REVIEW ARTICLE

Subclavian vessel injuries: difficult anatomy and difficult territory

J. D. Sciarretta • J. A. Asensio • T. Vu • F. N. Mazzini • J. Chandler •

F. Herrerias • J. M. Verde • P. Menendez • J. M. Sanchez •

P. Petrone • K. D. Stahl • H. Lieberman • C. Marini

Received: 16 June 2011 / Accepted: 19 June 2011 / Published online: 29 July 2011

� Springer-Verlag 2011

Abstract

Introduction Thoracic and thoracic related vascular inju-

ries represent complex challenges to the trauma surgeon.

Subclavian vessel injuries, in particular, are uncommon and

highly lethal. Regardless of the mechanism, such injuries

can result in significant morbidity and mortality.

Materials and methods Systematic review of the litera-

ture, with emphasis on the diagnosis, treatment and outcomes

of these injuries, incorporating the authors’ experience.

Conclusions These injuries are associated with significant

morbidity and mortality. Patients who survive transport are

subject to potentially debilitating injury and possibly death.

Management of these injuries varies, depending on

hemodynamic stability, mechanism of injury, and associ-

ated injuries. Despite significant advancements, mortality

due to subclavian vessel injury remains high.

Keywords Vascular � Trauma � Subclavian � Injury �Exposure � Management

Introduction

Thoracic and related vascular injuries represent complex

challenges for the trauma surgeon. In particular, subclavian

vessel injuries are uncommon and highly lethal. Regardless

of the mechanism, such injuries can result in significant

morbidity and mortality. Subclavian vessel injuries are

generally associated with multiple life-threatening injuries.

Over the years, the overall mortality has continued to

improve due to significant advancements in resuscitation,

emergency medical transport systems, and the increased

development of regionalized systems of trauma.

Historical perspective

In 1892, Halsted [1] performed the first successful sub-

clavian aneurysmal ligation. Given the infrequent occur-

rence of subclavian vessel injuries, surgeons had minimal

experience in their management prior to wartime. Com-

monly, the general practice was simple ligation. During

World War I, the American and British surgeons estimated

that the overall rate of vascular injury ranged from 0.4 to

1.3% [8]. In 1919, Makins [2] reported 45 subclavian artery

injuries amongst British casualties during World War I [1,

8]. A landmark study from Debakey and Simeone [10] in

1946 reported an incidence of less than 1%, accounting for

21 patients of 2,471 arterial injuries sustained by American

soldiers during World War II. During the Korean conflict,

Hughes [12], in a study of 304 major arterial vessel inju-

ries, reported only three subclavian artery cases. The rel-

atively few cases throughout the history of war may

account for exsanguination on the battle field. Penetrating

subclavian injuries comprised less than 1% of all vascular

injuries reported during the Vietnam conflict [11]. During

this time, 48 different surgeons treated this injury; only two

encountered this injury more than once, for a total of 68

reported cases. Rich [11] reported a total of 63 subclavian

artery injuries in the original report of the Vietnam

J. D. Sciarretta � J. A. Asensio (&) � T. Vu �F. N. Mazzini � J. Chandler � F. Herrerias �J. M. Verde � P. Menendez � J. M. Sanchez � P. Petrone �K. D. Stahl � H. Lieberman � C. Marini

Division of Trauma Surgery and Surgical Critical Care,

Dewitt–Daughtry Family Department of Surgery, Ryder Trauma

Center, University of Miami, 1800 NW 10 Avenue Suite T-247,

Miami, FL 33136-1018, USA

e-mail: jasensio@med.miami.edu

123

Eur J Trauma Emerg Surg (2011) 37:439–449

DOI 10.1007/s00068-011-0133-2

Vascular Registry for acute arterial vascular injuries during

the Vietnam conflict.

