Thoracic Outlet Vascular Injuries

Abstract

Management of vascular injuries at the thoracic outlet and neck continues to be a major problem to the trauma surgeon. Of 47 patients treated over an eighteen-year period, 45 were due to penetrating injuries (41 gunshot [87.2%], 4 stab wounds [8.5%]). In 16 patients shock was present at the time of admission. Five patients were operated on in comatose condition. In 37 patients immediate, and in 10 cases delayed, operation was performed. In 13 patients with arterial injuries, end-to-end anastomosis; in 24, saphenous vein graft; in 6, synthetic graft; in 2, lateral suture; and in 2, ligation were performed. Three subclavian arterial injuries repaired by saphenous vein graft occluded owing to thrombosis, requiring synthetic graft replacement. In 3 axillary arterial injuries, ligation was performed following the operation because of infection. One of these patients underwent amputation. Only 3 of 14 brachial plexus injuries (BPI) were primarily repaired. In only 1 of 3 repaired patients did complete function return. Overall mortality was 5 including 3 comatose patients with carotid injuries and 2 with axillary arterial injuries. In conclusion: (1) Subclavian and axillary artrial injuries may be overlooked by physical examination in the absence of critical ischemia. (2) We recommend ligation instead of revascularization in comatose carotid injury cases. (3) Synthetic grafts may be used, in cases of size discordance or in unstable patients, to end the operation as soon as possible. (4) In associated venous injuries, repair should be preferred to ligation. (5) In the presence of BPI due to gunshot wounds the results are not good in spite of nerve repair, and serious sequelae may remain.