Chapter 9: Axillosubclavian Arterial Injuries

BACKGROUND

Trauma to the axillary and subclavian arteries, collectively termed axillosubclavian injuries, occurs in 0.4% of all mechanisms of injury presenting to modern trauma centers¹ and accounts for approximately 4% of vascular injuries subsequently identified.² Although they are less well defined epidemiologically, iatrogenic complications occurring during in-hospital procedures such as attempts at central venous catherization also contribute to the number of injuries encountered at this anatomic location. Specific injury types that can be encountered include dissection, pseudoaneurysm, arteriovenous fistula, and transection.³ Outcomes following axillosubclavian injuries vary considerably depending upon a variety of factors, but mortality rates of 28% to 34% have been reported.^3,4

When axillosubclavian injuries require intervention, exposure and control of these specific arterial segments remains a clinical challenge. Open surgical approaches require dissection in an anatomic region characterized by a confined arrangement of key neurovascular structures within the apical thorax and junctional regions adjoining the neck and proximal upper extremity. Complex and uncommonly encountered anatomy, combined with the challenges of overlying bony structures, delay expeditious vascular control while avoiding inadvertent injury to adjacent structures.

Over the past 20 years, endovascular solutions for the management of these injuries have continued to evolve, with a growing utilization of these adjuncts in select patients.¹ The skills required to achieve endovascular repair, however, are not traditionally within the skill set of trauma surgeon. In contrast, vascular surgeons or interventional radiologists who are better trained in endovascular techniques may not have experience in the management of these injuries in the patient with multisystem trauma. The selection of optimal therapy requires the following: (1) knowledge of pertinent anatomy; (2) an understanding of the appropriate conduct of both open and endovascular management options; (3) an appreciation of the potential benefits and limitations of both approach types; and (4) the ability appropriately to combine both open and endovascular techniques in a hybrid approach.

ANATOMY

The subclavian and axillary arteries share some key similarities, one of which is a division into three segments by a relationship with overlying muscular anatomy with fairly consistent branches that can be identified on subsequent imaging. An understanding of these anatomic landmarks and their relationships is invaluable in achieving optimal outcomes (Fig. 9-1).

Subclavian Artery

The subclavian artery most commonly originates at the bifurcation of the innominate artery on the right and directly from the aortic arch on the left. The artery is then divided into three segments (Fig. 9-1):

1. First segment—origin to the medial border of the anterior scalene muscle.

2. Second segment—lies behind the anterior scalene muscle.

3. Third part—extends from the lateral border of the anterior scalene to the outer border of the first rib, where it ...