REVIEW ARTICLE
Subclavian vessel injuries: difficult anatomy and difficult territory
J. D. Sciarretta • J. A. Asensio • T. Vu • F. N. Mazzini • J. Chandler •
F. Herrerias • J. M. Verde • P. Menendez • J. M. Sanchez •
P. Petrone • K. D. Stahl • H. Lieberman • C. Marini
Received: 16 June 2011 / Accepted: 19 June 2011 / Published online: 29 July 2011
� Springer-Verlag 2011
Abstract
Introduction Thoracic and thoracic related vascular inju-
ries represent complex challenges to the trauma surgeon.
Subclavian vessel injuries, in particular, are uncommon and
highly lethal. Regardless of the mechanism, such injuries
can result in significant morbidity and mortality.
Materials and methods Systematic review of the litera-
ture, with emphasis on the diagnosis, treatment and outcomes
of these injuries, incorporating the authors’ experience.
Conclusions These injuries are associated with significant
morbidity and mortality. Patients who survive transport are
subject to potentially debilitating injury and possibly death.
Management of these injuries varies, depending on
hemodynamic stability, mechanism of injury, and associ-
ated injuries. Despite significant advancements, mortality
due to subclavian vessel injury remains high.
Keywords Vascular � Trauma � Subclavian � Injury �Exposure � Management
Introduction
Thoracic and related vascular injuries represent complex
challenges for the trauma surgeon. In particular, subclavian
vessel injuries are uncommon and highly lethal. Regardless
of the mechanism, such injuries can result in significant
morbidity and mortality. Subclavian vessel injuries are
generally associated with multiple life-threatening injuries.
Over the years, the overall mortality has continued to
improve due to significant advancements in resuscitation,
emergency medical transport systems, and the increased
development of regionalized systems of trauma.
Historical perspective
In 1892, Halsted [1] performed the first successful sub-
clavian aneurysmal ligation. Given the infrequent occur-
rence of subclavian vessel injuries, surgeons had minimal
experience in their management prior to wartime. Com-
monly, the general practice was simple ligation. During
World War I, the American and British surgeons estimated
that the overall rate of vascular injury ranged from 0.4 to
1.3% [8]. In 1919, Makins [2] reported 45 subclavian artery
injuries amongst British casualties during World War I [1,
8]. A landmark study from Debakey and Simeone [10] in
1946 reported an incidence of less than 1%, accounting for
21 patients of 2,471 arterial injuries sustained by American
soldiers during World War II. During the Korean conflict,
Hughes [12], in a study of 304 major arterial vessel inju-
ries, reported only three subclavian artery cases. The rel-
atively few cases throughout the history of war may
account for exsanguination on the battle field. Penetrating
subclavian injuries comprised less than 1% of all vascular
injuries reported during the Vietnam conflict [11]. During
this time, 48 different surgeons treated this injury; only two
encountered this injury more than once, for a total of 68
reported cases. Rich [11] reported a total of 63 subclavian
artery injuries in the original report of the Vietnam
J. D. Sciarretta � J. A. Asensio (&) � T. Vu �F. N. Mazzini � J. Chandler � F. Herrerias �J. M. Verde � P. Menendez � J. M. Sanchez � P. Petrone �K. D. Stahl � H. Lieberman � C. Marini
Division of Trauma Surgery and Surgical Critical Care,
Dewitt–Daughtry Family Department of Surgery, Ryder Trauma
Center, University of Miami, 1800 NW 10 Avenue Suite T-247,
Miami, FL 33136-1018, USA
e-mail: [email protected]
123
Eur J Trauma Emerg Surg (2011) 37:439–449
DOI 10.1007/s00068-011-0133-2
Vascular Registry for acute arterial vascular injuries during
the Vietnam conflict.
