Feasibility of endovascular repair in penetrating axillosubclavian injuries: A retrospective review

Background

Penetrating injuries to the axillary and subclavian vessels are a source of significant morbidity and mortality. Although the endovascular repair of such injuries has been increasingly described, an algorithm for endovascular versus conventional surgical repair has yet to be clearly defined. On the basis of institutional endovascular experience treating vascular injuries in other anatomic locations, we defined an algorithm for the management of axillosubclavian vascular injuries. Subsequently, a near decade long experience with the management of axillosubclavian vascular injuries was retrospectively analyzed, so as to more accurately assess the true feasibility of endovascular treatment in these patients.

Methods

We defined a management algorithm that included (1) indications, (2) relative contraindications, and (3) strict contraindications for the endovascular repair of axillosubclavian vascular injuries. Anatomic indications for endovascular repair were restricted to relatively limited axillosubclavian injuries (pseudoaneurysms, arteriovenous fistulas, first-order branch vessel injuries, intimal flaps, and focal lacerations). Relative contraindications for endovascular repair included injury to the axillary artery’s third portion, substantial venous injury (eg, transection), refractory hypotension, and upper extremity compartment syndrome with neurovascular compression. Strict contraindications to endovascular repair included long segmental injuries, injuries without sufficient proximal or distal vascular fixation points, and subtotal/total arterial transection. Within the context of these definitions, we retrospectively reviewed 46 noniatrogenic subclavian and axillary vascular injuries in 45 patients identified by a prospectively maintained computer registry during a 9-year period. Presentations were reviewed concurrently by two endovascular surgeons, and potential candidates for endovascular management were defined.

Results

Among 46 total case presentations and among the 40 patients who maintained vital signs on presentation, 17 were potentially treatable with endovascular therapy. Among the cohort of 40 presentations, the most common contraindications to endovascular therapy were hemodynamic instability (n = 10), vessel transection (n = 7), and no proximal vascular fixation site (n = 3).

Conclusions

Despite growing enthusiasm for endovascular repair of injuries to the axillary and subclavian vessels, realistic clinical presentation and anatomic locations restrict the broad application of this technique at present. In our experience, less than but approaching 50% of all injuries encountered could be addressed with an endovascular approach. This percentage will increase during the upcoming decades if the endovascular technologies available in hybrid endovascular operating rooms uniformly improve.