Eighteen years’ experience of traumatic subclavian vascular injury in a tertiary referral trauma center

Abstract

PurposeTraumatic subclavian vascular injury (TSVI) is rare but often fatal. The precise diagnosis of TSVI remains challenging mainly because of its occult nature, less typical presentations, and being overlooked in the presence of polytrauma. Compared to penetrating injuries, it is even more difficult to identify TSVI in patients who have blunt injuries and no visible bleeding. The risk factors associated with TSVI in patients with thoracic trauma are unclear. The aims of this study were to identify risk factors for TSVI in a cohort of patients with thoracic vascular injuries and to report outcomes after clinical treatment.MethodsFrom January 2009 to June 2017, 39586 patients were admitted to our hospital (a level I trauma center) due to trauma, and 136 patients with thoracic vascular injury were enrolled in this study. We retrospectively reviewed data from medical records including demographic characteristics, injury scoring systems (RTS, ISS, NISS, TRISS and AIS), management and outcomes. Patients were further divided into the TSVI group (patients with TSVI) and the non-TSVI group (patients with thoracic vascular injuries other than TSVI). Univariate and multivariate analyses were used to identify independent risk factors.ResultsThe enrolled 136 patients suffered mostly from blunt trauma (89.0%) and 22 of them had TSVI. When compared to the non-TSVI group, the TSVI group had lower Glasgow Coma Scale (GCS) scores (p = 0.002; especially GCS ≤ 12), less concurrent abdominal injury (p < 0.001), lower Injury Severity Scales (ISS) (p = 0.007) and New Injury Severity Scales (NISS) (p < 0.002) but had higher Abbreviated Injury Scales (AIS) of the head ≥ 3 (p = 0.009) and rates of clavicular or scapular fractures (p = 0.013). No difference was detected between the two groups with regard to age, gender, trauma mechanism, vital signs on arrival, or rate of facial and extremities injury. In multivariate regression analyses, GCS ≤ 12, AIS of the head ≥ 3 and the presence of clavicular or scapular fractures were independent risk factors for TSVI (p = 0.026, p = 0.043 and p = 0.005, respectively) after adjustment for confounding factors. Open and endovascular repair were two surgical procedures utilized for these TSVI patients with an overall mortality rate of 18.2%. No difference was found between these groups with regard to mortality rate and the length of ICU stay, but the patients in the TSVI group had a shorter length of hospital stay.ConclusionsOur results suggest that GCS ≤ 12, AIS of the head ≥ 3 and the presence of clavicular or scapular fractures were independent risk factors for TSVI in patients with thoracic vascular injuries. For patients with thoracic trauma, TSVI should be considered for prompt management when patients exhibit concurrent injuries to the head, clavicle or scapula.

Controle de danos para lesão de artéria subclávia

“…Em pacientes estáveis, o acesso cirúrgico pode considerar resultados de exames de imagem como angiotomografia e, ocasionalmente, angiografia e eco-Doppler. Pacientes com deterioração dos parâmetros fisiológicos devem ser submetidos a cirurgia imediata, com acesso baseado no mecanismo de trauma [1][2][3]11 .…”

“…Traumas penetrantes de vasos subclávios atingem mortalidade de até 60% no cenário pré-hospitalar, tornando a rapidez de acesso ao centro de trauma um fator decisivo. A mortalidade intraoperatória varia de 5-30% [1][2][3][4] .…”

“…A proximidade de estruturas neurovasculares, hematoma, alterações anatômicas e a necessidade de exposição adequada tornam desafiadora a cirurgia para tratamento desses traumas [3][4][5] . A mortalidade pós-operatória varia entre 5 e 40% 2,3 , e complicações pós-operatórias chegam a 24% 4 .…”

Current results of arterial injuries seen at femoral and popliteal arteries in civil society

“…In the industrialized world, deaths due to major arterial injuries constitute 20-25% of post-traumatic deaths. 1 Ischemia time is very critical to save patients' extremities and lives. Ischemia lasting more than eight hours can cause limb loss or death.…”

Major vascular trauma

“…Injury to the subclavian artery is an uncommon but potentially a fatal injury. The series published by Kou of 22 such injuries highlights the difficulties inherent in a rare but life-threatening injury (5), not only the challenge of diagnosis (particularly in blunt injury) but also the knowledge vacuum that exists around the optimal management of these lesions particularly with the relatively recent adoption of endovascular techniques. The authors noted that only 27.3% of their patients with subclavian injury had hard signs of vascular injury affecting their upper limb; not surprisingly GCS < 12, abbreviated injury scale of the head > 3 and the presence of clavicular or scapular fractures were found to be risk factors for subclavian injury.…”