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Penetrating Trauma totheSubclavian
Va
Subclavian a.
https://t.me/medicina_free
Vessels
DanielF.Du Toit
36
The management of penetrating injuries to the subclavian
vessels presents a considerable challenge to even the most
experienced surgeon. Complex surgical exposures required
for conventional open repair contribute to high morbidity
and mortality. The contemporary management of these injuries consists of a combination of open and endovascular surgeries. The availability of local expertise, resources, surgeon
Fig. 36.1 The anatomy of
the thoracic outlet showing
the relations of the subclavian
vessels
Brachial
plexus
Vertebral a.
Recurrent
laryngeal n.
gus n.
Common
carotid a.
preference, and clinical presentation will dictate the management of individual cases. A comprehensive knowledge of the
anatomy of the subclavian vessels is essential for the selection and execution of individualized patient management.
36.1 Applied Surgical Anatomy (Fig.36.1)
Scalenus
anterior m.
C6
Esophagus
Phrenic n.
Thoracic duct
Subclavian v.
D. F. Du Toit (*)
Department of Vascular Surgery, Mediclinic Cape Gate,
Cape Town, South Africa
e-mail: vascular@netactive.co.za
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_36
Trachea
SCM
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310
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D. F. Du Toit
36.1.1 The Subclavian Artery
On the right side, the subclavian artery arises from the
innominate artery behind the sternoclavicular joint; on the
left, it comes directly from the arch of the aorta. Each subclavian artery is divided into three parts for descriptive purposes. The rst part extends from its origin to the medial
border of the scalenus anterior muscle, the second part lies
behind this muscle, and the third part extends from its lateral
border to the outer aspect of the rst rib where it becomes the
axillary artery. The rst parts of the right and left subclavian
arteries differ with respect to course, length, and relation to
neighboring structures and require separate descriptions. The
second and third parts of the two arteries are essentially similar and will be described together:
36.1.1.1 First Part oftheRight Subclavian
Artery
Arising from the innominate artery behind the right sternoclavicular joint, it passes in a superolateral direction to the
medial border of the scalenus anterior muscle. The extent to
which it ascends above the clavicle varies. This can inuence
the ease with which it can be accessed via a supraclavicular
incision. It is covered anteriorly by the skin, supercial fascia, platysma muscle, deep fascia, the clavicular head of the
sternocleidomastoid muscle, and the sternohyoid and sternothyroid muscles. It is crossed by the internal jugular and vertebral veins, the vagus nerve, and a loop of the sympathetic
trunk. Posterior and inferior lie the pleura and apex of the
right lung as well as the sympathetic trunk and rst thoracic
vertebra. The recurrent nerve winds around its inferior and
posterior aspects.
36.1.1.2 First Part oftheLeft Subclavian Artery
This arises from the aortic arch posterior and lateral to the
left common carotid artery and ascends to the root of the
neck and then inclines laterally to the medial border of the
scalenus anterior muscle. Its anterior relations are similar to
the right side and posteriorly lies the esophagus and thoracic
duct. Medially lie the esophagus, trachea, thoracic duct, and
left recurrent nerve. Laterally, the left pleura and lung are to
be found.
36.1.1.4 Third Part oftheSubclavian Artery
This part runs in an inferolateral direction from the lateral
border of the scalenus anterior muscle to the outer aspect of
the rst rib where it becomes the axillary artery. It is covered
by the skin, platysma muscle, supraclavicular nerves, and the
deep cervical fascia. The external jugular vein and tributaries
cross the anterior and medial to it. The distal part of the artery
lies behind the clavicle and the subclavius muscle, with the
subclavian vein anterior and at a slightly lower level than the
artery. Posteriorly lies the brachial plexus which intervenes
between the artery and the scalenus medius muscle. Superiorly
and to the lateral side are the upper trunks of the brachial
plexus and the omohyoid muscle and inferiorly the rst rib.
