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Contemporary management of subclavian and axillary artery injuries—A Western Trauma Association multicenter review

Waller, Christine J. MD; Cogbill, Thomas H. MD; Kallies, Kara J.; Ramirez, Luis D.; Cardenas, Justin M.; Todd, S. Rob MD; Chapman, Kayla J. MD; Beckman, Marshall A. MD; Sperry, Jason L. MD; Anto, Vincent P. MD; Eriksson, Evert A. MD; Leon, Stuart M. MD; Anand, Rahul J. MD; Pearlstein, Maura DO; Capano-Wehrle, Lisa; Cothren Burlew, Clay MD; Fox, Charles J. MD; Cullinane, Daniel C. MD; Roberts, Jennifer C. MD; Harrison, Paul B. MD; Berg, Gina M. PhD; Haan, James M. MD; Lightwine, Kelly

Journal of Trauma and Acute Care Surgery: December 2017 - Volume 83 - Issue 6 - p 1023–1031
doi: 10.1097/TA.0000000000001645
WTA 2017 Plenary Papers
Editor's Choice

BACKGROUND Subclavian and axillary artery injuries are uncommon. In addition to many open vascular repairs, endovascular techniques are used for definitive repair or vascular control of these anatomically challenging injuries. The aim of this study was to determine the relative roles of endovascular and open techniques in the management of subclavian and axillary artery injuries comparing hospital outcomes, and long-term limb viability.

METHODS A multicenter, retrospective review of patients with subclavian or axillary artery injuries from January 1, 2004, to December 31, 2014, was completed at 11 participating Western Trauma Association institutions. Statistical analysis included χ2, t-tests, and Cochran-Armitage trend tests. A p value less than 0.05 was significant.

RESULTS Two hundred twenty-three patients were included; mean age was 36 years, 84% were men. An increase in computed tomography angiography and decrease in conventional angiography was observed over time (p = 0.018). There were 120 subclavian and 119 axillary artery injuries. Procedure type was associated with injury grade (p < 0.001). Open operations were performed in 135 (61%) patients, including 93% of greater than 50% circumference lacerations and 83% of vessel transections. Endovascular repairs were performed in 38 (17%) patients; most frequently for pseudoaneurysms. Fourteen (6%) patients underwent a hybrid procedure. Use of endovascular versus open procedures did not increase over the duration of the study (p = 0.248). In-hospital mortality rate was 10%. Graft or stent thrombosis occurred in 7% and graft or stent infection occurred in 3% of patients. Mean follow-up was 1.6 ± 2.4 years (n = 150). Limb salvage was achieved in 216 (97%) patients.

CONCLUSION The management of subclavian and axillary artery injuries still requires a wide variety of open exposures and procedures, especially for the control of active hemorrhage from more than 50% vessel lacerations and transections. Endovascular repairs were used most often for pseudoaneurysms. Low early complication rates and limb salvage rates of 97% were observed after open and endovascular repairs.

LEVEL OF EVIDENCE Prognostic/epidemiologic, level IV.

Supplemental digital content is available in the text.

From the Department of General Surgery, Gundersen Health System (C.J.W., T.H.C.), Department of Medical Research, Gundersen Medical Foundation (K.J.K., L.D.R.), La Crosse, WI; Division of General Surgery, Michael E. DeBakey Department of Surgery, Ben Taub Hospital (J.M.C., S.R.T.), Baylor College of Medicine, Houston, TX; Department of Surgery, Division of Trauma & Critical Care Medical College of Wisconsin (K.J.C., M.A.B.), Milwaukee, WI; Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center (J.L.S., V.P.A.), Pittsburgh, PA; Department of Surgery, Medical University of South Carolina (E.A.E., S.M.L.), Charleston, SC; Division of Acute Care Surgical Services, Virginia Commonwealth University School of Medicine (R.J.A.), Richmond, VA; Department of Surgery, Cooper University Hospital (M.P., L.C-W.), Camden, NJ; Department of Surgery, Denver Health Medical Center (C.C.B., C.J.F.), Denver, CO; Department of Surgery, Marshfield Clinic (D.C.C., J.C.R.), Marshfield, WI; Trauma Services, Wesley Medical Center (P.B.H., G.M.B.), Wichita, KS; and Department of Trauma Services, Via Christi Hospital on Saint Francis (J.M.H., K.L.), Wichita, KS.

Submitted: February 15, 2017, Revised: May 24, 2017, Accepted: June 26, 2017, Published online: July 17, 2017.

This article was presented at the 47th Annual Meeting of the Western Trauma Association on March 7, 2017, in Snowbird, Utah.

Dr. Pearlstein's current affiliation is Aria Health, Philadelphia, PA.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).

Address for reprints: Christine J. Waller, MD, Department of General Surgery Gundersen Health System 1900 South Ave., C05-001 La Crosse, WI 54601; email: cjwaller@gundersenhealth.org.

© 2017 Lippincott Williams & Wilkins, Inc.