During the recent conflicts of Iraq and Afghanistan, the
overall rate of vascular injury was reported to be greater
than in previously reported conflicts [32]. This increase in
rate may be related to improved hemorrhage control, shorter
evacuation times, and improved survivability [32]. High-
velocity-type injuries from explosives and gunshot wounds
accounted for the majority of these injuries. Interesting, the
incidence of vascular injury was higher in Iraq than
Afghanistan (12.5 and 9%, respectively). White et al. [32]
identified 1,570 US troops in both Iraq and Afghanistan
that presented with wartime-related vascular injuries. Of
these, 12% resulted in vascular injuries of the torso, with
subclavian vessel injuries accounting for 2.3%. Over a
24-month period, Clouse et al. [33] identified 301 arterial
vascular injuries, of which 3.7% were due to subclavian–
axillary injury. Nevertheless, both the management and
treatment strategies have evolved from the various wars and
battlefields over the course of time (see Table 1).
Anatomy
The subclavian arteries have different origins according to
their anatomic location (right versus left). On the right,
the subclavian artery arises from the innominate artery
behind the right sternoclavicular articulation; on the left
side it originates directly from the arch of the aorta. The
subclavian artery is divided into three portions. The first
portion courses from the origin to the medial border of the
scalenus anterior. The second portion lies behind this
muscle, while the third portion courses from the lateral
border of the scalenus anterior up to the lateral border of
the first rib (see Fig. 1).
The first portion of the right subclavian artery arises
behind the upper part of the right sternoclavicular articu-
lation, and passes upward and laterally to the medial
margin of the scalenus anterior. It ascends a little above the
clavicle, with the extent to which it does this varying in
different cases. It is crossed by the internal jugular and
vertebral veins, by the vagus nerve and the cardiac bran-
ches of the vagus nerve, and by the subclavian loop of the
sympathetic trunk, which forms a ring around the vessel.
The anterior jugular vein is directed lateralward in front of
the artery, but is separated from it by the sternohyoid and
sternothyroid strap muscles.
The first portion of the left subclavian artery arises
behind the left common carotid, and at the level of the
fourth thoracic vertebra; it ascends in the superior medi-
astinum to the root of the neck and then arches lateralward
to the medial border of the scalenus anterior. Its anatomic
relations are as follows. In front: the vagus, cardiac, and
phrenic nerves, which lie parallel with it, the left common
carotid artery, the left internal jugular and vertebral veins,
and the commencement of the left innominate vein. It is
covered by the sternothyroid, sternohyoid and sternoclei-
domastoid muscles. The second portion of the left sub-
clavian artery lies behind the scalenus anterior. It is very
short, and forms the highest part of the arch described by
the vessel.
On the right side of the neck, the phrenic nerve is sep-
arated from the second part of the artery by the scalenus
anterior, while on the left side it crosses the first part of the
artery close to the medial edge of the muscle. Behind
the vessel are the pleura and the scalenus medi-
us; above, the brachial plexus of nerves; below, the pleura.
The subclavian vein lies below and in front of the artery,
separated from it by the scalenus anterior.
The third portion of the left subclavian artery runs
downward and lateralward from the lateral margin of the
Table 1 Military experiencesConflict Author(s) Total arteries Subclavian Incidence (%)
WWI Makins (1919) 1,191 45 3.8
WWII DeBakey & Simeone (1946) 2,471 21 0.9
Korea Hughes (1958) 304 3 1
Vietnam Rich (1970) 1,000 8 0.8
Afghanistan Sherif (1992) 224 Combined with axillary N/A
Fig. 1 Anatomy of subclavian vessels
440 J. D. Sciarretta et al.
123
scalenus anterior to the outer border of the first rib, where it
becomes the axillary artery. The external jugular vein
crosses its medial part and receives the transverse scapular,
transverse cervical, and anterior jugular veins, which fre-
quently form a plexus in front of the artery. Behind the
veins, the nerve to the subclavius muscle descends in front
of the artery. The terminal part of the artery lies behind the
clavicle and the subclavius muscle and is crossed by the
transverse scapular vessels. The subclavian vein is in front
of and at a slightly lower level than the artery. Behind, it
lies on the lowest trunk of the brachial plexus, which
intervenes between it and the scalenus medius. Above and
to its lateral side are the upper trunks of the brachial plexus
and the omohyoid muscle.
The branches of the subclavian artery are the vertebral,
internal mammary, thyrocervical and costocervical trunks.
On the left side, all four branches generally arise from the
first portion of the vessel; on the right side, the costocer-
vical trunk usually originates from the second portion of
the vessel. On both sides of the neck, the first three bran-
ches arise close together at the medial border of the sca-
lenus anterior. In the majority of cases, there is a free
interval of 1.25–2.5 cm between the commencement of the
artery and the origin of the nearest branch.
