Keywords
Endovascular treatment, blunt trauma, subclavian artery injury, open clavicle fracture
Endovascular treatment, blunt trauma, subclavian artery injury, open clavicle fracture
Subclavian arterial injury caused by blunt trauma is rare with potentially high morbidity and mortality1,2. Open clavicle fractures caused by blunt trauma are also rare3,4. Here we report a blunt trauma case with open clavicle fractures and subclavian artery injury accompanied by upper extremity ischemia and the need for urgent treatment.
A 41-year-old man, who had no significant previous medical or family history, was thrown from the rear seat of a vehicle during an accident on the motorway. He was transferred to the emergency department of our hospital. Upon admission, he had an open airway, normal breathing with a respiratory rate of 16 breaths/min, was hemodynamically stable with a blood pressure of 123/79 mmHg, and a pulse rate of 88 beats/min. He was conscious and scored E3 for eye opening, V5 for verbal response, and M6 for motor response on the Glasgow Coma Scale. He had a left pneumothorax, a left, open, mid-shaft clavicle fracture accompanied by a 10 mm-sized laceration with numerous subcutaneous air bubbles trapped in the soft tissue on the lateral end of the clavicle, and left subclavian arterial injury (Gustilo Grade I) (Figure 1A–C). He had multiple lacerations of the forehead without abnormal findings in computed tomography of the head and neck. Both hands were warm with brisk capillary refill in the fingers. The radial and ulnar pulses in the left hand were palpable, but markedly weaker compared to those of the right hand. The blood pressure of the left arm was approximately half that of the right arm blood pressure. Despite no muscle weakness in the upper extremities, the patient had left hand numbness. The Injury Severity Score was 11. The patient was treated with urgent debridement and irrigation for the open clavicle fracture in the operating room followed by urgent angiography for the subclavian artery injury. Initial selective angiography of the left subclavian artery via the right common femoral artery revealed a segmental dissection of the distal subclavian artery with preserved blood flow to the left upper extremity (Figure 2A). Subsequent intravascular ultrasound via the left brachial artery revealed an intimal flap and a compressed true lumen by a thrombus of the pseudo lumen in the distal subclavian artery (length of the lesion, 3 cm). An 8 mm × 40 mm self-expanding nitinol stent (Smart Control, Cordis) was deployed. Adequate stent expansion and restoration of blood flow of the subclavian artery were confirmed (Figure 2B). After the endovascular stenting, the left radial and ulnar pulses were remarkably improved and the blood pressure difference between the left and right arm was significantly eliminated. Antithrombotic therapy to prevent stent thrombosis using intravenous heparin targeting aPTT of 2 times the control aPTT for 9 days was followed by an antiplatelet therapy using aspirin 100 mg plus cilostazol 200 mg daily for 12 months. On day 6, an open reduction and internal fixation of the clavicle fracture using a Kirschner wire were performed. The patient was discharged on day 22 and continued to be free of complications at the 2-month follow-up with stent patency determined using color duplex ultrasonography.
(A) Subclavian artery injury shown on contrast-enhanced computed tomography. (B and C) Clavicle fractures and subclavian artery injury shown on three-dimensional computed tomography angiography.
Clavicle fractures are common injuries and mostly treated non-operatively with good outcomes, while open clavicle fractures due to blunt trauma are rare, accounting for 0.2–1.3% of all clavicle fractures in a trauma clinic or Level I trauma center3,4. Open clavicle fractures caused by penetrating trauma are frequently associated with a great vessel injury, including subclavian artery injury, compared to those caused by blunt trauma3.
Subclavian artery injuries through blunt trauma are rare with a reported incidence of less than 1% of all arterial injuries or thoracic traumatic injuries5–7. Subclavian artery injuries are caused by stretching, transection, or compression of the subclavian artery by broken bone fragments. Unexpected neurovascular symptoms, a pseudoaneurysm rupture, or a thrombus associated with upper extremity ischemia often initiate weeks or months after initial injury. There have been reports of patients who had delayed symptom recognition but were treated successfully in late phases8,9. However, there have been cases with massive hemorrhage due to transection of the subclavian artery1 or cerebral infarction due to occlusion of the subclavian artery2 within hours after injury, highlighting the importance of urgent therapeutic management of subclavian artery injury. Our case presented an intimal injury of the subclavian artery with a thrombus leading to upper extremity ischemia, which could cause retrograde thromboembolization and cerebral infarction. We thus urgently treated for prevention of cerebral infarction and to salvage the limb.
An open surgical approach is one treatment option for subclavian artery injury. However, this approach requires an extensive incision to obtain proximal and distal control, which is invasive, difficult to perform, and associated with high morbidity6,10. In our case, the patient had an open fracture, which is a risk factor for graft infection in vascular surgery. Advances in endovascular treatments for vascular injuries have achieved increasing success for treatment of subclavian artery injury caused by penetrating trauma such as a gunshot, stab, or iatrogenic catheter injury10. Endovascular treatment is a viable option for cases of subclavian artery injury where there is a risk of extremity ischemia and cerebral infarction.
Written informed consent for publication of clinical details and images was obtained from the patient.
TN prepared the first draft of the manuscript. KI, HF, HO, SN and TM provided additional editing and expert content. All authors were involved in the revision of the draft manuscript and have agreed to the final content.
Views | Downloads | |
---|---|---|
F1000Research | - | - |
PubMed Central
Data from PMC are received and updated monthly.
|
- | - |
Competing Interests: No competing interests were disclosed.
Competing Interests: No competing interests were disclosed.
Alongside their report, reviewers assign a status to the article:
Invited Reviewers | ||
---|---|---|
1 | 2 | |
Version 1 19 Dec 14 |
read | read |
Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list:
Sign up for content alerts and receive a weekly or monthly email with all newly published articles
Already registered? Sign in
The email address should be the one you originally registered with F1000.
You registered with F1000 via Google, so we cannot reset your password.
To sign in, please click here.
If you still need help with your Google account password, please click here.
You registered with F1000 via Facebook, so we cannot reset your password.
To sign in, please click here.
If you still need help with your Facebook account password, please click here.
If your email address is registered with us, we will email you instructions to reset your password.
If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance.
Comments on this article Comments (0)