36.1.2 Branches oftheSubclavian Artery
• First Part:
– Vertebral artery:
Internal mammary artery
Thyrocervical trunk
• Second Part:
– Costocervical trunk
• Third Part:
– Dorsal scapular artery
36.1.3 Anatomical Anomalies
• The right subclavian artery can arise as a separate trunk
from the arch of the aorta as the rst, second, third, or last
branch of the arch.
• If it arises as the last branch, it passes from left to right
behind the trachea, esophagus, and right carotid or sometimes between the trachea and esophagus.
• It can pass anterior to the scalenus muscle, perforate it,
and can ascend as high as 4cm above the clavicle.
• The left subclavian artery generally does not reach as high
in the neck as the right.
36.1.4 The Subclavian Vein
36.1.1.3 Second Part oftheSubclavian Artery
This lies behind the scalenus anterior muscle, is short, and is
the most superiorly located part of the vessel. The phrenic
nerve runs from lateral to medial over the muscle. Posterior
to the vessel are the scalenus medius muscle and pleura,
superior to the brachial plexus, and inferior to the pleura. The
subclavian vein lies below and in front of the artery, separated from it by the scalenus anterior muscle.
The subclavian vein is a continuation of the axillary vein,
extending from the outer aspect of the rst rib to the manubrial head of the clavicle. Here it unites with the internal
jugular vein to form the innominate vein behind the
manubrio- clavicular joint. Its relations are as follows: anterior, the clavicle; posterosuperior, the subclavian artery separated by the phrenic nerve and the scalenus anterior muscle;
and inferior, the rst rib and the pleura.
e
(Various injuries)
Balloon compressing
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36.2 Clinical Presentation, Preoperative
Care, Diagnosis, andManagement
Principles (Fig.36.2)
Patients with subclavian vessel injuries can present in hypovolemic shock with active bleeding or in a stable condition
with Zone I or II neck or infraclavicular anterior chest
wounds. Zone I is dened as the area between the clavicle
and the cricoid cartilage and Zone II is the area between the
cricoid and the inferior border of the mandible. Resuscitation
should be managed according to ATLS guidelines and
adjunctive measures to control active bleeding include Foley
catheter tamponade (Fig.36.3) and manual compression. If
local control cannot be achieved or if the patient bleeds into
the pleural cavity as evidenced by continuous blood loss
from a chest drain, the patient should be transferred to the
operating room immediately. In this case, we prefer a midline sternotomy, with appropriate extension, if needed, to
provide access to most mediastinal and thoracic outlet structures. Stable patients or patients who remain stable after
resuscitation should be evaluated for arterial injury. In the
stable or stabilized patient, you should proceed to diagnostic
imaging. Controversy exists with regard to routine investigation of these surface wounds if no signicant other signs of
arterial injury are present. We currently favor routine CT
angiography to exclude arterial injuries. When hard signs of
arterial injury are present, it allows assessment of the extent
of the injury and planning of intervention. When only soft
signs are present, it acts as a low morbidity screening investigation to exclude arterial injuries. If an arterial injury is
diagnosed in this case, you should note the exact position
and extent of the arterial injury and evaluate the patient for
endovascular or open surgery.
In our practice, we prefer endovascular treatment by stent
grafts whenever possible as we believe that it greatly benets
the patient by limiting surgical morbidity and mortality. The
relative contraindications that can preclude endovascular
subclavian artery
Fig. 36.3 Balloon tamponade controlling bleeding from an injured
subclavian artery
Zone 1 Neck or chest
injuries
Unstable
Resuscitation/Foley catheter tamponade
Remain unstable
Open repair
• Subclavian vein
• Subclavian artery
• Both
Endovascular repair
DSA, digital substraction angiography
Fig. 36.2 Algorithm for the treatment of patients with potential subclavian vessel injuries
Sternotomy/neck exploration /claviculectomy
Open repair Options
• Contra indications to endovascular repair
• Failed endovascular repair
Stable
CT angiography/DSA
Subclavian artery injury
• Midline sternotomy
• Supraclavicular neck exploration
• Infraclavicular exposure
• Partial sternotomy
• Fourth interspace arterior thoractomy
• Fifth interspace postero lateral
thoracotomy
• Trap door thoracotomy/claviculectomy
Limited us
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D. F. Du Toit
management include clinical and angiographic factors.