During the recent conflicts of Iraq and Afghanistan, the

overall rate of vascular injury was reported to be greater

than in previously reported conflicts [32]. This increase in

rate may be related to improved hemorrhage control, shorter

evacuation times, and improved survivability [32]. High-

velocity-type injuries from explosives and gunshot wounds

accounted for the majority of these injuries. Interesting, the

incidence of vascular injury was higher in Iraq than

Afghanistan (12.5 and 9%, respectively). White et al. [32]

identified 1,570 US troops in both Iraq and Afghanistan

that presented with wartime-related vascular injuries. Of

these, 12% resulted in vascular injuries of the torso, with

subclavian vessel injuries accounting for 2.3%. Over a

24-month period, Clouse et al. [33] identified 301 arterial

vascular injuries, of which 3.7% were due to subclavian–

axillary injury. Nevertheless, both the management and

treatment strategies have evolved from the various wars and

battlefields over the course of time (see Table 1).

Anatomy

The subclavian arteries have different origins according to

their anatomic location (right versus left). On the right,

the subclavian artery arises from the innominate artery

behind the right sternoclavicular articulation; on the left

side it originates directly from the arch of the aorta. The

subclavian artery is divided into three portions. The first

portion courses from the origin to the medial border of the

scalenus anterior. The second portion lies behind this

muscle, while the third portion courses from the lateral

border of the scalenus anterior up to the lateral border of

the first rib (see Fig. 1).

The first portion of the right subclavian artery arises

behind the upper part of the right sternoclavicular articu-

lation, and passes upward and laterally to the medial

margin of the scalenus anterior. It ascends a little above the

clavicle, with the extent to which it does this varying in

different cases. It is crossed by the internal jugular and

vertebral veins, by the vagus nerve and the cardiac bran-

ches of the vagus nerve, and by the subclavian loop of the

sympathetic trunk, which forms a ring around the vessel.

The anterior jugular vein is directed lateralward in front of

the artery, but is separated from it by the sternohyoid and

sternothyroid strap muscles.

The first portion of the left subclavian artery arises

behind the left common carotid, and at the level of the

fourth thoracic vertebra; it ascends in the superior medi-

astinum to the root of the neck and then arches lateralward

to the medial border of the scalenus anterior. Its anatomic

relations are as follows. In front: the vagus, cardiac, and

phrenic nerves, which lie parallel with it, the left common

carotid artery, the left internal jugular and vertebral veins,

and the commencement of the left innominate vein. It is

covered by the sternothyroid, sternohyoid and sternoclei-

domastoid muscles. The second portion of the left sub-

clavian artery lies behind the scalenus anterior. It is very

short, and forms the highest part of the arch described by

the vessel.

On the right side of the neck, the phrenic nerve is sep-

arated from the second part of the artery by the scalenus

anterior, while on the left side it crosses the first part of the

artery close to the medial edge of the muscle. Behind

the vessel are the pleura and the scalenus medi-

us; above, the brachial plexus of nerves; below, the pleura.

The subclavian vein lies below and in front of the artery,

separated from it by the scalenus anterior.

The third portion of the left subclavian artery runs

downward and lateralward from the lateral margin of the

Table 1 Military experiencesConflict Author(s) Total arteries Subclavian Incidence (%)

WWI Makins (1919) 1,191 45 3.8

WWII DeBakey & Simeone (1946) 2,471 21 0.9

Korea Hughes (1958) 304 3 1

Vietnam Rich (1970) 1,000 8 0.8

Afghanistan Sherif (1992) 224 Combined with axillary N/A

Fig. 1 Anatomy of subclavian vessels

440 J. D. Sciarretta et al.

123

scalenus anterior to the outer border of the first rib, where it

becomes the axillary artery. The external jugular vein

crosses its medial part and receives the transverse scapular,

transverse cervical, and anterior jugular veins, which fre-

quently form a plexus in front of the artery. Behind the

veins, the nerve to the subclavius muscle descends in front

of the artery. The terminal part of the artery lies behind the

clavicle and the subclavius muscle and is crossed by the

transverse scapular vessels. The subclavian vein is in front

of and at a slightly lower level than the artery. Behind, it

lies on the lowest trunk of the brachial plexus, which

intervenes between it and the scalenus medius. Above and

to its lateral side are the upper trunks of the brachial plexus

and the omohyoid muscle.

The branches of the subclavian artery are the vertebral,

internal mammary, thyrocervical and costocervical trunks.

On the left side, all four branches generally arise from the

first portion of the vessel; on the right side, the costocer-

vical trunk usually originates from the second portion of

the vessel. On both sides of the neck, the first three bran-

ches arise close together at the medial border of the sca-

lenus anterior. In the majority of cases, there is a free

interval of 1.25–2.5 cm between the commencement of the

artery and the origin of the nearest branch.

