Penetrating Injuries to the Subclavian Artery

Penetrating trauma to the subclavian arteries are rare.  The basic principle of vascular injury management apply, with gaining proximal and distal control to the site of injury being an essential step.  The main issue rises in the relative inaccessibility to this area, especially proximal left subclavian injuries as in the patient previously described.  Per the study noted by Demetriades, only 3.5% of stab wounds to the neck resulted in subclavian/axillary injuries.  Despite the low incidence, the overall mortality, including death at the scene can reach 80%.¹  Of those that survive until intervention,  the morbidity and mortality can range from 5 to 39%.  

The role of endovascular management naturally developed as an alternative to technically difficult open interventions.  A retrospective cohort study by Danetz et al. had an endovascular intervention rate of 37-44%, of which less than 10% of these patients were treated with only endovascular repair.²  Another study by Xenox et al. had 30% of its study population undergo endovascular repair, and the patency rate of the repairs were similar to the open repair group after one year.³  Du Toit et al studied the long term patency rates (mean follow up of 48 months) of endovascular repairs of 57 patients and none had life, limb, or incapacitating symptoms.⁴  Although limited in the sheer volume of cases,  these studies all show that endovascular repair should be considered in a selected number of patients, with the expectation of equivocal or even superior morbidity and mortality compared to the traditional open repair.

Demetriades, D. “Subclavian and axillary vascular injuries”.  Surgical Clinics of North America. Vol 81.  Issue 6. Dec 2001.

Below is a simple management algorithm  to assess suspected subclavian artery injury.  The point is to make sure the mediastinal structures are intact prior to any intervention to the specific subclavian artery.

Burack JH. Triage and outcome of patients with mediastinal penetrating trauma. Ann Thorac Surg. 2007 Feb;83(2):377-82

from Isami Sakai, DO