Clinical factors are active uncontrollable hemorrhage, critical limb ischemia, airway or brachial plexus compression,
concomitant aero-digestive injuries, and infected wounds.
Angiographic factors include excessive luminal discrepancy
proximal and distal to the injury, an inability to traverse the
lesion by guide wire, and a dominant vertebral artery on the
injured side. Transfemoral endovascular management is our
rst choice if no contraindications are present.
If any of the above-mentioned are present, consider open
surgical repair. The basic approaches available for the exposure and proximal and distal control of subclavian vessel
injuries include a full or limited upper median sternotomy, a
supraclavicular incision, an infraclavicular incision, a limited anterolateral third-interspace thoracotomy, a full
fth- interspace posterolateral thoracotomy, a medial partial
resection of the clavicle, and a trapdoor thoracotomy. The
extent of the injury, pathology, the presence of a venous
injury, the part of the vessel, and surgeon preference will dictate which approach or, more usually, combination of
approaches to be used. In our practice, clavicle resection and
trapdoor thoracotomy are very rarely used, only for subclavian vein injuries that cannot be controlled via any of the
other approaches. This will usually be an extension of an
existing sternotomy and supraclavicular or infraclavicular
incision.
36.3 Surgical Exposures
36.3.1 Midline Sternotomy intheUnstable
Patient withNo Diagnostic Imaging
(Fig.36.4)
Here the source of bleeding could be from a number of large
vessels in the mediastinum and thoracic outlet, or even from
the heart. In this scenario, it is best to position the patient for
a midline sternotomy with a small sandbag between the
scapula, with the ipsilateral arm in 30° lateral abduction,
allowing for the manipulation of the thoracic outlet and better access to the distal subclavian/proximal axillary arteries.
If time permits, it is prudent to clean a proximal thigh for
harvesting saphenous vein, should this be required.
This preparation should be effected within minutes. It is
also a good practice to ascertain that a working pneumatic
saw and a vascular instrument tray are available in the operation room. While pressure on or in the wound is maintained,
you can, with good suction and two Langenbeck retractors,
coordinate the release of pressure, and a “quick peep” into
the wound can sometimes be of value. A visible vessel (subclavian or a large branch) can sometimes be glimpsed and
clamped with one or two straight atraumatic vascular clamps.
This should happen in seconds and you should not attempt
more than two “peeps”; otherwise the patient is in danger of
Fig. 36.4 Upper mediastinal
access via a partial or full
midline sternotomy
Partial sternotomy
Extend to
full sternotomy
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exsanguinating. With luck, control, or partial control, it can
be achieved in this fashion. You can complete the procedure
by formal supraclavicular neck exploration.
If control cannot be achieved in this way, the best option
is to proceed to a midline sternotomy. A vertical midline
incision is made from the suprasternal notch to 2cm distal to
the xiphoid process. You can extend the incision superiorly
along the anterior border of the sternocleidomastoid muscle,
or in the case of a true subclavian artery injury being identied, continue obliquely over the two heads of this muscle
laterally about 2 cm above the clavicle for supraclavicular
exposure. The sternal incision is deepened to the periosteum
with electrocautery. In the sternal notch, deepen the midline
space between the two sternal heads of the sternocleidomastoid muscles with a combination of sharp and blunt dissection. One or two large but unimportant veins may be
encountered. Entry to the retrosternal space is affected by
blunt nger dissection between the strap muscles, which
implants on the posterior aspect of the sternum. Inferiorly
the xiphoid is mobilized and a plane should be developed
retrosternally, in an upward direction. The anesthesiologist
should arrest ventilation in expiration (to prevent lung
injury), and the sternum is divided in the midline using a
pneumatic saw or Lebsche knife. Bleeding from the sternal
edges is controlled by electrocautery and bone wax. The latter is used to prevent infection and impaired wound healing.
