-up showed complete patency and no complications at 9 months after the procedure. CONCLUSIONS The dual bull's-eye technique can be used as a resource tool in cases of arterial rupture, when the arterial continuity cannot be re-established by conventional approaches.
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Affiliation(s)
- Carmen González Canga
- Vascular Surgery Department, Asturias University Central Hospital (HUCA), Oviedo, Spain.
| | - Sara Busto Suárez
- Vascular Surgery Department, Asturias University Central Hospital (HUCA), Oviedo, Spain
| | | | - Florentino Vega García
- Vascular & Interventional Radiology Department, Asturias University Central Hospital (HUCA), Oviedo, Spain
| | | | | | - Manuel Alonso Pérez
- Vascular Surgery Department, Asturias University Central Hospital (HUCA), Oviedo, Spain
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Axillary artery intimal dissection with thrombosis and brachial plexus injury after reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2019; 28:e393-e397. [PMID: 31636009 DOI: 10.1016/j.jse.2019.07.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/02/2019] [Indexed: 02/01/2023]
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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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Glaser JD, Kalapatapu VR. Endovascular Therapy of Vascular Trauma—Current Options and Review of the Literature. Vasc Endovascular Surg 2019; 53:477-487. [DOI: 10.1177/1538574419844073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objective: To review the current use of endovascular techniques in trauma. Summary Background Data: Multiple studies have demonstrated that, despite current guidelines, endovascular therapies are used in instances of arterial trauma. Methods: The existing literature concerning arterial trauma was reviewed. Studies reviewed included case reports, single-center case series, large database studies, official industry publications and instructions for use, and society guidelines. Results: Endovascular therapies are used in arterial trauma in all systems. The use of thoracic endografts in blunt thoracic aortic trauma is accepted and endorsed by society guidelines. The use of endovascular therapies in other anatomic locations is largely limited to single-center studies. Advantages potentially include less morbidity due to smaller incisions as well as shorter operating room times. Many report using endovascular therapies even with hard signs of injury. Long-term results are limited by a lack of long-term follow-up but, in general, suggest that these techniques produce acceptable outcomes. The adoption of these techniques may be limited by resource and surgeon availability. Conclusions: The use of endovascular therapies in trauma has gained acceptance despite not yet having a place in official guidelines.
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Affiliation(s)
- Julia D. Glaser
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Venkat R. Kalapatapu
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
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Dias-Neto M, Ramos JF, Teixeira JF. Blunt Injury of the Innominate Artery: What Surprises to Expect? A Case Report. Vasc Endovascular Surg 2018; 52:226-232. [DOI: 10.1177/1538574418758230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Injuries of the supra-aortic trunk after blunt chest trauma are rare. This is a case report of a blunt traumatic lesion of the innominate artery (IA) origin that exhibited aortic arch involvement with a focus on imaging and treatment. A 41-year-old fisherman presented an IA injury secondary to a high-impact blunt chest trauma. Upon physical examination, vital signs were stable and upper extremity pulses were present. In addition to several bone fractures (costal ribs, clavicle, scapula, temporal, maxillary, and sphenoid), computed tomography angiography revealed dissection/pseudoaneurysm of the IA sparing the bifurcation. The patient underwent emergent angiography, which confirmed that the IA dissection was not ruptured, but it was unclear whether there was a pseudoaneurysm at the origin of the IA or aortic arch involvement. The patient was considered for open surgery. An ascending aorta-to-IA bypass was achieved by the off-pump beating heart approach. The IA stump was carefully observed, but oversewing was not possible due to the extension of the intimal-medial lesions into the artic arch. An on-pump intervention was then required for aortic angioplasty with a pericardial patch that was reinforced by Gel Seal. The postoperative course was uneventful. The patient was discharged without any complications. Conventional surgery provides good results and should remain in the armamentarium for the treatment of traumatic lesions at the IA origin, particularly if aortic arch involvement cannot be ruled out, to ensure a truly patient-tailored approach.
