Contemporary Review of Traumatic Axillary and Subclavian Artery Injuries at an Urban Level One Trauma Center
Sellers Boudreau, Jessica Schucht, Abindra Sigdel, Amit Dwivedi, Erik J Wayne
University of Louisville, Louisville, KY
INTRODUCTION: Traumatic axillary and subclavian artery injuries are uncommon. Limited data is available regarding patient and injury characteristics, as well as management strategies and outcomes.METHODS: Retrospective chart review was performed on patients presenting to University of Louisville Hospital, an urban Level One Trauma Center, with traumatic axillary and subclavian artery injuries from 2015-2021. Patients were identified using trauma database, radiology database, and billing database searches. Data from the electronic medical record was collected in a Microsoft Excel spreadsheet, with variables including: Age, Sex, Injury Severity Score (ISS), Length of stay (LOS), Mechanism of injury, Diagnostic modality, Artery involved, Side involved, Injury grade/type, Concomitant major vein/bone/brachial plexus injury, Management strategy, Revascularization success, Need for fasciotomy, In-hospital death, Amputation, Need for re-intervention during index admission, Stent/graft thrombosis/infection, and Outpatient follow-up. Descriptive statistics were calculated. Comparisons were performed using Fisher’s Exact and Chi-squared tests.RESULTS: Forty-four patients with traumatic axillo-subclavian arterial injuries were identified for analysis. Mean age of patients was 39 years old with most of them being male (77%). Mean ISS was 20. Blunt and penetrating trauma were equally represented, with most penetrating injuries due to gunshot wounds (82%). Most patients were diagnosed based on CT angiography, however 9% of patients were diagnosed intra-operatively. A variety of injury types were seen: minimal injury 23%, laceration 14%, pseudoaneurysm 11%, transection 27%, occlusion 18%, arteriovenous fistula 7%. Many patients had concomitant injuries including major vein injury (41%), bone fracture (77%), and brachial plexus injury (39%). Management strategies were also variable, including non-operative (27%), endovascular only (18%), planned hybrid approach (25%), open (23%), and endovascular to open conversion (7%). Revascularization success was very high (97%) with low likelihood of thrombosis (6%) or infection (0%). Amputation rate was 5% and mortality rate was 9%. Regarding arterial involvement, blunt injury was more likely to affect the subclavian than the axillary artery (p=0.04). No significant difference was seen in brachial plexus injury based on artery involved (p=0.14) or mechanism (p=0.22). Non-operative management was more likely with subclavian artery injury versus axillary artery injury (p=0.008). There was no significant difference between non-operative and operative management based on mechanism (p=0.09). Transection injury was associated with an open repair strategy (p=0.0003). Of the three patients requiring endovascular to open conversion, two required amputation, indeed the only two patients in the study undergoing amputation.CONCLUSIONS: Both open and endovascular/hybrid strategies are useful when treating traumatic axillary and subclavian artery injuries and are associated with very high likelihood of revascularization success, with low rates of thrombosis or infection. Some minimal injuries can be successfully managed non-operatively. Though transection injury can technically be treated with an endovascular strategy, it usually requires an open approach. Failure of endovascular management requiring open conversion may portend limb amputation.
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