Insert a sternal retractor and open it carefully, a few turns at
a time to prevent sternal and rib fractures.
In the fully retracted position, a divided sternum reveals
the structures of the anterior, superior, and middle mediastinum (Fig. 36.5). The thymus gland is encountered rst.
Divide it vertically to expose the left innominate vein that
runs obliquely from the left to its conuence with its rightsided counterpart to form the superior vena cava. This vein
Fig. 36.5 The mediastinal structures exposed at sternotomy. Note blue
vascular loops around both common carotid arteries. The trachea can be
seen at the back between both vessels
can be mobilized by dividing its numerous tributaries, and
exposure of the arch can thus be achieved without dividing it.
In an emergency situation with active bleeding, you can
divide it and ligate it without any morbidity. The aortic arch
with the origin of the innominate artery and the left common
carotid is now visible.
On the right, the origin of the innominate artery at the
aortic arch is identied and then carefully followed cranially
for about 3–5cm, where it will divide into subclavian and
common carotid arteries. At this bifurcation, the right vagus
nerve crosses the anterior to the rst part of the subclavian
artery and then descends into the mediastinum posterior to
the right innominate vein. The recurrent laryngeal branch of
the right vagus nerve loops around the inferior border of the
subclavian artery and ascends medially in the neck between
the trachea and the esophagus. When exposing and controlling the short rst part of the right subclavian artery, take
care to avoid injury to these nerves. In the event of overwhelming bleeding from the right subclavian artery, the origin of the innominate artery can be temporarily clamped to
facilitate dissection with immediate transfer of the clamp
upon exposure of the proximal subclavian artery. Take care
in the case of the “bovine arch” where both the carotid arteries and the right subclavian artery originate from the innominate artery. This congenital anomaly is present in about 10%
of cases and can result in major brain damage if the innominate artery is clamped for any extended duration.
Depending on the rotation of the aortic arch, the origin of
the left subclavian artery can vary from anterior to far posterior in the left half of the sternotomy wound (Fig.36.6). In
the latter situation, it can be difcult to get a good exposure
of this vessel and you should take care to avoid inadvertent
clamping the left common carotid artery, thereby impeding
cerebral blood ow. In the acute bleeding situation, the left
pleural space can be entered before mediastinal dissection to
facilitate compression of a subclavian artery, that is, bleeding
into the pleural space. To locate the origin of the left subclavian artery, you should follow the aortic arch posterolaterally
to the left past the origin of the left common carotid artery,
taking care to prevent injury to the left vagus nerve as it
descends between the carotid and left subclavian arteries to
cross anteriorly over the left side of the aortic arch. The left
recurrent laryngeal branch passes under the aortic arch and
then courses medially to the tracheoesophageal groove.
In an unstable patient, the relevant subclavian artery
should be clamped at its origin and then dissected further to
achieve distal control. On the right side, this usually entails a
supraclavicular extension of the incision for exposure of the
second and third parts of the right subclavian artery. The
right-sided strap muscles and the sternal and clavicular heads
of the right sternocleidomastoid muscle should be divided to
facilitate full exposure of the rst part of the right subclavian
artery and its branches up to the medial border of the scale-
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vertebral a.
Left
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D. F. Du Toit
Left
subclavian
vein
carotid
art.
Fig. 36.6 Sternotomy combined with supraclavicular extension and
medial resection of the clavicle demonstrating exposure of the proximal
left subclavian artery, left subclavian, and innominate vein
Left
art.
Aorta
subclavian
art.
nus anterior muscle. The internal jugular vein passes anterior
to the subclavian artery, and it can be mobilized or divided if
needed. The left subclavian artery has a much longer intrathoracic course which sometimes allows distal control in the
chest without supraclavicular extension. Complete control
and a bloodless eld can be difcult to achieve because
branches of the rst part of the subclavian artery can cause
problematic back bleeding. The vertebral and internal mammary arteries should be preserved if possible. The actual
repair of a subclavian artery is described later.
At this level, dissect the soft tissue overlying the sternum on
both sides toward the intercostal spaces with electrocautery.
