Repair of blunt thoracic outlet arterial injuries: an evolution from open to endovascular approach

Thoracic outlet artery injuries due to blunt trauma are uncommon. Exposure of these arteries is associated with significant morbidity and mortality. An endovascular approach is a less invasive alternative approach for these technically challenging injuries.

A retrospective review of patients who presented with blunt traumatic injuries to the innominate, subclavian, and axillary arteries between 1998 and 2009 was performed. Demographic data, concomitant injuries, preoperative workup, treatment, and outcomes were recorded.

During the study period, 34 patients (80% men) meeting selection criteria were admitted (11 innominate, 16 subclavian, and 7 axillary). Management was nonoperative in 6, open in 16, and endovascular in 12 patients. In the latter group, eight patients had successful stent-graft insertions. These were approached in an antegrade femoral or retrograde brachial fashion. In three cases of complete artery transaction, both methods were used. Shorter operative time (149 minutes vs. 230 minutes; p = 0.03) and less blood loss (50 mL vs. 1,225 mL; p = 0.03) were seen in the endovascular group compared with the open repair group. There was a trend for less blood transfusion, but it was not significant (0 median units vs. 4.5 median units; p = 0.3). Hospital length of stay was shorter (19 days vs. 29 days; p = 0.4).

Covered stents are a feasible alternative to open repair in the multiply injured blunt trauma patients with thoracic outlet arterial injuries. This can be used in the damage control setting as it offers shorter operative time, less blood loss, and overall less morbidity to the patient. Long-term follow-up is needed.