Surgical management of subclavian artery injury.

During a 10 year period, we have had operative experience with 13 injuries to the subclavian artery. The factors that led to the successful management in 10 consecutive patients were analyzed. Nonspecific signs, such as pain and swelling, were present in all of the patients. Some aspect of vascular injury was present in each patient and included change in the quality of the distal pulse, hematoma, active hemorrhage, and bruit. Roentgenologic signs such as lung opacification, fractured clavicle, fracture of the first or second rib, and pulmonary opacification were present in each patient. Arteriograms were obtained from all stable patients in whom this injury was suspected. There were no false-positive or false-negative findings. The operative approach for the right subclavian vessels was midline sternotomy, whereas for exposure of proximal left subclavian injuries, anterolateral thoracotomy was utilized. Claviculectomy permitted excellent exposure for distal subclavian artery injuries. This exposure was associated with minimal blood loss and permitted direct repair of complex injuries of the arteries and veins. All patients who reached the emergency room with measurable vital signs survived, and all those who underwent subclavian vascular repair had circulation restored. Principal morbidity was due to associated brachial plexus and lung injuries. A high index of suspicion, rapid transportation, aggressive resuscitation, and proper surgical exposure and repair are essential for the successful management of these rare vascular injuries.