A potential extrapleural space is carefully developed bilaterally dissecting the internal mammary artery away from the
transaction plane of the sternum. Then divide the sternum in
the midline to the level of this intercostal space using a pneumatic saw. Then divide horizontally the lower end of the sternum forming an inverted T by inserting the saw in the
juxtasternal spaces that were created. The remainder of the
dissection is exactly as described for the full sternotomy, and
access to the aortic arch and its branches can be easily
achieved. This approach should not be used for unstable
patients as it takes more time and limits access to the rest of
the mediastinal structures.
36.3.2.2 The Supraclavicular Exposure
oftheSubclavian Artery (Figs.36.7
and36.8)
This incision should be used for proximal control in part 2
and 3 injuries or for distal control and repair in part 1 injuries. Position the patient for sternotomy with a small sandbag
between the scapulae, the head rotated to the opposite side,
and if infraclavicular exposure is expected, prep and drape
the ipsilateral arm free on a narrow lateral arm board to facilitate this exposure. The neck, anterior chest, and ipsilateral
arm should be included in the surgical eld. Make a transverse incision 1–2 cm above and parallel to the clavicle,
beginning at the sternal notch and extending laterally for
about 7cm. Deepen the incision through the platysma muscle to the scalene fat pad, and the external jugular vein
divided. The scalene fat pad is divided transversely, and it
usually contains branches of the thyrocervical trunk and the
36.3.2 The Midline Sternotomy intheStable
Patient withImaging
This approach is exactly the same as described for the unstable patient and can be combined with the supraclavicular
approach as described above.
36.3.2.1 The Limited Upper or Partial
Sternotomy (Fig.36.4)
This incision should be reserved for stable patients with preoperative imaging diagnosing a subclavian artery injury. The
patient is prepped and draped for a full sternotomy. The
upper part of the dissection in the sternal notch is similar to
a full sternotomy, and the vertical midline incision is
extended to the level of the third or fourth intercostal space.
Jugular v.
Ligated
Rt subclavian a.
SCV
Subclavian
Fig. 36.7 The supraclavicular exposure of the right subclavian artery
with the division of the scalenus anterior and the clavicular head of the
sternocleidomastoid muscles
Carotid a.
Vagus n.
scalenus
Lef
Phrenic
Third intercostal
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Sternocleido-
mastoid m.
Left subclavian
artery
t common
carotid art.
Left
jugular v.
Fig. 36.8 Interposition graft repair of an injury to the second part of
the left subclavian artery via a supraclavicular exposure
nerve
Left subclavian v.
Ant.
scalenus m.
Graft
Ant.
muscle
Left
subclavian
art.
omohyoid muscle. Take care to divide and control the lymphatic ducts in this area, as on the left; this includes the thoracic duct. In the same horizontal plane, divide the clavicular
and sternal heads of the sternocleidomastoid muscle,
exposing the carotid sheath with the internal jugular vein
enclosed in its lateral edge.
The scalenus anterior muscle will now come into view
and care should be taken to preserve the phrenic nerve that
courses from lateral to medial over the anterior aspect of this
muscle. It should be carefully mobilized and retracted with a
thin elastic sling. The scalenus muscle should be mobilized
down to its origin from the rst rib and carefully divided taking care not to damage the subclavian vein (anterior) or the
subclavian artery (posterior). The subclavian artery will now
be visible from the lateral border of the internal jugular vein
to where it disappears beneath the clavicle. The internal
mammary, vertebral, and thyrocervical branches of the rst
part are usually now visible. You can extend the medial
access by retracting the internal jugular vein (or even dividing it) and dividing the lateral part of the strap muscles. The
rst part of the subclavian artery can be followed into the
mediastinum on the left and to its origin from the innominate
artery on the right. Care should be taken to prevent injury to
the carotid arteries and the vagus and phrenic nerves. Control
and/or repair should be achieved and then the wound must be
closed in layers over a suction drain if needed. There is no
need to repair the scalenus muscle, but the sternocleidomastoid can be repaired using a 2/0 absorbable suture and turning the head to the neutral position. You can use this incision
in continuity with the midline sternotomy from its medial
end. An infraclavicular incision should always be separated;
do not connect these two incisions when used in the same
patient. Division of the clavicle for arterial injuries is not
advised.
