Challenging Case

Subclavian Artery Gunshot Repair

By CHARLES B. ROSS, MD, AND CARL M. JOHNSON, MD
 

CASE PRESENTATION
A 21-year-old white male presented by EMS transport to the ER with a through-and-through, .380-caliber gunshot wound entering the chest at the inferior level of the right sternoclavicular joint and exiting posteriorly at midscapular level. He was hypotensive at the scene, and IV fluid resuscitation was initiated. On arrival, he had regained hemodynamic stability with a BP of 159/96 and a heart rate of 74 BPM.

The patient’s body habitus was large and muscular. He complained of pain in the chest and right shoulder and numbness of his right arm. Axillary, brachial, and radial pulses were not palpable. Soft, monophasic Doppler signals were present over the brachial and radial arteries. Grip strength and wrist and forearm flexion were diminished. A chest x-ray demonstrated widening of the superior mediastinum extending into the right supraclavicular region, volume loss in the right lung, and elevated right hemidiaphragm.

HOW WOULD YOU PROCEED?
1. Would you take the patient to the radiology suite for a diagnostic arteriogram or computer-tomographic angiogram (CTA)?
2. Would you take the patient directly to the operating room for treatment?

ANGIOGRAPHIC FINDINGS
We obtained percutaneous right femoral access. Selective innominate (Figures 1 and 2), right subclavian, and right vertebral arteriograms demonstrated disruption of the right postvertebral subclavian artery with contained extravasation and a large arteriovenous fistula at the confluence of the right internal jugular and subclavian veins. The right vertebral and internal mammary arteries were uninjured.

COURSE OF ACTION
We brought the patient to the operating endovascular suite for both diagnostic and definitive management of his vascular injuries. We induced general endotracheal anesthesia and positioned the patient supine, with his right chest and shoulder slightly elevated, neck hyperextended, and right arm extended on a radiolucent arm board. The chest, neck, shoulder, axilla and right arm as well as right groin and thigh were prepped and draped.

We exposed the right brachial artery by cutdown. Next, we passed a 300-cm, 0.035-inch, J-tip guidewire and a 5F glide-catheter (Terumo Medical, Inc., distributed by Boston Scientific Corporation, Natick, MA) from the brachial artery and guided it across the subclavian arterial defect into the innominate artery, where we secured the guidewire with a 2.5-cm Amplatz Goose Neck Snare catheter (ev3, Inc., Plymouth, MN). We directed the catheter and wire into the descending thoracic aorta, and then withdrew the wire through the right femoral sheath. The sheath was exchanged for a 90-cm, 7F Brite Tip sheath (Cordis Endovascular, a Johnson & Johnson company, Miami, FL) positioned in the distal innominate artery. Thus, we achieved single-guidewire, bidirectional access to the site of injury. At this point, we induced systemic anticoagulation with 5,000 units of intravenous heparin.

We advanced a 12-mm X 50-mm Wallgraft (Boston Scientific) in bareback retrograde fashion from the brachial artery and positioned it across the subclavian arterial disruption. Precise deployment of the Wallgraft was aided by antegrade contrast injections through the proximal sheath (Figure 3). A small amount of extravasation was still observed after simple deployment (Figure 4). We performed angioplasty utilizing a 10-mm X 20-mm peripheral balloon catheter to ensure adequate opening of the stent-graft. We left the balloon inflated within the Wallgraft across the level of arterial disruption at full profile for approximately 3 minutes (Figure 5).
Completion arteriograms showed resolution of extravasation, complete closure of the AV fistula, and excellent restoration of flow into the axillary artery (Figure 6). Femoral closure was achieved with Perclose (Abbott Laboratories, Abbott Park, IL), while the brachial artery was surgically repaired. Intraoperative cardiology consultation was obtained for transthoracic echocardiography, which ruled out occult intrapericardial injury. We woke the patient in the endovascular operating suite, extubated him, and brought him to the ICU for observation.
Water-soluble contrast swallow, performed to rule out occult esophageal injury, was negative. A CT scan showed only moderate brachial plexus hematoma. Surgical consultants elected not to explore, as the brachial plexus dysfunction appeared more likely to be caused by direct trauma than compression by hematoma. A fluoroscopic sniff test confirmed paralysis of right hemidiaphragm due to phrenic nerve injury. The patient’s upper extremity segmental pressure and Doppler examinations were normal.

OUTCOME
The patient’s length of hospital stay was 4 days, during which we initiated physical therapy. No blood transfusions were required. A follow-up CTA at 6 weeks showed resolution of hematoma with a widely patent Wallgraft. Because the Wallgraft crosses the lateral border of the first rib and may be subjected to mechanical stresses over time, this patient will require long-term vascular follow-up. We also recommended indefinite baseline antiplatelet therapy with one 325-mg aspirin daily. The patient continues to undergo physical and occupational therapy for his right arm and hand.
The surgical approach to penetrating injuries involving the subclavian artery has many permutations and has been a source of controversy for decades.1 Median sternotomy with clavicular extension is generally recommended for right subclavian injuries, whereas anterolateral thoracotomy, with or without clavicular extension, has been used on the left. Difficult left-sided injuries are occasionally approached through a trapdoor incision, which includes anterolateral thoracotomy, sternotomy, and clavicular extension.