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Affiliation(s)
- Marina Dias-Neto
- Department of Angiology and Vascular Surgery, São João Hospital Centre, Oporto, Portugal
| | - José F. Ramos
- Department of Angiology and Vascular Surgery, São João Hospital Centre, Oporto, Portugal
| | - José F. Teixeira
- Department of Angiology and Vascular Surgery, São João Hospital Centre, Oporto, Portugal
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Otsuka H, Sato T, Sakurai K, Aoki H, Yamagiwa T, Iizuka S, Inokuchi S. Use of interventional radiology as initial hemorrhage control to improve outcomes for potentially lethal multiple blunt injuries. Injury 2018; 49:226-229. [PMID: 29221814 DOI: 10.1016/j.injury.2017.11.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/29/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Recently, trauma management has been markedly improved with interventional radiology (IVR) and damage-control strategies. However, the indications for its use in hemodynamically unstable patients with severe trauma remains unclear. In some cases, IVR may be more effective than surgery for damage-control hemostasis; however, performing IVR in life-threatening trauma settings is challenging. To address this, we practiced and evaluated a trauma-management system with emergency physicians who trained for both severe trauma management, and techniques of surgery and IVR. MATERIALS AND METHODS Among the 1822 patients with severe trauma admitted between October 2014 and December 2016, 201 underwent emergency surgery or IVR. Among these, 16 patients whose systolic blood pressure was ≤90 mmHg, without improvement following primary resuscitation, and whose first intervention was IVR, were analyzed. We retrospectively evaluated the admission characteristics, IVR-related characteristics, and prognoses, and compared several parameters before and after IVR. RESULTS This study included 10 men and 6 women (median age: 46 years). IVR was performed for 10 pelvic fractures; five liver-, one splenic-, and one renal injury; and one transection each of the external carotid-, vertebral-, axillosubclavian-, intercostal-, and lumbar arteries. The mean times from the patient arrival, and diagnosis to the start of IVR were 56.3 ± 26.6 and 15.1 ± 3.8 min, respectively. The mean time spent in the angiography suite was 50 min. The systolic blood pressure, pulse rate, base excess/deficit, serum-lactate levels, and D-dimer values were significantly improved after IVR. Although two patients needed additional treatment for morbidities following IVR intervention, all achieved complete recovery. The mortality rate was 25.0%, and no preventable deaths were noted. Eight patients showed unexpected survival. CONCLUSIONS In some cases, IVR may be the best first measure for resuscitative hemostasis in potentially lethal multiple injuries, given efficient diagnoses/actions and the ability to deal with complications.
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Affiliation(s)
- Hiroyuki Otsuka
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Toshiki Sato
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Keiji Sakurai
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Hiromichi Aoki
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Takeshi Yamagiwa
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Shinichi Iizuka
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Sadaki Inokuchi
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
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Babu A, Garg H, Sagar S, Gupta A, Kumar S. Penetrating neck injury: Collaterals for another life after ligation of common carotid artery and subclavian artery. Chin J Traumatol 2017; 20:56-58. [PMID: 28233726 PMCID: PMC5343100 DOI: 10.1016/j.cjtee.2015.12.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 12/23/2015] [Indexed: 02/04/2023] Open
Abstract
Neck, being not protected by skeleton, is vulnerable to external trauma and injury which involves blood vessels, trachea, esophagus and other endocrine and nervous system organs. Vascular injuries can not only cause potentially life-threatening hemorrhage but also need profound surgical expertise in management. Development of collateral circulation in neck is well known; however, there is scarcity of literature on the role of collateral formation in neck trauma. Here, we present a unique case of penetrating gunshot injury to neck with right common carotid and right subclavian artery injury with hemorrhagic shock managed with ligation of these vessels as a life-saving procedure. The patient presented with no neurological or motor deficits in immediate postoperative period owing to the collateral circulation between right vertebral artery and right common carotid and right subclavian artery.
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Diaz-Gutierrez I, Rana MA, Ali B, Marek JM, Langsfeld M. Hybrid Repair of Complex Left Subclavian Artery Injury with Partial Transection and Complete Thrombosis in an Unstable Patient following Blunt Trauma. Ann Vasc Surg 2016; 40:298.e11-298.e14. [PMID: 27903481 DOI: 10.1016/j.avsg.2016.08.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/01/2016] [Accepted: 08/05/2016] [Indexed: 10/20/2022]
Abstract
Blunt subclavian artery injuries are rare and are associated with high morbidity and mortality. Several case reports have suggested that endovascular repair is safe with short operative times and minimal blood loss. We report a case of a 20-year-old male patient involved in a high-speed motor vehicle collision that resulted in partial transection of left subclavian artery with complete luminal thrombosis. Patient also had a left main-stem bronchus avulsion along with major intra-abdominal injuries and multiple spine and long bone fractures. He underwent emergent abdominal exploration due to multisystem trauma and hemodynamic instability. Following laparotomy and resuscitation, the subclavian artery injury was repaired using a hybrid technique geared at protecting the patent vertebral and axillary arteries from embolization. We used supraclavicular dissection and arterial control with endovascular stent-graft placement in retrograde fashion to repair the left subclavian artery injury. At 6-month follow-up, computed tomography scan confirmed patency of the left subclavian artery stent and there was no evidence of vertebrobasilar insufficiency or left upper extremity ischemia. In conclusion, stent-graft repair of blunt subclavian artery injuries is expedient and safe. Supraclavicular vascular dissection and control are effective in preventing distal embolization in rare cases complicated with luminal thrombosis.