36.3.2.3 The Left Third-Interspace
Anterolateral Thoracotomy (Fig.36.9)
The rationale for this exposure is the fact that the left subclavian artery originates from the posterolateral aspect of the
aortic arch and is therefore difcult to access via a midline
sternotomy. In mediastinal bleeding of unknown origin, it is
better to do a midline sternotomy because it does not limit
your options as this incision does. It is not an easy approach
and only allows for limited dissection and clamping of the
left subclavian artery. Repair of the injury still needs supraclavicular or more extensive mediastinal dissection. The
only scenario where this incision can be used with potential
benet is in a stable patient with a diagnosed left subclavian
artery injury.
The patient is placed supine. A sandbag is placed behind
the left shoulder. We prefer the third-interspace incision
above the nipple line, but some prefer a fourth-interspace
incision below the nipple. Place the incision horizontally
over the superior margin of the fourth rib from the lateral
space
Fig. 36.9 Control of the left proximal subclavian artery via a thirdinterspace anterolateral thoracotomy. Repair is usually completed via a
supraclavicular incision (dotted line)
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D. F. Du Toit
sternal border to the anterior axillary line. Divide the intercostal muscles, staying clear of the neurovascular bundle, by
entering the parietal pleura along the top of the fourth rib.
The lung will collapse away from the chest wall, and the
wound is fully opened. Lung collapse can be aided by
double- lumen tracheal intubation. Care should be taken to
prevent injury to the internal mammary artery and vein in the
medial aspect of the wound when slowly opening the wound
with a rib spreader. Retract the upper lobe of the left lung
downward, and then, the aortic arch with the origin and intrathoracic part of the left subclavian artery will be visible and
still covered by the parietal pleura. This should be carefully
opened, avoiding injury to the left vagus nerve which courses
down the medial aspect of the subclavian artery and crosses
the anterolateral aspect of the aortic arch. You can now mobilize and encircle with a vessel loop the left subclavian artery
ready for clamping. Repair of the injury can then be completed via the supraclavicular incision. Close the wound in
layers after the insertion of an intercostal drain.
This approach is becoming redundant in the era of endovascular repair and the preference for a midline sternotomy
in unstable patients.
36.3.2.4 The Left Fifth-Interspace
Posterolateral Thoracotomy
This approach has limited application in the management of
left subclavian artery injuries. It is time-consuming and it
limits options because the patient must be placed in the true
lateral position that does not allow access to the neck for
supraclavicular exposure. The only possible place for this
exposure might be in a stable patient with injury to the rst
part of the left subclavian artery where proximal and distal
control as well as repair can be completed in the chest.
36.3.2.5 The Infraclavicular Exposure
oftheDistal Subclavian andProximal
Axillary Artery (Fig.36.10)
This incision is usually used for distal control of a second or
more commonly a third part of subclavian artery injury. The
classic injury is the one posterior to the clavicle at the junction between the distal subclavian and proximal axillary
arteries. Proximal control can be achieved by the supraclavicular incision as described, but distal control and repair
require control of the rst part of the axillary artery via an
infraclavicular exposure.
Fig. 36.10 Infraclavicular
incision with control of the
distal subclavian/proximal
axillary artery by splitting the
pectoralis major and dividing
or retracting the pectoralis
minor muscles
minor m.
Clavicle
Supraclavicul
incision
Clavipectoral
fascia
process
Cephalic v.
Brachial a.
Axillary a.
Pectoralis
major m.
Rt. jugular
Pectoralis
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Position the patient for the supraclavicular incision with
the arm, chest, neck, and supraclavicular area prepped and
draped. The ipsilateral arm should be free, draped 90°
abducted on a narrow arm board allowing the surgeon and
the assistant to stand comfortably close to the operative eld.
