A 10-year review of penetrating subclavian artery injury at a major trauma center in South Africa.

Abstract

Penetrating subclavian artery injuries are uncommon but notoriously difficult to manage. Heterogeneity in clinical features, hemodynamic stability, and injury patterns make timely diagnosis challenging. Open surgical repair is technically demanding owing to the vessel's location and carries high morbidity and mortality. Advancements in imaging, treatment modalities, and perioperative care alter the spectrum and management of such injuries and warrant ongoing evaluation. We performed a retrospective review of all cases over a 10-year period. Consecutive patients with penetrating subclavian artery injury confirmed on CTA or intraoperatively were included. Demographics, injury patterns, investigations, operative record, and clinical outcome were recorded. We included 53 patients. There were 51 males (96%) with a mean age of 20 years (range, 19-59 years). The mean injury severity scale and revised trauma score on presentation were 14 (range, 1-36) and 7.8 (range, 6-8), respectively. Thirteen patients (24%) had hard signs of arterial injury, 20 (38%) had soft signs only, and the remainder had no signs. Six patients (11%) had an inflated Foley catheter balloon in situ, five of whom were subsequently stable enough for imaging. Almost all patients (96%) proceeded to CTA on presentation, with the most common findings being intimal injury (47%) and pseudoaneurysm (33%). Twenty-two patients (42%) were treated with open surgery, 8 (15%) with endovascular stenting, and the remainder conservatively with anticoagulation. There were no recorded cases of limb loss or in-hospital mortality. The management and assessment of penetrating subclavian artery injuries has changed substantially over the years. Liberal use of the CTA identifies lower-grade intimal injuries that would have previously been missed, altering the injury profile seen in practice. Endovascular stenting offers an attractive alternative to open surgery with lower morbidity. The use of judicious resuscitation and techniques to control noncompressible junctional hemorrhage reduce the proportion of patients that require emergent surgery. Continued evaluation is required to refine treatment protocol and optimize outcomes across the changing spectrum of penetrating subclavian artery injuries.