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Affiliation(s)
- Ilitch Diaz-Gutierrez
- Department of Surgery, Division of Vascular Surgery, University of New Mexico, Albuquerque, NM
| | - Muhammad A Rana
- Department of Surgery, Division of Vascular Surgery, University of New Mexico, Albuquerque, NM.
| | - Barkat Ali
- Department of Surgery, Division of Vascular Surgery, University of New Mexico, Albuquerque, NM
| | - John M Marek
- Department of Surgery, Division of Vascular Surgery, University of New Mexico, Albuquerque, NM
| | - Mark Langsfeld
- Department of Surgery, Division of Vascular Surgery, University of New Mexico, Albuquerque, NM
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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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Sladojevic M, Markovic M, Ilic N, Pejkic S, Banzic I, Djoric P, Koncar I, Tomic I, Davidovic L. Open Treatment of Blunt Injuries of Supra-Aortic Branches: Case Series. Ann Vasc Surg 2015; 31:205.e5-205.e10. [PMID: 26647209 DOI: 10.1016/j.avsg.2015.07.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 06/22/2015] [Accepted: 07/06/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Blunt injuries of the supra-aortic branches are rare entity, and majority of patients die before arrival at the hospital. Those who arrive alive require complex and fast procedure that requires sternotomy. We report 3 successfully managed cases. CASE REPORTS We report 3 patients with injury of supra-aortic branches. One was treated urgently due to longitudinal rupture on the posterior wall of innominate artery after car accident, and another 2 had chronic false aneurysm located at the very orifice of the right subclavian and left common carotid artery. In first and second patient bypass grafting with a hand-made, Y-shaped, 8-mm Dacron graft from the ascending aorta to the right common carotid and proximal right subclavian artery were performed, whereas in last 1 bypass grafting from the ascending aorta to the cervical part of the left common carotid artery was performed. In our facility, there were no possibilities for any endovascular treatment. CONCLUSIONS When endovascular technology is not available, open surgical repair of blunt injuries of supra-aortic vessels can be performed without complications. No matter to that, endovascular and hybrid procedures should be considered whenever possible.
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Affiliation(s)
- Milos Sladojevic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia.
| | - Miroslav Markovic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nikola Ilic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sinisa Pejkic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Igor Banzic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Predrag Djoric
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Igor Koncar
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivan Tomic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Lazar Davidovic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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14
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Endovascular management of traumatic peripheral arterial injuries. J Surg Res 2015; 199:557-63. [DOI: 10.1016/j.jss.2015.04.086] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 03/24/2015] [Accepted: 04/30/2015] [Indexed: 11/13/2022]
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15
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Martín-Trenor A. Avulsión del tronco arterial innominado por aplastamiento torácico. ANGIOLOGIA 2015. [DOI: 10.1016/j.angio.2014.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Lee CW, Song S, Choi SU, Kim SH, Lee HC. Hybrid Repair for Anastomotic Pseudoaneurysm on the Innominate Artery Following Blunt Chest Trauma. J Card Surg 2015; 30:836-8. [PMID: 26358900 DOI: 10.1111/jocs.12631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A 55-year-old male with a previous open surgical repair of a traumatic right subclavian artery rupture was admitted following a fall with a rupture of the bifurcation of the innominate artery. The right common carotid artery was debranched from the left common carotid artery using a ringed 8 mm vascular graft. Simultaneously, a 16 × 80 mm vascular stent graft was inserted from the origin of the innominate artery to the mid portion of the subclavian artery, successfully covering the rupture site.
