Blunt Injury to the Thoracic Outlet Arteries: The Experience of a Level I Trauma Center

Objective: Injury to the thoracic outlet arteries is uncommon and usually occurs in severely injured patients. Surgical exposure of these vessels can be difficult and is associated with significant morbidity and mortality. Endovascular methods have been increasingly utilized for the management of these injuries and may offer an alternative approach to these technically challenging injuries. We sought to describe the experience of a level I trauma center in managing these injuries.
Methods: We retrospectively reviewed patients who presented to a Level I trauma center with blunt traumatic injuries to the innominate, subclavian, and axillary arteries between January 1, 1998 and February 7, 2009. Demographic data, mechanism of injury, concomitant injuries, pre-operative workup, treatment method, and 30 days outcomes were recorded.
Results: Thirty-six patients with blunt thoracic outlet vessels injuries were admitted to our institution over an 11 year period. Mean age was 22, and 81% were male. Lesion types include pseudoaneurysm (n=9), transection (n=12), occlusion (n=12), and intimal tear (n=3). Open operative repair was undertaken in 22 patients, 8 patients underwent endovascular repair, and 6 was treated conservatively. The approach for open repair was via a median sternotomy (n=10) , infraclavicular incision (n=6), thoracotomy (n=2), or other (n=2). The approach for endovascular repair was via retrograde femoral, retrograde brachial, or through-and-through brachial-femoral wire. Technical success was 100% in the open surgical group and 73% in the endovascular group. Estimated intra operative blood loss (997 mL vs. 56 mL, p < 0.001) and hospital length of stay (26 days vs. 16 days, p < 0.05) were significantly greater in the open repair vs. endovascular repair.
Conclusions: Endovascularly placed covered stents are a feasible alternative to open repair in properly selected patients with thoracic outlet arterial injuries. Compared to the open approach, endovascular repair results in lower morbidity and hospital length of stay in the polytrauma patient with blunt vascular trauma. An endovascular approach as “damage control” should be considered in all patients presenting with these injuries.