Incidence

Subclavian vessel injuries account for approximately 5% of

all vascular injuries [3, 4, 28]. Busy urban trauma centers

report admitting between two and four subclavian vascular

injuries per year, although some international trauma cen-

ters have reported admitting as high as four patients per

month [4, 5, 15, 24]. Subclavian artery injury specifically

accounts for 1–2% of all acute vascular injuries [3, 4, 8, 9,

26, 27]. While the majority of these injuries are penetrat-

ing, up to 25% are related to a blunt mechanism of injury

[14]. The low incidence of subclavian artery injury is pri-

marily explained by the anatomic location and the pro-

tective barrier provided by the clavicle and thoracic cage.

In a study combining both prospective and retrospective

reviews, Demetriades [9] reported that isolated subclavian

vein injuries were present in 44% of the patients, isolated

subclavian artery involvement in 39%, and combined

injuries in approximately 17% of the cases. On the other

hand, Lin et al. [23] reported that 24 of 54 patients pre-

senting with subclavian artery injuries also sustained

associated venous injuries.

The subclavian vessels are relatively well protected by

the overlying clavicle and first rib, but fractures to these

and other adjacent osseous structures may lead to serious

life-threatening injury. In one of the largest series pub-

lished, Natali reported a total of 10 patients with clavicle

fracture-induced injury [21]. The incidence of clavicular

fractures and associated subclavian vessel injury is esti-

mated to be less than 1% [35, 40]. Richardson [19] iden-

tified the first rib fracture as an useful indicator of severe

upper thoracic trauma. In this study, 55 patients with first

rib fractures were evaluated, of which 5.5% sustained

associated blunt subclavian artery injuries. A comparable

review by Phillips demonstrated similar findings in the

presence of displaced first rib fractures, with 9% presenting

with associated blunt subclavian artery injuries [20].

The majority of subclavian vessel injuries in the civilian

population result from penetrating trauma. Over the past

several decades, there has been a steady rise in firearm-

Table 2 Civilian subclavian

artery reportsCities Year Author Injuries

Louisville 1962 Cook 3

Memphis 1964 Pate & Wilson 12

Rochester 1968 Matloff & Morton 3

Chicago 1969 Amato 14

Houston 1970 Bricker 14

Baltimore 1970 Brawley 11

Durban 1978 Robbs 24

Johannesburg 1987 Demetriades 127

Johannesburg 1994 Degiannis 56

Houston 1999 Cox 56

Los Angeles 1999 Demetriades & Asensio 79

Durban 2000 McKinley 260

Atlanta 2000 Kalakuntla 25

Chicago 2003 Lin 54

Istanbul 2004 Aksoy 12

Houston 2008 Carrick 15

Subclavian vessel injuries 441

123

related injuries in the US as a result of increased civilian

use of weaponry. Several published series observed a

similarly low incidence of blunt versus a relatively high

incidence of penetrating injury across the globe [5–47].

Graham [4], who studied the largest civilian series, repor-

ted that 93 patients sustained subclavian artery injuries

over a 24-year period. Of these, only two resulted from a

nonpenetrating injury. Over a period of 10 years, a retro-

spective review by Lin [23] identified 54 patients with

penetrating subclavian artery injuries, of which 85%

resulted from gunshot wounds. Conversely, McKinley [24]

reported that 82% of subclavian artery injuries resulted

from stab wounds and 10% from low-velocity gunshot

wounds, a trend not appreciated in US regional trauma

centers (see Table 2).

On the other hand, blunt subclavian artery injuries occur

far less frequently. Urban trauma centers report that

approximately 1–3% of all traumatic subclavian artery

injuries result from blunt trauma [4–21]. The relatively low

incidence of blunt vascular trauma is due to the protected

anatomic location of the subclavian vessels. Both rapid

deceleration injury and bony fractures are responsible for

blunt injury of this artery. Not uncommonly, however, the

injury remains unrecognized secondary to normal physical

examination findings. In other cases, patients experience a

delay in symptoms after their initial injury, thereby post-

poning treatment.