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Affiliation(s)
- Chung Won Lee
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Seunghwan Song
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Seon Uoo Choi
- Department of Trauma Surgery, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Seon Hee Kim
- Department of Trauma Surgery, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Han Cheol Lee
- Division of Cardiology, Department of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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17
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Zakko J, Scali S, Beck AW, Klodell CT, Beaver TM, Martin TD, Huber TS, Feezor RJ. Percutaneous thoracic endovascular aortic repair is not contraindicated in obese patients. J Vasc Surg 2014; 60:921-8. [PMID: 24845111 DOI: 10.1016/j.jvs.2014.04.051] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 04/15/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE There are limited data describing the preclose technique with the Perclose ProGlide device (Abbott Vascular, Redwood City, Calif) in percutaneous thoracic endovascular aortic repair (P-TEVAR), particularly in obese patients, in whom use of this technique is thought to be relatively contraindicated. The purpose of this analysis was to describe our experience with P-TEVAR and to compare outcomes in patients with or without obesity. METHODS All TEVAR procedures at a single institution from 2005 to 2011 were reviewed, and P-TEVAR patients were stratified by body mass index (obesity ≥ 30 kg/m2). Preoperative computed tomography scans were analyzed for access vessel depth, calcification, and morphology. Technical success was defined as the ability to achieve hemostasis and to maintain limb perfusion without the need for common femoral artery exposure or obligate surgical repair of the vessel within a 30-day postoperative period. Generalized estimating equations and stepwise logistic regression were used to develop prediction models of preclose failure. RESULTS The review identified 536 patients, in whom 355 (66%) P-TEVAR procedures were completed (366 arteries; n = 40 [11%] bilateral). Compared with nonobese patients (n = 264), obese patients (n = 91) were typically younger (59 ± 16 years vs. 66 ± 16 years; P = .0004) and more likely to have renal insufficiency (28% vs. 17%; P = .05) or diabetes mellitus (19% vs. 9%; P = .02). The number of Perclose deployments was similar between groups (P = NS). Mean sheath size (25.4F vs 25.0F; P = .04), access vessel inner diameters (8.5 ± 1.9 mm vs. 7.9 ± 2.0 mm; P = .02), and vessel depth (50 ± 20 mm vs. 30 ± 13 mm; P < .0001) were greater in obese patients. Adjunctive iliac stents were used in 7% of cases (10 [11%] in obese patients vs 16 [6%] in nonobese patients; P = .2). Overall technical success was 92% (92% for nonobese patients vs 93% for obese patients; P = .7). Three patients required subsequent operations for access complications, two obese patients (2%) and one nonobese patient (0.4%) (P = .3). Independent predictors of failure were adjunctive iliac stent (odds ratio [OR], 9.5; 95% confidence interval [CI], 3.3-27.8; P < .0001), more than two Perclose devices (OR, 7.0; 95% CI, 2.3-21; P = .0005), and smaller access vessel diameter to sheath size ratio (OR multiplies by 1.1 for each .01 decrease in ratio; 95% CI, 1.02-1.2; P = .007) (area under the receiver operating characteristic curve = .75). CONCLUSIONS Obesity is not a contraindication to P-TEVAR. P-TEVAR can be performed safely, despite the need for larger diameter sheaths. However, patients predicted to need adjunctive stenting or possessing smaller access vessel diameter to sheath size ratios are at highest risk of preclose failure with the Perclose ProGlide device, and selective use of this technique is recommended.
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Affiliation(s)
- Jason Zakko
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Charles T Klodell
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Tomas D Martin
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Robert J Feezor
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
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18
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Rohlffs F, Larena-Avellaneda AA, Petersen JP, Debus ES, Kölbel T. Through-and-through wire technique for endovascular damage control in traumatic proximal axillary artery transection. Vascular 2014; 23:99-101. [PMID: 24729014 DOI: 10.1177/1708538114531259] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Repair of blunt shoulder trauma with transection of the subclavian or proximal axillary artery poses a surgical challenge, especially in instable patients. Endovascular treatment for initial damage control in arterial transection has evolved as a promising technique to improve outcome, but technical success can be limited in cases of complete transection as the lesion cannot be passed by a guidewire. This report describes an endovascular approach using a through-and-through brachial-femoral wire to control complete traumatic transection of the proximal axillary artery in a hemodynamically unstable patient. Endovascular therapy is used as a bridging method for open surgical repair three days later under optimized conditions with an interdisciplinary team. The brachial-femoral guidewire technique helps to overcome limitations in endovascular therapy in patients with blunt traumatic transection of thoracic outlet arteries.