Incidence
Subclavian vessel injuries account for approximately 5% of
all vascular injuries [3, 4, 28]. Busy urban trauma centers
report admitting between two and four subclavian vascular
injuries per year, although some international trauma cen-
ters have reported admitting as high as four patients per
month [4, 5, 15, 24]. Subclavian artery injury specifically
accounts for 1–2% of all acute vascular injuries [3, 4, 8, 9,
26, 27]. While the majority of these injuries are penetrat-
ing, up to 25% are related to a blunt mechanism of injury
[14]. The low incidence of subclavian artery injury is pri-
marily explained by the anatomic location and the pro-
tective barrier provided by the clavicle and thoracic cage.
In a study combining both prospective and retrospective
reviews, Demetriades [9] reported that isolated subclavian
vein injuries were present in 44% of the patients, isolated
subclavian artery involvement in 39%, and combined
injuries in approximately 17% of the cases. On the other
hand, Lin et al. [23] reported that 24 of 54 patients pre-
senting with subclavian artery injuries also sustained
associated venous injuries.
The subclavian vessels are relatively well protected by
the overlying clavicle and first rib, but fractures to these
and other adjacent osseous structures may lead to serious
life-threatening injury. In one of the largest series pub-
lished, Natali reported a total of 10 patients with clavicle
fracture-induced injury [21]. The incidence of clavicular
fractures and associated subclavian vessel injury is esti-
mated to be less than 1% [35, 40]. Richardson [19] iden-
tified the first rib fracture as an useful indicator of severe
upper thoracic trauma. In this study, 55 patients with first
rib fractures were evaluated, of which 5.5% sustained
associated blunt subclavian artery injuries. A comparable
review by Phillips demonstrated similar findings in the
presence of displaced first rib fractures, with 9% presenting
with associated blunt subclavian artery injuries [20].
The majority of subclavian vessel injuries in the civilian
population result from penetrating trauma. Over the past
several decades, there has been a steady rise in firearm-
Table 2 Civilian subclavian
artery reportsCities Year Author Injuries
Louisville 1962 Cook 3
Memphis 1964 Pate & Wilson 12
Rochester 1968 Matloff & Morton 3
Chicago 1969 Amato 14
Houston 1970 Bricker 14
Baltimore 1970 Brawley 11
Durban 1978 Robbs 24
Johannesburg 1987 Demetriades 127
Johannesburg 1994 Degiannis 56
Houston 1999 Cox 56
Los Angeles 1999 Demetriades & Asensio 79
Durban 2000 McKinley 260
Atlanta 2000 Kalakuntla 25
Chicago 2003 Lin 54
Istanbul 2004 Aksoy 12
Houston 2008 Carrick 15
Subclavian vessel injuries 441
123
related injuries in the US as a result of increased civilian
use of weaponry. Several published series observed a
similarly low incidence of blunt versus a relatively high
incidence of penetrating injury across the globe [5–47].
Graham [4], who studied the largest civilian series, repor-
ted that 93 patients sustained subclavian artery injuries
over a 24-year period. Of these, only two resulted from a
nonpenetrating injury. Over a period of 10 years, a retro-
spective review by Lin [23] identified 54 patients with
penetrating subclavian artery injuries, of which 85%
resulted from gunshot wounds. Conversely, McKinley [24]
reported that 82% of subclavian artery injuries resulted
from stab wounds and 10% from low-velocity gunshot
wounds, a trend not appreciated in US regional trauma
centers (see Table 2).
On the other hand, blunt subclavian artery injuries occur
far less frequently. Urban trauma centers report that
approximately 1–3% of all traumatic subclavian artery
injuries result from blunt trauma [4–21]. The relatively low
incidence of blunt vascular trauma is due to the protected
anatomic location of the subclavian vessels. Both rapid
deceleration injury and bony fractures are responsible for
blunt injury of this artery. Not uncommonly, however, the
injury remains unrecognized secondary to normal physical
examination findings. In other cases, patients experience a
delay in symptoms after their initial injury, thereby post-
poning treatment.