Clinical presentation

Patients sustaining penetrating thoracic inlet injuries pre-

senting with hemodynamically instability should undergo

early intubation, judicious fluid resuscitation, and imme-

diate treatment of life-threatening injuries upon presenta-

tion. Contralateral upper extremity or lower extremity

intravenous access and orotracheal intubation should be

carried out in cases where cervical and/or mediastinal

swelling are present, resulting from expanding hematomas

caused by subclavian vessel injury [13].

In a retrospective study of subclavian vessel injury,

DeGiannis [31] reported that 50% of the patients in their

series presented with an initial systolic blood pressure

of \100 mmHg. Several published series confirm similar

hemodynamic findings consistent with hypovolemic shock

upon presentation [18, 24, 30]. In the experience of

Agarwal [18], profound shock was present in 80% of those

who sustained injury to both the subclavian artery and vein.

The unstable patient in hypovolemic shock who is unre-

sponsive to resuscitation should be transported immedi-

ately to the operating room.

Any penetrating injury to the subclavian artery with

pulsatile bleeding should be controlled with direct external

compression. When possible, manual compression should

be continued until primary vascular control in the operating

room is achieved. In cases of penetrating retroclavicular

injuries, direct pressure may not be effective, and thus

balloon tamponade may be a life-saving option [39]. In a

combined retrospective and prospective study, Demetri-

ades [9] reported active bleeding from the wound in 65% of

the patients upon initial evaluation, along with findings of

shock in 72%. More than 20% of patients with subclavian

or axillary vascular injuries reach the hospital with no vital

signs or with imminent cardiac arrest as a result of exan-

guinating blood loss [39]. Of note, associated intrathoracic

injuries are also found in about 28% of these patients [39].

Once the airway is secured, these patients should undergo

immediate Emergency Department thoracotomy (EDT) on

the side of injury; if necessary, the incision may be

extended to the opposite side.

McKinley et al. [24] reported a prospective study of 260

patients, among whom approximately 25% with subclavian

artery injuries had minimal symptoms and delayed com-

plications, prompting the patients to seek medical advice.

In a series reported by Lim et al. [15], only 24% of the

patients had a pulse deficit. Apparent soft tissue ecchy-

mosis and hematoma at the base of neck and upper chest

can be a diagnostic clue during physical examination.

Other characteristic findings of brachial plexus palsy, arm

swelling, pulsatile hematomas or bruit may indicate trau-

matic arteriovenous fistula.

Diagnosis

Early diagnosis of a subclavian vessel injury is essential.

Physical examination findings of a subclavian arterial

injury may be more subtle than obvious pulsatile bleeding

as seen with penetrating wounds. Other concomitant inju-

ries adjacent to the subclavian vessels are highly suspicious

for a neurovascular injury. Neurologic deficits of the upper

extremity, overlying bruits, decreased or absent pulses in

the brachial, radial or ulnar arteries, and ipsilateral clavicle

or rib fracture are diagnostic clues. The clinical diagnosis

may be obvious, with a comprehensive vascular exam

revealing a cool, pulseless, and pale upper extremity.

Specific signs of subclavian artery injury may also include

expanding or pulsatile hematomas in the supraclavicular

space or the axilla, as the hematoma dissects along the

neurovascular sheath. Brachial plexopathy can also be a

reliable predictor of underlying subclavian injury [34].

Radiographic investigations should only be performed

in hemodynamically stable patients. In these cases, an

initial plain chest X-ray is completed without delay. Gra-

ham [4] reported that 16% of their 93 patients with pene-

trating subclavian injuries had radiographic evidence of

442 J. D. Sciarretta et al.

123

mediastinal widening. Injuries to the proximal portions of

the subclavian vessels may present with massive hemo-

thorax and mediastinal widening on chest X-ray. Other

diagnostic investigations include obtaining a simple ankle

brachial index (ABI) in patients that are hemodynamically

stable; an ABI of less than 0.9 is considered abnormal and

believed diagnostic or suspicious for underlying arterial

injury. However, normal ABI indices may result even in

the presence of a subclavian arterial injury, due to the rich

collateral circulation from this vessel.