The degree of abduction of the arm can be manipulated during the procedure, thereby facilitating peri-clavicular movement and control of the vessel.
Make a horizontal subclavicular skin incision parallel and
2cm below the clavicle with its outer third slightly curved in
the deltopectoral groove and the medial part originating at
midclavicular level. Deepen the incision through the subcutaneous tissue to the level of the pectoralis major muscle.
Pull this muscle downward or split its bers by blunt dissection, allowing exposure of the clavipectoral fascia. This fascia should be entered by sharp dissection, and the axillary
sheath will become visible below the clavicle. Exposure can
be enlarged by encircling the pectoralis minor muscle in the
lateral aspect of the wound and either retracting or dividing
it. The rst part of the axillary artery usually lies superior
and deep to the vein and anterior to the cords of the brachial
plexus. It should be carefully explored by the division of
venous branches and encircled with a vessel loop. Attain
control by careful placement of a vascular clamp, avoiding
inadvertent clamping of the brachial plexus.
A “behind the clavicle” injury is usually not amenable to
primary repair, and the vessel should be controlled and transected above and below the clavicle. Repair of the defect will
then need an interposition graft with the proximal anastomoses being performed end-to-end above the clavicle. The graft
must then be tunneled posterior to the clavicle, and the distal
anastomosis is performed below the clavicle in an end-toend fashion to the axillary artery. The arm should be in 90°
abduction when deciding on the length of the graft.
The clavicle should not be divided as all injuries can be
managed by working around the clavicle as described.
Division of the clavicle takes time and can result in major
venous bleeding from the subclavian vein lying posterior to
it.
This wound should be closed in layers with or without a
suction drain in place.
36.3.2.6 The Trapdoor Thoracotomy andPartial
Resection oftheClavicle (Figs.36.6
and36.11)
This incision combines the supraclavicular exposure, the
partial midline sternotomy, and a fourth-intercostal space
anterolateral thoracotomy. This approach is rarely used as it
has limited advantages, if any, over the standard full midline
sternotomy combined with a supraclavicular approach. It is a
complex exposure, takes a lot of time, the pleural space is
entered, and it has a propensity for excess bleeding. It is not
a routine option in the unstable patient with an undiagnosed
Rt. subclavian
artery
Subclavian
Cephalic
vein
minor m.
Fig. 36.11 Medial resection of the right clavicle exposing the right
subclavian vein and its conuence with the internal jugular vein
Pectoralis
major m.
vein
vein
Clavicle
injury but might be of limited benet in subclavian vein injuries where more lateral exposure needs to be achieved to
access the vein behind the clavicle. Resection of the medial
half of the clavicle in combination with a midline sternotomy
is preferred for better exposure and control of venous injuries. A partial medial claviculectomy is time-consuming but
increases exposure to this area signicantly.
36.3.2.7 The Surgical Repair oftheSubclavian
Vessels
The subclavian artery is a friable elastic artery, and the principles of repair for all arterial injuries should be adhered to.
This includes proximal and distal control via the surgical
approaches as described, control of branches, and debridement of the injured area. You should do a proximal and distal
embolectomy with a number 3 Fogarty catheter, and in case
of an isolated injury with no coagulopathy, you should
administer systemic heparin (70U/kg). Prophylactic antibiotics, such as 1g of cefazolin, should be given intravenously.
Attain control as close as possible to the injured area as
major branches, especially on the rst part can cause substantial back bleeding if not isolated. These branches can be
temporarily controlled or they can be ligated if necessary.
The vertebral artery is an exception and you should preserve
it, if at all possible. If it was demonstrated to be a dominant
vessel on preoperative imaging, it should be revascularized
during the repair. In the rare case of the internal mammary
artery being a bypass conduit of a previous coronary bypass,
it should also be protected or repaired at all costs.
