British Jourtiul o / Surgery 1994.

81,524-526

Penetrating injuries of the subclavian vessels

E . D E G I A N N I S , G. V E L M A H O S , D. K R A W C Z Y K O W S K I , R. D. LEVY, I . S O U T E R and R . SAADIA
Dcportriicnt of Surgcvy, Baragwanuth Hospital and University of the Witwatersrand, Johannesburg, South Africa
~ ‘ i J r ~ e ~ p [ ~ tto: R. Saadia. Department of Surgery. Medical School, 7 York Road, Parktown, 2193 Johannesburg, South Africa
i ~ ~Proliwor
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A s t u d y was made of 76 patients with subclavian vessel
injury. The mechanism of trauma was stabbing in 40
patients (53 per cent) and gunshot in 36 (47 per cent). There
were marked differences between the two groups in clinical
presentation, operative management and outcome. The
group with gunshot injury was characterized by a more
immediate threat to life, and a greater need for a median
sternotomy and use of interposition grafts. The mortality
rate in patients with gunshot wounds was more than twice
that in the group with stab injury.

Experience at Baragwanath Hospital of the management of 90
patients with subclavian vessel injury was reported’ in 1987;
98 per cent of these wounds were inflicted by a knife. The
admission t o the hospital of 3000 patients with gunshot wounds
in 1992 alone bears witness t o the recent dramatic increase in
the use of firearms in civilian violence. The aim of the present
study was to identify differences in presentation, surgical
management a n d outcome between stab a n d gunshot injury to
the subclavian vessels.
Patients and methods
A rctrospective study was performed over a period of 3 years between
1990 and 1992. Seventy-six patients with subclavian vessel injury were
treated during this period. All except three were male; the mean age
was 31 years. The mechanism of injury was stabbing in 40 patients
(53 per cent), while the remaining 36 (47 per cent) were victims of
gunshot wounds. The injury was right-sided in 21 patients with gunshot
wounds and in only I 1 stabbed patients, perhaps because most of the
assailants were right-handed. Right-sided injuries to the hrachiocephalic
trunk were excluded from the study.
Gwrrul n i u ~ ~ a g m ~ ~ ~ r i t
Initial resuscitation and investigations were conducted along Advanced
Trauma Life Support principlesz. A few points bear emphasis. An
emergency room thoracotomy was performed after endotracheal
intubation in patients who sustained a cardiac arrest within a few
minutes of admission. In patients with external bleeding direct
compression was applied and. in some cases, a Foley catheter inserted
into the wound in an attempt to tamponade the source of bleeding
with the inflated halloon3. The Trendelenburg position was used
whenever possible to decrease the risk of air embolism. In the majority
of cases the diagnosis was clinically obvious. Cervical spine and chest
radiography was performed only in haemodynamically stable patients.
An ipsilateral intercostal chest drain was inserted on the slightest clinical
suspicion in unstable patients or as required on completion of chest
radiography. Angiography was reserved for stable patients with
equivocal clinical or radiographic findings. Perioperative antibiotic
therapy consisted of intravenous cephazolin. This was started
immediately before operation and continued for 48 h after surgery
unless a synthetic graft was used, in which case the antibiotic was
prescribed for at least 7 days.
a stab wound) could be resuscitated and taken to the operating theatre.
Table 1 outlines the clinical presentation of the 76 patients.
Surgical managenient
The operative approach consisted of either a clavicular incision alone,
with division of the clavicle or disarticulation of the sternoclavicular
joint, or a clavicular incision associated with a median sternotomy.
Soft tissue debridement was reserved for patients with gunshot wounds;
it was performed meticulously in those with a suspected high-velocity
bullet injury. The operative approach in stab-inju: < patients was a
clavicular incision alone in 32 with an additional median sternotomy
in six. In the group with gunshot wounds, the clavicular incision alone
and associated with a median sternotomy were performed in seven and
24 patients respectively. In one patient a ‘trapdoor’ incision was first
performed. but it afforded poor exposure of the left subclavian artery
and had to be converted to a full median sternotomy. The injured
structures and type of procedure performed are described in Tables2
and 3. One of the two brachial plexus injuries in the group with stab
wounds was repaired primarily: no neural repair was undertaken
primarily in patients with gunshot injury. There were no patients in
this series with injury so extensive as to warrant primary amputation.
The mean blood transfusion for patients with stab and gunshot wounds
was 7 (range 5-12) units and 1 1 (range 621) units respectively. No
other correlation was found between blood transfusion requirement
and the nature of the vessels (artery and/or vein) injured.
Table 1 Clinical presentation of 76 patients with subclavian vessel
injury caused by stabbing or gunshot
Stab wound Gunshot wound
Systolic pressure 2 100 mmHg 3 (8) 0 (0)
Systolic pressure < 100 mmHg 27 (68) I1 (31)
Unrecordable blood pressure 8 (20) 20 (56)
Cardiac arrest 2 (5) 5 (14)
Total 40 (100) 36 (100)
Values in parentheses are percentages
Table 2 Subclavian vessel injury in patients reaching the operating
theatre alive
~

