|Year : 2016 | Volume
| Issue : 2 | Page : 67-70
Left subclavian artery injury: Is there still a role for trap door incision in the minimally invasive Era?
Jonathan Nwiloh, Kenneth Etukokwu, Obinna Orakwe, Chiedozie Ikwu, Chinyere Onyenwuzor, Norbeth Iziga
Dr. Joe Nwiloh Heart Center, St. Joseph's Hospital, Adazi-Nnukwu, Anambra State, Nigeria
|Date of Web Publication||16-Dec-2016|
Dr. Joe Nwiloh Heart Center, St. Joseph's Hospital, Adazi-Nnukwu, Anambra State
Source of Support: None, Conflict of Interest: None
The surgical approach to the management of subclavian artery injuries is usually guided by the location and clinical presentation. With the advent of endovascular surgery, many surgeons are likely to have limited experience with the trap door approach sometimes necessary for control and repair of proximal left subclavian artery (LSA) injuries due to their relative rarity. A 69-year-old male sustained a left lower neck stab wound 3 weeks before his presentation with a pulsatile left supraclavicular swelling, weak radial pulse, and upper extremity weakness. Duplex ultrasound scan revealed a pseudoaneurysm confirmed on computed tomography angiogram and shown to be fed from the LSA. The patient successfully underwent elective open surgical repair of the injury located in the first portion of the subclavian artery through a trap door approach. Although the injury might have been treated minimally invasively with endovascular repair, this technique is currently not available in Nigeria and most Sub-Saharan African countries. Surgery remains the only treatment option for these types of injuries in low-resource countries. Surgeons involved in the management of vascular injuries should, therefore, be conversant with all surgical approaches, including the trap door incision which should be part of their armamentarium.
Keywords: Penetrating trauma, subclavian artery, surgical exposure
|How to cite this article:|
Nwiloh J, Etukokwu K, Orakwe O, Ikwu C, Onyenwuzor C, Iziga N. Left subclavian artery injury: Is there still a role for trap door incision in the minimally invasive Era?. Niger J Cardiovasc Thorac Surg 2016;1:67-70
|How to cite this URL:|
Nwiloh J, Etukokwu K, Orakwe O, Ikwu C, Onyenwuzor C, Iziga N. Left subclavian artery injury: Is there still a role for trap door incision in the minimally invasive Era?. Niger J Cardiovasc Thorac Surg [serial online] 2016 [cited 2020 Dec 3];1:67-70. Available from: http://www.nigjourcvtsurg.org/text.asp?2016/1/2/67/195957
| Introduction|| |
Subclavian artery injuries result mainly from penetrating trauma, and because of their relative rarity, many surgeons have limited experience with their management. They have traditionally been treated with surgery until recent years when complex vascular injuries are increasingly managed through catheter-based therapy in suitable patients who are hemodynamically stable at presentation. However, in most of Sub-Saharan Africa (SSA) countries, surgery continues to be the only available treatment option and so the need for familiarity among surgeons with the trap door incision which is sometimes required for injuries of the proximal left subclavian artery (LSA).
