Penetrating Trauma to the Subclavian Vessels

Abstract

The management of penetrating subclavian vessel injuries remains a surgical challenge. Patients can present in a stable condition with only a chest or neck wound or hemodynamically unstable with an actively bleeding wound. Patients must be resuscitated according to ATLS principles and bleeding must be stopped by manual or Foley catheter tamponade. Stable or stabilized patients must be investigated with CT or digital subtraction angiography. If a subclavian artery injury is diagnosed, it must be evaluated for endovascular treatment. Open surgery must be done if contraindications to endovascular treatment exist. True subclavian artery injuries usually require access via a sternotomy, supraclavicular incision, or both. If no arterial injury is demonstrated on arteriography, a subclavian vein injury must be suspected if the patient presented with active bleeding. In this case, the patient should be observed for 24–48 h or if a Foley catheter tamponade is in place, it must be removed after this period and the patient observed for rebleeding. A patient that cannot be stabilized must be taken to the operating room and a midline sternotomy must be done to attain proximal control of bleeding vessels. A supraclavicular incision is usually added to achieve distal control and repair in arterial injuries and a medial claviculectomy can be added in case of troublesome bleeding from a venous injury posterior to the clavicle.