Stab wound Gunshot wound

Chicut prewntulion
Artery alone 15 (38) 10 (32)
Seven patients had a cardiac arrest within 10 min of arrival at hospital. Artery and vein 16 (41) 15 (48)
Of these, five had gunshot injury and two had been stabbed. All
underwent an emergency room thoracotomy. Only one patient (with Vein alone 8 (20) 6 (19)
Total 39 (loo) 31 (100)
Paper accepted 20 August 1993 Values in parentheses are percentages

524
 PENETRATING INJURY O F SUBCLAVIAN VESSELS
Table 3 Type of arterial repair in patients surviving operation
Stab wound Gunshot wound
Simple repair or end-to-end 25 (81) 6 (24)
anastomosis
Saphenous graft 4 (13) 3 (12)
Polytetrafluoroethylene graft 2 (6) 14 (56)
Ligation 0 (0) 2 (8)
Total 31 (100) 25 (100)
Values in parentheses are percentages
Results
Mortality and immediate morbidity
There were eight deaths (20 per cent) among stab-injured
patients: one in the emergency room, five in the operating
theatre and two in the immediate postoperative period. In the
group with gunshot wounds there were 17 deaths (47 per cent):
five in the emergency room, 11 in the operating theatre and
one after surgery. Excluding death in the emergency room, the
operative mortality rate was 18 per cent for stabbed patients
and 39 per cent in the group with gunshot wounds.
In the group with stab injury, there were eight major
complications (affecting 25 per cent of survivors); one of these
was a vein graft thrombosis and the remainder were pulmonary
in nature. Twelve major complications occurred in the group
with gunshot injury (affecting 63 per cent of survivors); there
were two graft occlusions (one venous, one synthetic) and ten
pulmonary complications. Of the 17 pulmonary complications
overall in the series, there were five bronchopleural fistulas,
seven ipsilateral pneumonias, three infected ipsilateral pleural
effusions and two apical pulmonary abscesses. All these
pulmonary complications were successfullytreated by conserva-
tive means. There were no short-term complications resulting
from ligation of the subclavian vein.
FoIIo W-UP
Long-term follow-up is difficult in this hospital, particularly in
patients with trauma, mainly because of socioeconomic factors.
At 1 month after discharge, only 15 patients (29 per cent of
survivors) came back for review and only eight of these returned
for at least one further visit. In the patients without brachial
plexus injury no new complications occurred and the functional
outcome, assessed clinically, was excellent. The patient with an
associated brachial plexus injury who underwent primary repair
was lost to follow-up. The other patient with a brachial plexus
injury underwent secondary repair at 5 months and has
regained only partial motor and sensory function.
Discussion
There is a wide experience at Baragwanath Hospital of the
management of injury to the neck and shoulder girdle'^^. The
principles of resuscitation and operative management of stab
wounds of the subclavian vessels have previously been discussed
in detail'. Gunshot injuries to these vessels are now encountered
with greater frequency; in the past 3 years 47 per cent of
penetrating injuries to the subclavian vessels were inflicted by
firearms. These injuries differ greatly from stab wounds in
presentation, operative management and outcome. Compared
with stab-injured patients, the group with gunshot wounds was
characterized by a more dramatic clinical presentation. Some
14 per cent of patients in the latter group had a cardiac arrest
within minutes of admission compared with only 5 per cent in
British Journal of Surgery 1994, 81, 524-526
525
the former. Of the patients who underwent surgery in the
operating theatre, 68 per cent were shocked and 20 per cent
had an unrecordable blood pressure in the stabinjured group
whereas, among those with gunshot injury, 31 per cent were
shocked and the blood pressure was unrecordable in 56 per cent.
Emergency room thoracotomy in patients with stab wounds
of the neck or chest and no recordable vital signs is a valuable
procedure5. In the present series one of seven patients who
arrested in the casualty department could be resuscitated in
such a manner and then taken to the operating theatre, where
definitive repair of the subclavian artery was performed. A less
aggressive approach would certainly have resulted in this
patient's death. It should be emphasized that the success of
emergency room thoracotomy depends on the availability in
the casualty department of an experienced surgeon of at least
senior registrar level.
The surgical approach adopted in the two groups was
different, reflecting the greater severity of clinical presentation
in those with gunshot injury. Although the operations were
performed by different surgeons and in the absence of a
pre-existing protocol. there was a definite preference for the
addition of a median sternotomy to the standard clavicular
exposure in patients with gunshot wounds; the combined
approach was used in 77 per cent of gunshot injuries compared
with 16 per cent of stab wounds. The more critical the patient's
condition, the more imperative it is to achieve rapid proximal
arterial control. The clavicular approach alone affords a rather
slow and limited exposure of the artery: a median sternotomy,
on the other hand, can be performed expeditiously offering
immediate proximal access to the artery. The authors have
limited experience with the 'trap-door' approach consisting of
three components in continuity: a clavicular incision, a limited
median sternotomy and an anterolateral thoracotomy. We do
not recommend it.
In patients with arterial injury there was a greater use of
interposition gr&s (saphenous or synthetic) for gunshot
wounds (68 per cent) than for stabbing (19 per cent), as opposed
to simple repair or end-to-end anastomosis; this is a reflection
of the greater anatomic disruption caused by bullets. Other
authors6,' have recommended the use of polytetrafluoroethylene
(PTFE) grafts in vascular trauma, as it obviates the tedious
saphenous dissection in an unstable patient and provides better
size match between vessel and graft. The present findings
confirm the safety of PTFE grafts with regard to early sepsis,
even in gunshot injury. Given the insufficient follow-up in the
present study, however, we are unable to comment about late
low-grade sepsis or long-term patency. Rich et al." demonstrated
the safety of subclavian artery ligation. This was performed,
only as a desperate measure, in two gunshot victims in the
present study who eventually died. Perhaps the overall
mortality rate would have been lower with a more liberal use
of arterial ligation. Injuries to the subclavian vein were managed
by ligation in 61 per cent of the present patients with venous
injuries; no significant postoperative oedema of the arm was
noted.
The operative mortality rate of 18 per cent of stabinjured
patients is comparable to the mortality rate of 155 per cent
reported in an earlier series from this hospital'. In the group
with gunshot injury the operative mortality rate was 39 per cent.
The reason for this difference is not immediately clear. The
possibility that a gunshot injury to the subclavian vessels might
have been associated in a significant number of cases with
trauma to other vital structures cannot account for this
difference; most of the gunshot victims reaching the operating
theatre alive underwent a median sternotomy and there were
no other associated sources of bleeding within the thorax. No
autopsy results are available to corroborate the operative
526 E. DEGIANNIS, G. VELMAHOS, D. KRAWCZYKOWSKI, R. D. LEVY, I. SOUTER and R. SAADIA