Clinical presentation
Patients sustaining penetrating thoracic inlet injuries pre-
senting with hemodynamically instability should undergo
early intubation, judicious fluid resuscitation, and imme-
diate treatment of life-threatening injuries upon presenta-
tion. Contralateral upper extremity or lower extremity
intravenous access and orotracheal intubation should be
carried out in cases where cervical and/or mediastinal
swelling are present, resulting from expanding hematomas
caused by subclavian vessel injury [13].
In a retrospective study of subclavian vessel injury,
DeGiannis [31] reported that 50% of the patients in their
series presented with an initial systolic blood pressure
of \100 mmHg. Several published series confirm similar
hemodynamic findings consistent with hypovolemic shock
upon presentation [18, 24, 30]. In the experience of
Agarwal [18], profound shock was present in 80% of those
who sustained injury to both the subclavian artery and vein.
The unstable patient in hypovolemic shock who is unre-
sponsive to resuscitation should be transported immedi-
ately to the operating room.
Any penetrating injury to the subclavian artery with
pulsatile bleeding should be controlled with direct external
compression. When possible, manual compression should
be continued until primary vascular control in the operating
room is achieved. In cases of penetrating retroclavicular
injuries, direct pressure may not be effective, and thus
balloon tamponade may be a life-saving option [39]. In a
combined retrospective and prospective study, Demetri-
ades [9] reported active bleeding from the wound in 65% of
the patients upon initial evaluation, along with findings of
shock in 72%. More than 20% of patients with subclavian
or axillary vascular injuries reach the hospital with no vital
signs or with imminent cardiac arrest as a result of exan-
guinating blood loss [39]. Of note, associated intrathoracic
injuries are also found in about 28% of these patients [39].
Once the airway is secured, these patients should undergo
immediate Emergency Department thoracotomy (EDT) on
the side of injury; if necessary, the incision may be
extended to the opposite side.
McKinley et al. [24] reported a prospective study of 260
patients, among whom approximately 25% with subclavian
artery injuries had minimal symptoms and delayed com-
plications, prompting the patients to seek medical advice.
In a series reported by Lim et al. [15], only 24% of the
patients had a pulse deficit. Apparent soft tissue ecchy-
mosis and hematoma at the base of neck and upper chest
can be a diagnostic clue during physical examination.
Other characteristic findings of brachial plexus palsy, arm
swelling, pulsatile hematomas or bruit may indicate trau-
matic arteriovenous fistula.
Diagnosis
Early diagnosis of a subclavian vessel injury is essential.
Physical examination findings of a subclavian arterial
injury may be more subtle than obvious pulsatile bleeding
as seen with penetrating wounds. Other concomitant inju-
ries adjacent to the subclavian vessels are highly suspicious
for a neurovascular injury. Neurologic deficits of the upper
extremity, overlying bruits, decreased or absent pulses in
the brachial, radial or ulnar arteries, and ipsilateral clavicle
or rib fracture are diagnostic clues. The clinical diagnosis
may be obvious, with a comprehensive vascular exam
revealing a cool, pulseless, and pale upper extremity.
Specific signs of subclavian artery injury may also include
expanding or pulsatile hematomas in the supraclavicular
space or the axilla, as the hematoma dissects along the
neurovascular sheath. Brachial plexopathy can also be a
reliable predictor of underlying subclavian injury [34].
Radiographic investigations should only be performed
in hemodynamically stable patients. In these cases, an
initial plain chest X-ray is completed without delay. Gra-
ham [4] reported that 16% of their 93 patients with pene-
trating subclavian injuries had radiographic evidence of
442 J. D. Sciarretta et al.
123
mediastinal widening. Injuries to the proximal portions of
the subclavian vessels may present with massive hemo-
thorax and mediastinal widening on chest X-ray. Other
diagnostic investigations include obtaining a simple ankle
brachial index (ABI) in patients that are hemodynamically
stable; an ABI of less than 0.9 is considered abnormal and
believed diagnostic or suspicious for underlying arterial
injury. However, normal ABI indices may result even in
the presence of a subclavian arterial injury, due to the rich
collateral circulation from this vessel.