Color flow Doppler (CFD) studies are an additional

noninvasive technique for assessing subclavian vessel

injury. Unfortunately, CFD studies can be suboptimal in

those with a large body habitus, and are also limited in their

views of the aortic arch, innominate vessels, and left sub-

clavian artery. Readily available spiral CT scans with

intravenous contrast have become a favorable option in

identifying vascular injuries. CT angiography is a potential

alternative in selected cases, avoiding conventional angi-

ography in 85% of the cases [46].

The value of emergent angiography is restricted and

should only be entertained for hemodynamically stable

patients after appropriate resuscitation. Ideally, the surgeon

should accompany the patient to the angiography suite. If

acute decompensation occurs, the angiogram should be

aborted, and the patient transferred to the operating room.

Positive studies without clinical exam findings may war-

rant surgical exploration of the affected segment, as in

cases of intimal dissection, pseuodoaneurysm, and/or

contained transection. Many advocate the routine use of

angiography with subclavian artery injuries. Precise sur-

gical planning and the identification of additional arterial

injuries support these views.

In Graham’s series [4], 20% of concomitant arterial

injures were identified by angiography. Nevertheless, color

flow Doppler and CT angiography are now more frequently

utilized than conventional angiography. Angiography,

however, remains the ‘‘gold standard,’’ and should be

reserved for those without any evidence of hemodynamic

compromise.

Surgical management

The operative approach for subclavian vessel injury

requires great familiarity with the local anatomy. The basic

vascular surgical principles of proximal and distal control

are imperative. Historically, a variety of classical operative

exposures have been described for the management of

subclavian artery injuries. The surgical approach is dictated

by the clinical presentation and site of injury. The patient is

initially placed in the supine position, with the ipsilateral

arm abducted at 30� and the head turned away from injury.

Fig. 2 Clavicular incision with clavicle removal to expose sub-

clavian vessels for a gunshot wound

Fig. 3 Thrombosed right subclavian artery post gunshot wound

Fig. 4 Polytetrafluoroethylene (PTFE) 8 mm graft

Subclavian vessel injuries 443

123

A clavicular incision is planned, with the initial incision

made in the region of the sternoclavicular junction and

extending over the medial half of the clavicle, and, if

necessary, continuing onto the deltopectoral groove (see

Figs. 2, 3, 4, 5). Adjacent muscle attachments are stripped

off the clavicle to better facilitate upward retraction. Cla-

vicular resection and disarticulation of the sternoclavicular

joint are surgical techniques that offer additional exposure

to proximal injuries. Henly subclavian clamps are useful

for providing proximal and distal control (see Fig. 6).

A median sternotomy with cervical extension also

provides optimal control of proximal right subclavian

injuries [39]. Well described, but not recommended nor

used often nowadays, is the ‘‘trapdoor’’ incision, which

allows for exposure to the first and second parts of the left

subclavian artery. The components of this approach

include a clavicular incision, limited median sternotomy,

and an anterolateral thoracotomy. This exposure is

advantageous only for left subclavian injuries, not right,

because of the vessel’s posterior location. These described

surgical approaches are individually selected on a case-by-

case basis and according to each surgeon’s overall

experience.

Traditionally, the operative management of subclavian

artery injury includes ligation, primary repair, or interpo-

sition graft. The vascular repair chosen is influenced by the

degree and level of injury. Ligation should be reserved for

those who are unstable with multiple life-threatening

associated injuries, extensive shoulder trauma, or infected

Fig. 5 Doppler probe being utilized to ascertain flow and velocity

postrepair

Fig. 6 Henly subclavian clamps (arrows)

Fig. 7 Young female that sustained a stab wound to the left thoracic

inlet. Arrived in cardiopulmonary arrest. Required left anterolateral

thoracotomy and open CPR. In the OR she required median

sternotomy and supraclavicular incision to control a left subclavian

arterial injury. Clamps are providing proximal and distal control

Fig. 8 Partial transection of the left subclavian artery in the previous

patient. Required resection and interposition graft with autogenous

reversed saphenous vein graft

444 J. D. Sciarretta et al.

123

or ruptured aneurysm [14, 24]. Anatomically, extensive

collateral flow through the thyrocervical trunk permits the

safe ligation of the subclavian arteries [36]. Arterial

reconstruction should, however, be attempted whenever

feasible. Occasionally, temporary shunting can be used

with the intention of arterial repair at a later stage.