The local pathology can also inuence the type of repair
needed. Large false aneurysms and arteriovenous stulas
mandate more extensive dissection for wider proximal and
distal control, as well as arterial and venous control in the
latter. The extent of the arterial defect will dictate the type of
318
in subclavian a.
https://t.me/medicina_free
repair needed. The basic principles are debridement of all
damaged arterial walls and then establishing a tension-free
repair. This can include mobilization of the artery with primary repair by lateral suture using 60 polypropylene suture
materials in a continuous or interrupted fashion. If the defect
is too extensive, an interposition graft is required. The
options are autologous saphenous veins or synthetic materials such as PTFE or Dacron. Vein grafts tend to be favored,
but, in this location, no clear long-term benet has been demonstrated. Disadvantages include the availability and time
delay especially in the unstable patient, the risk of kinking,
impingement between the clavicle and the rst rib, and
potential size discrepancy. It is, therefore, reasonable to use
externally reinforced PTFE or Dacron grafts of appropriate
size. No clear inferior long-term patency or signicantly
higher sepsis rate has been reported in the literature when
compared to vein grafts.
In case of proximal subclavian artery injuries close to the
origin, interposition grafting from subclavian to subclavian
artery might not be possible. Proximal takeoff of the graft
might then be from the ascending aorta, innominate artery, or
the adjacent carotid arteries. Transpositions of the debrided
subclavian artery to the ipsilateral carotid arteries are also a
possibility. In extreme cases where the procedure is seen as a
damage control situation, the subclavian artery should simply be ligated proximal and distal to the injury. This is usually well tolerated and repair can be deferred to when the
patient is stable or if he/she develops upper limb
claudication.
D. F. Du Toit
Amplutz wire
False aneurysm
5 Fr diagnostic
catheter in aorta
Short 9 Fr
introducer
Fig. 36.12 Stent graft repair of a false aneurysm of the left subclavian
artery by using a double femoral puncture technique
Femoral a.
Short 5 Fr
introducer
36.3.2.8 Endovascular Management
(Fig.36.12)
This is our treatment option of choice for all stable patients
with subclavian artery injuries. This treatment modality is
now well established as a safe alternative to open surgery
with less morbidity, shorter hospitalization, less blood loss,
and acceptable short- and long-term follow-up results. The
absence of local expertise and angiography facilities as well
as surgeon preference might inuence the choice of management options. Patient selection is based on clinical presentation and diagnostic angiography. Clinical and radiological
factors precluding stent graft treatment were already
mentioned.
The procedure is performed in an arteriography suite or a
hybrid operating room equipped for general anesthesia and
conventional surgery. Intravenous heparin (50units/kg) and
prophylactic cefazolin were routinely administered before
stent graft deployment and empirically continued for 24h, at
a dosage of 5000units subcutaneously and 1g intravenously
respectively every 8 h. Transfemoral arterial access is
attained under local anesthesia. The anatomical location of
lesions and proximal and distal vessel diameters are determined with routine angiography, and a nal decision regard-
ing stent graft treatment is then taken. If a preoperative
CT-angiogram was done, a more directed approach is
possible.
The stent graft is placed via a percutaneous transfemoral
approach. Bilateral transfemoral access (5F and 9F Cordis®
[Johnson & Johnson, Waterloo, Belgium] introducer sheaths)
is obtained. Engage the subclavian artery to be stented with
a diagnostic catheter (5F Headhunter). Do a diagnostic run
and measure the diameter of the subclavian artery. Choose a
stent graft 1–2 mm larger than the subclavian artery and
cover at least 1cm proximal and distal to the lesion. If the
vertebral artery has to be covered, the presence of a goodquality contralateral vertebral artery has to be conrmed. It is
usually unnecessary to coil-embolize subclavian artery
branches in the area to be stented unless they clearly contribute to an AV stula. Using a road map, pass the subclavian
artery lesion with a steerable hydrophilic guide wire and
steer the wire to the midbrachial artery. Advance the diagnostic catheter over the guide wire into the brachial artery
and exchange it for a stiff wire (Amplatz®). The appropriate
stent graft is introduced via the 9F sheath (11cm in length)
over a stiff guide wire, crossing the lesion, and angiographic
control for precise deployment was provided by a diagnostic
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