findings in the patients who died during surgery or shortly after.
Admittedly, gunshot victims were likely to be more haemo-
dynamically compromised than stabbed patients, most
probably as a result of a greater disruption of the subclavian
vessels. This hypothesis is supported by the greater use, in
gunshot victims, of an interposition graft for the arterial repair.
The association of both subclavian artery injury and vein injury
was also proportionately more common in patients with
gunshot wounds.
References
1 Demetriades D, Rabinowitz B, Pezikis A, Franklin J, Palexas G.
Subclavian vascular injuries. Br J Surg 1987; 7 4 1001-3.
2 The American College of Surgeons. Advanced Trauma Life Support.
5th ed. Chicago, Illinois: ACS, 1992.
3 Gilroy G, Lakhoo M, Charalambides D, Demetriades D. Control of
life-threatening haemorrhage from the neck a new indication for
balloon tamponade. Injury 1992; 23: 557-9.
4 Demetriades D, Stewart M. Penetrating injuries of the neck. Ann R
CON Sure Engl1985; 67 714.
5 Demetriades D, Rabinowitz B, Sofianos C. Emergency room
thoracotomy for stab wounds to the chest and neck. J Trauma 1987;
27: 483-5.
6 Feliciano D, Mattox K, Graham J, Bitondo C. Five-year experience
with FTFE grafts in vascular wounds. J Trmmza 1985; 25: 71-82.
7 Thomas JH, Pierce GE, Iliopoulos 11, Hermreck AS. Vascular graft
selection. Surg Clin North Am 1988;68: 865-73.
8 Rich NM,Baugh JH, Hughes C. Acute arterial injuries in Vietnam:
lo00 cases. J Trauma 1970; 1 0 359-69.

Announcement
First Charles Clyne Memorial Meeting
Charles Clyne died on 1 July 1992 aged 46 years. Born in Huddersfield, he qualified at Liverpool
University Medical School in 1969, working in Portsmouth, Hammersmith Hospital and
Southampton before becoming a consultant in general and vascular surgery in Torbay in 1984.
Throughout his career Charles was devoted t o his family and found time for sport, farming
(he bred prize-winning sheep) and producing medical videos. In all this his warm personality,
sense of humour and enthusiasm earned the affection and respect of those around him.
Charles Clyne published widely within the vascular field and was a member of the BJS Editorial
Board. He initiated and organized the Torbay Imperial Conferences, symposia devoted to
aspects of vascular surgery. These conferences continue as a fitting tribute to him. The first
Charles Clyne Memorial Meeting, ‘Difficult Issues in Vascular Surgery’, takes place at the
Imperial Hotel in Torquay, Devon, on 6-7 May 1994. Further details can be obtained from:
Mr W.B. Campbell, Department of Surgery, Royal Devon and Exeter Hospital, Barrack Road,
Exeter EX2 5DW, UK.

W.B. Campbell

British Journal of Surgery 1994,81,524-526