Stab wounds can sometimes be managed appropriately

with debridement and repair (see Figs. 7, 8). Simple lateral

arteriorrhaphy is the preferred technique in the appropriate

setting, but this method can only be used 20% of the time

(see Figs. 9, 10, 11) [3]. Ligating multiple arterial branches

may provide additional length during primary repair, but

considerable mobilization should be performed cautiously,

as these branches provide an extensive collateral network

to the upper extremity. On the other hand, gunshot wounds

generally cause significant blast injury and usually require

an interposition graft (see Figs. 12, 13). Autogenous

reverse saphenous vein or prosthetic grafts with end-to-end

anastomosis following debridement is one of the conven-

tional methods utilized with arterial injury. Prosthetic

grafts can be safely used with acceptable outcomes due to

Fig. 9 Gunshot wound: right infraclavicular area

Fig. 10 Segmental resection of the injured right subclavian artery

Fig. 11 Repaired with an autogenous reverse saphenous vein graft

Fig. 12 Gunshot wound: right subclavian artery. Vessel debridement

and resection

Fig. 13 6 mm polytetrafluoroethylene (PTFE) graft inserted

Subclavian vessel injuries 445

123

their reported low incidence of graft infection (see

Figs. 14, 15, 16) [37, 38]. At the same time, prosthetic

grafts offer expedient repair compared to the delay asso-

ciated with autologous vein harvesting. Lateral venorrha-

phy should be attempted for subclavian venous injuries if it

does not cause significant luminal narrowing (see Fig. 17).

If it is not feasible, simple ligation is acceptable with little

morbidity [3, 39].

Recent advancements in endovascular techniques have

provided another viable option to those who are poor sur-

gical candidates and those who meet strict select criteria.

Minimally invasive approaches to subclavian artery injuries

are well documented and are promising alternatives in the

management of these injuries. Carefully selected patients,

such as those with arterial stenosis, false aneurysms or

arteriovenous fistulas, may be managed with catheter-based

stent grafts by interventional services. Definitive catheter-

based repairs by stent grafts are, unfortunately, not without

consequence. At this time, however, endovascular repair

does not appear to be superior to traditional surgical ther-

apy, although it does remain an alternative option for very

carefully selected patients. Similarly, there are no reported

data on their long-term outcome (see Table 3).

Morbidity

Delay in diagnosis, complicated operative exposure, and

associated injuries are all contributing factors influencing

the patient’s overall morbidity at the time of admission.

Hemodynamic compromise on arrival to the hospital also

corresponds to higher morbidity and longer hospitaliza-

tions, as demonstrated in Kalakuntla’s [30] 6-year

Fig. 14 Blunt injury to right subclavian artery (A) at take-off of

brachiocephalic trunk (B). C Origin of the right common carotid

artery

Fig. 15 Resected segment of the subclavian artery. Intimal flap is

seen

Fig. 16 8 mm polytetrafluoroethylene (PTFE) interposition graft

from the origin of the right subclavian artery (A). B Brachiocephalic

trunk

Fig. 17 Lacerated left subclavian vein

446 J. D. Sciarretta et al.

123

retrospective review of managing subclavian artery inju-

ries. The morbidity and mortality with subclavian artery

injuries is greatly influenced by the number of concomitant

injuries. In penetrating wounds, the severity of the injury

correlates with the location, and for cases of gunshot

wounds, the velocity of the missile. Neighboring structures,

particularly the subclavian vein, brachial plexus, lung,

clavicle and first rib, are most susceptible to injury.

Generally, the long-term morbidity of subclavian artery

injury is closely linked to the presence of associated bra-

chial plexus injuries. Brachial plexus symptoms have

resulted in debilitating ipsilateral neurosensory deficits

from contusion or crush (direct trauma) and traction injury.

In Graham’s [47] series of 65 patients, associated brachial

plexus injuries were observed in 35% of the patients. A

similar finding of 43% was reported by Johnson [34]. In

this series, they identified 83% of partial brachial plexus

injuries on follow-up, demonstrating some functional

improvement, indicating that neuropraxia was the initial

deficit. Unfortunately, cases of complete brachial plexus

transection and secondary nerve repair may only return

minimal functional improvement and render the patient

with permanent functional disability.