| Case Report|| |
A 69-year-old male sustained a stab wound to the left upper back/lower neck with a kitchen knife during an altercation 3 weeks before presentation. He subsequently developed pain, progressive swelling over the left shoulder, and denied any fever, chills, cough, or shortness of breath. Blood pressure (BP) was 120/71 mmHg, pulse rate 88 beats/min, respiratory rate 20 cycles/min, and temperature 36.8°C at presentation. Significant physical examination findings were 12 cm × 10 cm tender, warm, pulsatile swelling with a bruit over the base of the left neck and extending to the upper back; and 1.5 cm healing stab wound at the superior aspect of the swelling, weakness of the left upper extremity with a weak radial pulse compared to the right. Pertinent laboratory results were white blood cell 4.73 × 10 9 /L, Hgb 11.1 g/dl, platelet count 229 × 10 9 /L, prothrombin time 18.8, international normalized ratio 1.93, activated partial thromboplastin time 44.8 s, and erythrocyte sedimentation rate 26 mm. Duplex ultrasound scan of the mass showed a large pseudoaneurysm and arteriovenous shunt deep to the subcutaneous tissue in the left supraclavicular region. A conventional angiogram was not available locally and so a computed tomography (CT) angiogram was obtained, which confirmed the pseudoaneurysm feeding from the proximal LSA [Figure 1]. The patient subsequently underwent elective surgery with first performance of a forth intercostal anterior thoracotomy to obtain proximal control of the LSA at the takeoff from the aortic arch. Next, a supraclavicular incision was made to expose the subclavian artery, with severe bleeding encountered on entering the pseudoaneurysm despite clamping the proximal LSA. With direct pressure applied over the supraclavicular fossa to slow the bleeding, an infraclavicular incision was quickly made to expose the distal subclavian and proximal axillary artery for distal clamping. However, despite both proximal and distal controls, severe bleeding persisted which was now attributed to back bleeding from the arterial branches and collaterals in the first portion of the LSA. The site of arterial injury was inaccessible as it was located behind the sternoclavicular joint (SCJ) [Figure 2]. To gain access, the anterior thoracotomy and supraclavicular incisions were connected through a partial upper sternotomy to create a trap door for easy visualization of injury site. Bleeding was then quickly controlled and primary repair of a 1 cm laceration performed with 4/0 prolene suture. There was no cell saver machine, so patient required several units of blood transfusion intraoperatively due to near exsanguinating hemorrhage before obtaining control of the bleeding. The incisions were closed in the standard fashion, and the patient was extubated within 24 h and remained hemodynamically stable postoperatively.
| Discussion|| |
Subclavian artery and vein injuries are relatively rare with most busy urban trauma centers encountering only 2-4 cases a year. Both account for about 5% of all vascular injuries while subclavian artery injury alone accounts for only 1%-2%.  Most cases of reported subclavian vascular injuries in civilian populations are predominantly from penetrating trauma, with very low incidence of blunt trauma which are usually from clavicle and first rib fractures.  The rarity of subclavian vascular injuries is thought to be partly related to the anatomy of the superior mediastinum and thoracic inlet which offers muscular and bony protection to the underlying traversing vessels. Paradoxically, these are the same protective musculoskeletal structures that hinder exposure for emergency control of bleeding when these vessels are injured. The relative ease of exposure and surgical approach depends on the portion of the subclavian artery injured and whether it is on the right or left side as they have different vessels of origin. The subclavian artery is anatomically divided into three parts based on its relation to the anterior scalene muscle (ASM). The first portion starts from the origin to the medial border of the ASM, the second portion lies behind the ASM, and the third portion starts from the lateral border of the ASM to the lateral border of the first rib where it becomes the axillary artery [Figure 2]. The first portion of the subclavian artery is the least accessible compared to the second and third portions because of its course behind the SCJ. The proximal right subclavian artery (RSA) can be more easily exposed through an upper sternotomy with a cervical extension because the innominate artery from which it arises is located more anteriorly unlike the more posterior origin of the LSA from the aortic arch. Exposing the origin of the LSA is, therefore, more difficult and usually requires an anterior thoracotomy through the third or fourth intercostal space. The major named branches of the LSA - vertebral, thyrocervical, costocervical, and internal mammary arteries (IMAs) - arise from the first portion, similar to the RSA with exception of the costocervical trunk which arises from the second portion. These vessels provide an extensive collateral flow, thus allowing safe ligation of the subclavian artery without major sequela in unstable situations with multiple life-threatening injuries  and also coverage of the LSA in urgent thoracic endovascular aortic repair for life-threatening acute aortic syndromes without carotid to subclavian artery bypass revascularization.  This rich collateral network also accounts for the persistent severe bleeding sometimes seen in injuries to the first portion despite proximal and distal control of the LSA as was encountered in our patient. Because part of the first portion of the subclavian artery runs behind the SCJ, injuries in this region are the most difficult to access for control. This is especially true for a proximal LSA injury which may sometimes need a trap door incision for adequate exposure as was required in our patient. Dorsey et al.  in a review of 15 patients with subclavian artery injuries over a 15-year period in an older era of 1968-1982 used a trap door incision in 2 patients with RSA and 3 LSA injuries with no postoperative complications from the incision. Another report of very proximal blunt traumatic LSA injury 2 cm distal to the aortic arch was repaired through only the left forth interspace posterolateral thoracotomy with cardiopulmonary bypass standby.  