Color flow Doppler (CFD) studies are an additional
noninvasive technique for assessing subclavian vessel
injury. Unfortunately, CFD studies can be suboptimal in
those with a large body habitus, and are also limited in their
views of the aortic arch, innominate vessels, and left sub-
clavian artery. Readily available spiral CT scans with
intravenous contrast have become a favorable option in
identifying vascular injuries. CT angiography is a potential
alternative in selected cases, avoiding conventional angi-
ography in 85% of the cases [46].
The value of emergent angiography is restricted and
should only be entertained for hemodynamically stable
patients after appropriate resuscitation. Ideally, the surgeon
should accompany the patient to the angiography suite. If
acute decompensation occurs, the angiogram should be
aborted, and the patient transferred to the operating room.
Positive studies without clinical exam findings may war-
rant surgical exploration of the affected segment, as in
cases of intimal dissection, pseuodoaneurysm, and/or
contained transection. Many advocate the routine use of
angiography with subclavian artery injuries. Precise sur-
gical planning and the identification of additional arterial
injuries support these views.
In Graham’s series [4], 20% of concomitant arterial
injures were identified by angiography. Nevertheless, color
flow Doppler and CT angiography are now more frequently
utilized than conventional angiography. Angiography,
however, remains the ‘‘gold standard,’’ and should be
reserved for those without any evidence of hemodynamic
compromise.
Surgical management
The operative approach for subclavian vessel injury
requires great familiarity with the local anatomy. The basic
vascular surgical principles of proximal and distal control
are imperative. Historically, a variety of classical operative
exposures have been described for the management of
subclavian artery injuries. The surgical approach is dictated
by the clinical presentation and site of injury. The patient is
initially placed in the supine position, with the ipsilateral
arm abducted at 30� and the head turned away from injury.
Fig. 2 Clavicular incision with clavicle removal to expose sub-
clavian vessels for a gunshot wound
Fig. 3 Thrombosed right subclavian artery post gunshot wound
Fig. 4 Polytetrafluoroethylene (PTFE) 8 mm graft
Subclavian vessel injuries 443
123
A clavicular incision is planned, with the initial incision
made in the region of the sternoclavicular junction and
extending over the medial half of the clavicle, and, if
necessary, continuing onto the deltopectoral groove (see
Figs. 2, 3, 4, 5). Adjacent muscle attachments are stripped
off the clavicle to better facilitate upward retraction. Cla-
vicular resection and disarticulation of the sternoclavicular
joint are surgical techniques that offer additional exposure
to proximal injuries. Henly subclavian clamps are useful
for providing proximal and distal control (see Fig. 6).
A median sternotomy with cervical extension also
provides optimal control of proximal right subclavian
injuries [39]. Well described, but not recommended nor
used often nowadays, is the ‘‘trapdoor’’ incision, which
allows for exposure to the first and second parts of the left
subclavian artery. The components of this approach
include a clavicular incision, limited median sternotomy,
and an anterolateral thoracotomy. This exposure is
advantageous only for left subclavian injuries, not right,
because of the vessel’s posterior location. These described
surgical approaches are individually selected on a case-by-
case basis and according to each surgeon’s overall
experience.
Traditionally, the operative management of subclavian
artery injury includes ligation, primary repair, or interpo-
sition graft. The vascular repair chosen is influenced by the
degree and level of injury. Ligation should be reserved for
those who are unstable with multiple life-threatening
associated injuries, extensive shoulder trauma, or infected
Fig. 5 Doppler probe being utilized to ascertain flow and velocity
postrepair
Fig. 6 Henly subclavian clamps (arrows)
Fig. 7 Young female that sustained a stab wound to the left thoracic
inlet. Arrived in cardiopulmonary arrest. Required left anterolateral
thoracotomy and open CPR. In the OR she required median
sternotomy and supraclavicular incision to control a left subclavian
arterial injury. Clamps are providing proximal and distal control
Fig. 8 Partial transection of the left subclavian artery in the previous
patient. Required resection and interposition graft with autogenous
reversed saphenous vein graft
444 J. D. Sciarretta et al.
123
or ruptured aneurysm [14, 24]. Anatomically, extensive
collateral flow through the thyrocervical trunk permits the
safe ligation of the subclavian arteries [36]. Arterial
reconstruction should, however, be attempted whenever
feasible. Occasionally, temporary shunting can be used
with the intention of arterial repair at a later stage.