Known vascular complications such as thrombosis, graft

infection, and aneurysm formation are familiar postopera-

tive drawbacks. At the same time, postponement of medi-

cal attention following injury with symptoms of arm

paralysis may occur due to a large false aneurysm com-

pressing the brachial plexus. These patients met with poor

outcomes despite intervention [24, 42]. In the cases of

venous ligation, Demetriades and Asensio [39] observed

transient swelling of the upper extremity, but no significant

venous-related complication. Elevation of the affected

extremity over a course of several days results in consid-

erable improvement. Clavicular division also has the

potential for debilitating consequences such as osseous

malunion, pseudoarthrosis, and osteomyelitis [24].

Other complications in the management of subclavian

vessel injury may predispose the patient to local surgical

wound infections, coagulopathy, massive transfusions,

thoracic duct injury, and air embolism. The risk of pros-

thetic graft infection also exists, but remains low, with long-

term graft patency rates of 94% [38]. Scapulothoracic dis-

sociation, although rare, is without question a devastating

injury that results from high-energy trauma. A constellation

of injuries includes clavicular fracture or dislocation,

avulsed shoulder muscles, and neurovascular damage. In

cases of absent brachial plexus function, vascular recon-

struction should not be attempted, and the arm should be

amputated below the shoulder [40].

Outcomes and mortality

Both penetrating trauma and occasionally blunt trauma to

the subclavian vessels can result in significant blood loss

and hemorrhagic shock prior to presentation. Select

patients that have short transport times and hemorrhage

control by contained hematoma or thrombosis experience

improved hemodynamic status upon arrival and thus have

better survival rates. In-hospital mortality ranges from 5 to

35% with penetrating injuries, which is higher than for

blunt trauma [4, 6, 7]. The reported overall mortality ran-

ges from 39 to 80%, with the majority succumbing prior to

arrival at the hospital [9, 14, 23, 24]. This unfortunate

statistic is directly related to exsanguination or associated

head trauma in cases of blunt injury [9, 14]. The series of

McKinley et al. [24] confirms these findings, and also

details a post mortem evaluation of violent deaths over

4 years, documenting 135 deaths resulting from isolated

injury to the subclavian artery and exsanguination.

The reported operative mortality in published civilian

series ranges from 4.7 to 30% [4, 9, 15, 28, 30, 44], with

higher mortality rates seen for combined subclavian artery

and vein injuries. In a large series of 228 penetrating

subclavian vessel injuries, 61% of the patients were dead

on arrival [9]. In these series, venous injuries led to a

higher mortality rate than arterial injuries: 82 and 60%,

respectively. Similar findings were found in another pub-

lished series of 20 patients, where isolated subclavian vein

injuries resulted in a mortality rate of 50% [39]. This may

be due to possible venous embolus or ongoing bleeding

from venous injury without the vasoconstrictive effects of

arterial injuries [39].

The morbidity and mortality associated with subclavian

artery injuries is greatly influenced by the number of

associated injuries. Lin [23] reported that patients with

three or more associated injuries incurred a mortality rate

Table 3 Results of subclavian

artery repairAuthor Year Injuries Repairs Complications Amputations Deaths

Amato 1969 14 13 0 0 0

Bricker 1970 14 11 0 0 3

Rich 1970 8 7 1 0 0

Drapanas 1970 16 0 0 1 4

Perry 1971 23 0 0 0 1

Subclavian vessel injuries 447

123

of 83%, versus 17% for those with isolated subclavian

artery injuries. At the same time, those presenting with

hypotension had a much higher mortality of 57, versus 18%

for nonhypotensive patients.

Conclusions

The rarity of traumatic subclavian vessel injuries prevents

many trauma surgeons or trauma centers from developing

substantial experience of their management. These injuries

are associated with significant morbidity and mortality.

Patient that survive transport are subject to potentially

debilitating injury and possibly death. Management of

these injuries varies, depending on hemodynamic stability,

mechanism of injury, and associated injuries. Despite sig-

nificant advancements, mortality from subclavian vessel

injury remains high.

Conflict of interest None.

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