The necessity for wide anatomic exposure in a traumatized, actively bleeding field with closely associated major nerves represents one of the greatest operative challenges in the surgical management of vascular trauma. The injuries are morbid and potentially life- and limb-threatening, yet difficult surgical exposures may actually compound the morbidity. This scenario demands an endovascular alternative to the traditional surgical approach.

In 1991, Becker et al first described endovascular repair of a subclavian artery injury.2 Since then, multiple cases and small series have been reported. Hilfiker et al noted technical and clinical success in the placement of intraluminal stent-grafts in all nine of their own cases and in 95.5% of 22 cases they reviewed from published reports.3 In long term follow-up, however, mechanical compression at the thoracic outlet resulted in many problems including stent fracture, deformation, and thrombosis. Two out of nine patients in the series presented by Hilkifer et al and three of the 22 patients they reviewed from the literature experienced such late complications. Although newer stent-graft designs offered by the Wallgraft and Viabahn (W.L. Gore, Inc., Flagstaff, AZ) devices may theoretically reduce the likelihood of late complications, long-term follow-up and antiplatelet therapy seem prudent for patients who have subclavian arterial intraluminal stent-grafts.

Dual access via the brachial and femoral arteries with a single guidewire facilitates precise stent placement within the innominate and right subclavian arteries. This is a simple extension of the through-and-through technique for recanalization of occluded iliac arteries first reported in 1988 by Gaines and Cumberland.4 In the present case, we were able to maintain patency of both the vertebral and internal mammary arteries through puffed, antegrade contrast injections while deploying the Wallgraft from a brachial approach. Brachiocephalic to femoral, bidirectional, single-guidewire techniques are safe as long as the guidewire is covered with a catheter or sheath to protect the aortic arch and great vessels during guidewire and device manipulations. The additional femoral or brachial access adds little to the morbidity of the procedure, while greatly facilitating precise placement of intraluminal devices in the innominate and right subclavian arteries.

We elected to take this patient directly to the endovascular operating suite and to proceed under general anesthesia in order to maximize our options for managing his injuries. We felt it was prudent to be ready to proceed with median sternotomy for proximal control of the subclavian artery immediately, should hemodynamic instability return.

Our vascular center provides a dedicated endovascular operating suite located in the surgery department. The suite includes a radiolucent table (International Surgical Systems, Phoenix, AZ), a dedicated OEC 9800 C-arm with a 12-inch image intensifier and vascular software package from General Electric (Milwaukee, WI), a power injector for contrast studies (MedRad, Inc., Indianola, PA), and an extensive inventory of interventional devices and equipment. Such a facility greatly improves the conduct of combined open and endovascular cases and adds a layer of safety to those procedures in which preparation for expeditious conversion from an endovascular to an open approach is deemed prudent.

Endovascular repair of traumatic injuries to the subclavian artery represents a preferred alternative to traditional surgical approaches. Referral centers caring for patients with traumatic vascular injuries should have commercially available stent-grafts on hand and endovascular specialists and facilities readily available to implement these techniques.

Charles B. Ross, MD, is Medical Director of the Lourdes Vascular Center at Lourdes Hospital in Paducah, Kentucky and Clinical Assistant Professor of Vascular Surgery at Vanderbilt University in Nashville, Tennessee. He holds no financial interest in any of the products mentioned herein. Dr. Ross may be reached at (800) 599-7874; cbrvsurg@apex.net.
Carl M. Johnson, MD, practices cardiothoracic surgery at Western Kentucky Heart and Chest Surgery Associates, PSC in Paducah, Kentucky. He holds no financial interest in any of the products mentioned herein. Dr. Johnson may be reached at (270) 443-5564.

1. Ernst CB. Exposure of the subclavian artery. Semin Vasc Surg. 1989;2:202-08.
2. Becker GJ, Benenati JF, Zemel G, et al. Percutaneous placement of a balloon-expandable intraluminal graft for life-threatening subclavian arterial hemorrhage. J Vasc Intervent Radiol. 1991;2:225-229.
3. Hilfiker PR, Razavi MK, Kee ST. Stent-graft therapy for subclavian artery aneurysms and fistulas: Single-center mid-term results. J Vasc Intervent Radiol. 2000;11:578-584.
4. Gaines PA, Cumberland DC. Wire-loop technique for angioplasty of total iliac occlusions. Radiology. 1988;168:273-274.

 

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