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Affiliation(s)
- Fiona Rohlffs
- Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Jan Philipp Petersen
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Eike Sebastian Debus
- Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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19
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Simsek E, Karapinar K, Ince I, Ulus AT. Brachial index does not reflect upper extremity functionality following surgery for vascular trauma. J Vasc Bras 2014. [DOI: 10.1590/jvb.2014.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES: Vascular injuries to the upper extremities requiring surgical repair are common after accidents. However, neither postoperative functionality nor hemodynamic status of the extremity are routinely described. We evaluated the postoperative functional and hemodynamic status of patients with vascular traumas in the upper extremities. METHODS: 26 patients who suffered penetrating vascular traumas in the upper extremities from November 2008 to December 2011 were retrospectively evaluated. Data on first approach, surgical technique employed and early postoperative outcomes were recorded. Further data on the post-discharge period, including clinical functional status of the arm, Doppler ultrasonography and brachial-brachial index were also evaluated. RESULTS: Average follow up was 33.5±10.8 months. Right (1.05±0.09) and left (1.04±0.08) brachial indexes were measured during follow up,. Doppler ultrasonography showed arterial occlusion in 4 patients (15%). Near-normal brachial-brachial indexes was observed in all four of these patients with occlusion of one of the upper extremity arteries, even though they exhibited limited arm function for daily work. CONCLUSIONS: Evaluation of the postoperative outcomes of this small series of patients with penetrating vascular traumas in the upper extremity revealed that 15% of them suffered occlusion of one artery of the upper extremity. Artery occlusion did not correlate with brachial-brachial Doppler index, probably due to rich collateral circulation, but occlusion was associated with an extremity that was dysfunctional for the purposes of daily work. The result of the brachial-brachial index does not therefore correlate with functionality.
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Affiliation(s)
- Erdal Simsek
- Turkiye Yuksek Ihtisas Training and Research Hospital
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20
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Mosquera VX, Velasco C, Gulias D, Fariña MM. Traumatic Brachiocephalic Trunk Pseudoaneurysm. J Card Surg 2013; 28:430-2. [DOI: 10.1111/jocs.12117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Victor X. Mosquera
- Department of Cardiac Surgery; Complejo Hospitalario Universitario de A Coruña; A Coruña Spain
| | - Carlos Velasco
- Department of Cardiac Surgery; Complejo Hospitalario Universitario de A Coruña; A Coruña Spain
| | - Daniel Gulias
- Department of Interventional Radiology; Complejo Hospitalario Universitario de A Coruña; A Coruña Spain
| | - Monica Mourelo Fariña
- Intensive Care Unit; Complejo Hospitalario Universitario de A Coruña; A Coruña Spain
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21
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Bennett S, Hannon E, Okoye B. Cervical approach to the thoracic inlet in paediatric patients with broncho-pulmonary foregut malformations. J Pediatr Surg 2013; 48:445-8. [PMID: 23414883 DOI: 10.1016/j.jpedsurg.2012.11.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/26/2012] [Accepted: 11/05/2012] [Indexed: 11/28/2022]
Abstract
Lesions of the thoracic inlet present a significant challenge to the surgeon due to the difficulty of access and proximity to important neurovascular structures within the region. We describe two cases of benign disease of the thoracic inlet in children, one bronchogenic cyst and an esophageal duplication, and report the cervical approach used to manage them. Both lesions extended from the neck through the thoracic inlet, but demonstrate how benign lesions in this area can be delivered up into a cervical incision, negating the need for the more invasive modified thoracotomies. A cervical approach can be safely and successfully used to approach benign pathology, such as bronchogenic cysts and oesophageal duplications of the thoracic inlet. Careful multidisciplinary planning is required for such procedures.
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Affiliation(s)
- Stephen Bennett
- Department of Paediatric Surgery, St George's Hospital, SW17 0QT Tooting, London
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22
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Assenza M, Centonze L, Valesini L, Campana G, Corona M, Modini C. Traumatic subclavian arterial rupture: a case report and review of literature. World J Emerg Surg 2012; 7:18. [PMID: 22710070 PMCID: PMC3447637 DOI: 10.1186/1749-7922-7-18] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Accepted: 06/18/2012] [Indexed: 11/14/2022] Open
Abstract
Subclavian artery injuries represent an uncommon complication of blunt chest trauma, this structure being protected by subclavius muscle, the clavicle, the first rib, and the deep cervical fascia as well as the costo-coracoid ligament, a clavi-coraco-axillary fascia portion. Subclavian artery injury appears early after trauma, and arterial rupture may cause life-treatening haemorrages, pseudo-aneurysm formation and compression of brachial plexus. These clinical eveniences must be carefully worked out by accurate physical examination of the upper limb: skin color, temperature, sensation as well as radial pulse and hand motility represent the key points of physical examination in this setting. The presence of large hematomas and pulsatile palpable mass in supraclavicular region should raise the suspicion of serious vascular injury. Since the first reports of endovascular treatment for traumatic vascular injuries in the 90’s, an increasing number of vascular lesions have been treated this way. We report a case of traumatic subclavian arterial rupture after blunt chest trauma due to a 4 meters fall, treated by endovascular stent grafting, providing a complete review of the past twenty years’ literature.
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Affiliation(s)
- Marco Assenza
- Emergency Department, Division of Emergency Surgery and Trauma, Policlinico "Umberto I", Rome, Italy.
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