The subclavian arteries are protected by the skin, the clavicle, the superficial fascia, platysma, the supraclavicular nerves, and deep cervical fascia.
This type of injury will not be discussed in this review. Iatrogenic injury of the subclavian artery can also occur due to a failed central venous catheter placement attempt. Subclavian artery injuries from penetrating trauma are associated with an increased mortality rate, whereas blunt trauma has a higher morbidity rate due to injury to surrounding structures. In blunt trauma, complete brachial plexus injuries are more common, usually secondary to a fall on an outstretched hand. Associated injuries also vary by mechanism. Penetrating trauma more commonly results in the formation of a pseudoaneurysm. While blunt mechanisms are less common than penetrating, subclavian artery injuries caused by blunt trauma are being reported in the literature more frequently due to the increasing use of imaging for diagnosis. Further prospective study is needed to validate this proposed redefinition of categorization of presentations of extremity arterial injury.Ĭopyright © 2020 American Association for the Surgery of Trauma.Due to the protected anatomic location of the subclavian vessels, most subclavian artery trauma is usually caused by a penetrating mechanism secondary to firearm injuries or knife wounds. A strategy of using hemorrhagic and ischemic signs of vascular injury is of greater clinical utility. Hard signs have limitations in identification and characterization of extremity arterial injuries. There was no difference in amputation rate, reintervention rate, hospital length of stay, or mortality in comparing groups who underwent CTA versus exploration. Patients with ischemic signs undergoing exploration for diagnosis received more units of packed red blood cells during the first 24 hours. Hemorrhagic signs were associated with arterial transection, while ischemic signs were associated with arterial occlusion. Of the 490 patients presenting with ischemic signs, CTA was performed 31.6% of the time and was associated with higher rates of EHR and observation. Of 915 patients presenting with hemorrhagic signs, CTA was performed 14.5% of the time and was associated with a higher rate of EHR and observation. Patients undergoing CTA were more likely to undergo endovascular or hybrid repair (EHR) (10.7%) compared with patients who underwent exploration for diagnosis (1.5%). Computed tomography angiography (CTA) was more commonly used as the diagnostic modality in patients without hard signs, while operative exploration was primarily used for diagnosis in hard signs. Of 1,910 cases, 1,108 (58%) had hard signs of vascular injury.
We propose that hard signs are outdated and that hemorrhagic and ischemic signs of vascular injury may be of greater clinical utility.Įxtremity arterial injuries from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry were analyzed to examine the relationships between hard signs, ischemic signs, and hemorrhagic signs of extremity vascular injury with workup, diagnosis, and management. Despite advances in management of extremity vascular injuries, "hard signs" remain the primary criterion to determine need for imaging and urgency of exploration.