Stab wounds can sometimes be managed appropriately
with debridement and repair (see Figs. 7, 8). Simple lateral
arteriorrhaphy is the preferred technique in the appropriate
setting, but this method can only be used 20% of the time
(see Figs. 9, 10, 11) [3]. Ligating multiple arterial branches
may provide additional length during primary repair, but
considerable mobilization should be performed cautiously,
as these branches provide an extensive collateral network
to the upper extremity. On the other hand, gunshot wounds
generally cause significant blast injury and usually require
an interposition graft (see Figs. 12, 13). Autogenous
reverse saphenous vein or prosthetic grafts with end-to-end
anastomosis following debridement is one of the conven-
tional methods utilized with arterial injury. Prosthetic
grafts can be safely used with acceptable outcomes due to
Fig. 9 Gunshot wound: right infraclavicular area
Fig. 10 Segmental resection of the injured right subclavian artery
Fig. 11 Repaired with an autogenous reverse saphenous vein graft
Fig. 12 Gunshot wound: right subclavian artery. Vessel debridement
and resection
Fig. 13 6 mm polytetrafluoroethylene (PTFE) graft inserted
Subclavian vessel injuries 445
123
their reported low incidence of graft infection (see
Figs. 14, 15, 16) [37, 38]. At the same time, prosthetic
grafts offer expedient repair compared to the delay asso-
ciated with autologous vein harvesting. Lateral venorrha-
phy should be attempted for subclavian venous injuries if it
does not cause significant luminal narrowing (see Fig. 17).
If it is not feasible, simple ligation is acceptable with little
morbidity [3, 39].
Recent advancements in endovascular techniques have
provided another viable option to those who are poor sur-
gical candidates and those who meet strict select criteria.
Minimally invasive approaches to subclavian artery injuries
are well documented and are promising alternatives in the
management of these injuries. Carefully selected patients,
such as those with arterial stenosis, false aneurysms or
arteriovenous fistulas, may be managed with catheter-based
stent grafts by interventional services. Definitive catheter-
based repairs by stent grafts are, unfortunately, not without
consequence. At this time, however, endovascular repair
does not appear to be superior to traditional surgical ther-
apy, although it does remain an alternative option for very
carefully selected patients. Similarly, there are no reported
data on their long-term outcome (see Table 3).
Morbidity
Delay in diagnosis, complicated operative exposure, and
associated injuries are all contributing factors influencing
the patient’s overall morbidity at the time of admission.
Hemodynamic compromise on arrival to the hospital also
corresponds to higher morbidity and longer hospitaliza-
tions, as demonstrated in Kalakuntla’s [30] 6-year
Fig. 14 Blunt injury to right subclavian artery (A) at take-off of
brachiocephalic trunk (B). C Origin of the right common carotid
artery
Fig. 15 Resected segment of the subclavian artery. Intimal flap is
seen
Fig. 16 8 mm polytetrafluoroethylene (PTFE) interposition graft
from the origin of the right subclavian artery (A). B Brachiocephalic
trunk
Fig. 17 Lacerated left subclavian vein
446 J. D. Sciarretta et al.
123
retrospective review of managing subclavian artery inju-
ries. The morbidity and mortality with subclavian artery
injuries is greatly influenced by the number of concomitant
injuries. In penetrating wounds, the severity of the injury
correlates with the location, and for cases of gunshot
wounds, the velocity of the missile. Neighboring structures,
particularly the subclavian vein, brachial plexus, lung,
clavicle and first rib, are most susceptible to injury.
Generally, the long-term morbidity of subclavian artery
injury is closely linked to the presence of associated bra-
chial plexus injuries. Brachial plexus symptoms have
resulted in debilitating ipsilateral neurosensory deficits
from contusion or crush (direct trauma) and traction injury.
In Graham’s [47] series of 65 patients, associated brachial
plexus injuries were observed in 35% of the patients. A
similar finding of 43% was reported by Johnson [34]. In
this series, they identified 83% of partial brachial plexus
injuries on follow-up, demonstrating some functional
improvement, indicating that neuropraxia was the initial
deficit. Unfortunately, cases of complete brachial plexus
transection and secondary nerve repair may only return
minimal functional improvement and render the patient
with permanent functional disability.