The trap door incision, however, has become unpopular in the modern era with the advent of endovascular therapy and trend toward minimally invasive surgical approaches. Sobnach et al.  in a large series of 50 patients with subclavian artery injuries from South Africa preferred a median sternotomy with supraclavicular extension if the injury was proximal to the vertebral artery, involved the first part of the subclavian artery or if there was active bleeding from the supraclavicular region. While patients with infraclavicular bleeding first underwent a supraclavicular incision for proximal control and if this failed, then a median sternotomy was performed. Similarly, Kalakuntla et al.'s  review from a busy urban level 1 trauma center in the US of 25 patients with subclavian artery injury performed thoracotomy with or without supraclavicular extensions for left and median sternotomy with or without supraclavicular extensions for the right-sided proximal arterial injuries. However, with the goal of reducing the morbidity and mortality associated with open surgical procedures, endovascular repair is being increasingly advocated in hemodynamically stable patients with injuries suitable for a catheter-based approach. , Because the majority of patients with subclavian vascular injuries present in shock with systolic BP <100 mmHg as reported by Degiannis et al.,  endovascular therapy can only be used in the selected patients. In fact, Demetriades et al.  reported that these patients arrive at the hospital with no vital signs or with impending cardiac arrest in more than 20% of cases. Obviously, these cohorts of patients will require emergency room thoracotomy. Patients with active bleeding and hemodynamic instability will need to proceed to the operating room with ongoing resuscitation and no time for an angiogram. Although majority of subclavian artery injuries present early within 24-48 h, some patients with minimal initial symptoms may present late as was the case with our patient. McKinley et al.  in a review of 260 patients from 1977 to 1996 found that 25% presented more than 48 h after injury. The late presentation of our patient was due to his hemodynamic stability likely because the bleeding rate from the injury was somewhat contained by surrounding muscular and fascial structures. He could have been a suitable candidate for conventional angiography, and endovascular therapy had this treatment option being available locally, thereby obviating the need for a major open surgical procedure. The mortality and morbidity of subclavian vascular injuries is also determined by the associated injuries. Reported mortality ranges from 4.7% to 30% in civilian populations, with higher rates for combined arterial and venous injuries.  Although conventional angiogram used to be the gold standard, this has been overtaken by CT angiography in most centers as the procedure of choice.  Some, however, continue to advocate for conventional angiography as a means of identifying additional injuries, with 20% concomitant injuries found on angiography in the series of Graham et al.  In addition, conventional angiography is also needed for endovascular therapy. Unfortunately, due to the cost of equipment and dearth of skilled workforce, conventional angiography and endovascular therapy are unavailable in most of the SSA countries. As a result of these limitations, the majority of patients with major vascular injuries in SSA can only be treated through traditional open surgical approaches. However, because of the rarity of subclavian vascular injuries even in large, busy urban trauma centers in the West, surgeons in SSA working in smaller regional trauma centers are even less likely to be exposed to these injuries. They may, therefore, find it challenging to obtain expeditious exposure and control when confronted with an emergency. We feel it is necessary that all surgeons involved in the care of vascular trauma patients should be conversant with median sternotomy and trap door incisions which may be required to control exsanguinating hemorrhage involving the proximal subclavian artery. On the left side, the trap door incision can start with a third or fourth anterior thoracotomy to first obtain control of the proximal LSA, and then a partial sternotomy to connect the thoracotomy. The upper sternotomy incision is then extended to the supraclavicular region, and the sternum and ribs are then elevated with a chest retractor for exposure of the underlying vessels [Figure 3] and [Figure 4]. Closure is fairly straight forward using sternal wires for the sternotomy and heavy sutures for the thoracotomy. A crucial caveat is to identify and ligate the IMA proximally and distally before completely connecting the sternal and thoracic incisions. If this is not done at the beginning because of the need for expeditious control of exsanguinating hemorrhage, the divided ends of the IMA should later be identified and ligated before chest closure to prevent possible major postoperative bleeding.
| Conclusion|| |
Although the trap door incision appears quite extensive in the present era of minimally invasive surgery and endovascular therapy, it remains a useful approach in certain injuries involving the proximal LSA when it might prove crucial in controlling exsanguinating hemorrhage. It should, therefore, be in the repertoire of any surgeon involved in the management of patients with traumatic vascular injuries, especially in SSA where alternative treatment options are limited.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 3], [Figure 4]