Known vascular complications such as thrombosis, graft
infection, and aneurysm formation are familiar postopera-
tive drawbacks. At the same time, postponement of medi-
cal attention following injury with symptoms of arm
paralysis may occur due to a large false aneurysm com-
pressing the brachial plexus. These patients met with poor
outcomes despite intervention [24, 42]. In the cases of
venous ligation, Demetriades and Asensio [39] observed
transient swelling of the upper extremity, but no significant
venous-related complication. Elevation of the affected
extremity over a course of several days results in consid-
erable improvement. Clavicular division also has the
potential for debilitating consequences such as osseous
malunion, pseudoarthrosis, and osteomyelitis [24].
Other complications in the management of subclavian
vessel injury may predispose the patient to local surgical
wound infections, coagulopathy, massive transfusions,
thoracic duct injury, and air embolism. The risk of pros-
thetic graft infection also exists, but remains low, with long-
term graft patency rates of 94% [38]. Scapulothoracic dis-
sociation, although rare, is without question a devastating
injury that results from high-energy trauma. A constellation
of injuries includes clavicular fracture or dislocation,
avulsed shoulder muscles, and neurovascular damage. In
cases of absent brachial plexus function, vascular recon-
struction should not be attempted, and the arm should be
amputated below the shoulder [40].
Outcomes and mortality
Both penetrating trauma and occasionally blunt trauma to
the subclavian vessels can result in significant blood loss
and hemorrhagic shock prior to presentation. Select
patients that have short transport times and hemorrhage
control by contained hematoma or thrombosis experience
improved hemodynamic status upon arrival and thus have
better survival rates. In-hospital mortality ranges from 5 to
35% with penetrating injuries, which is higher than for
blunt trauma [4, 6, 7]. The reported overall mortality ran-
ges from 39 to 80%, with the majority succumbing prior to
arrival at the hospital [9, 14, 23, 24]. This unfortunate
statistic is directly related to exsanguination or associated
head trauma in cases of blunt injury [9, 14]. The series of
McKinley et al. [24] confirms these findings, and also
details a post mortem evaluation of violent deaths over
4 years, documenting 135 deaths resulting from isolated
injury to the subclavian artery and exsanguination.
The reported operative mortality in published civilian
series ranges from 4.7 to 30% [4, 9, 15, 28, 30, 44], with
higher mortality rates seen for combined subclavian artery
and vein injuries. In a large series of 228 penetrating
subclavian vessel injuries, 61% of the patients were dead
on arrival [9]. In these series, venous injuries led to a
higher mortality rate than arterial injuries: 82 and 60%,
respectively. Similar findings were found in another pub-
lished series of 20 patients, where isolated subclavian vein
injuries resulted in a mortality rate of 50% [39]. This may
be due to possible venous embolus or ongoing bleeding
from venous injury without the vasoconstrictive effects of
arterial injuries [39].
The morbidity and mortality associated with subclavian
artery injuries is greatly influenced by the number of
associated injuries. Lin [23] reported that patients with
three or more associated injuries incurred a mortality rate
Table 3 Results of subclavian
artery repairAuthor Year Injuries Repairs Complications Amputations Deaths
Amato 1969 14 13 0 0 0
Bricker 1970 14 11 0 0 3
Rich 1970 8 7 1 0 0
Drapanas 1970 16 0 0 1 4
Perry 1971 23 0 0 0 1
Subclavian vessel injuries 447
123
of 83%, versus 17% for those with isolated subclavian
artery injuries. At the same time, those presenting with
hypotension had a much higher mortality of 57, versus 18%
for nonhypotensive patients.
Conclusions
The rarity of traumatic subclavian vessel injuries prevents
many trauma surgeons or trauma centers from developing
substantial experience of their management. These injuries
are associated with significant morbidity and mortality.
Patient that survive transport are subject to potentially
debilitating injury and possibly death. Management of
these injuries varies, depending on hemodynamic stability,
mechanism of injury, and associated injuries. Despite sig-
nificant advancements, mortality from subclavian vessel
injury remains high.
Conflict of interest None.
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