Arterial injuries of the thoracic outlet: a ten-year experience

Arterial injuries of the thoracic outlet are complex and require a precise plan for adequate management and prompt exposure of injured vessels. Our 10-year experience with 28 such injuries is reviewed. Arteriography was performed whenever possible in stable patients (15) and aided in planning the operative approach. Unstable patients with active bleeding, pulsatile or expanding hematoma, or pulse deficit were taken to the operating room without delay. A thoracic approach was required in 15 patients, and the exposure was extrathoracic in 12 patients. Airway was secured with liberal use of emergency endotracheal intubation (16 patients). Primary repair was possible in 16 patients, with grafting performed in eight and ligation in three. One vertebral artery injury was successfully controlled with embolization. Venous injuries were repaired in six patients and ligation was necessary in eight; there was no significant morbidity. Two patients died in this series from complications of severe hemorrhage. Significant morbidity was encountered from associated neurologic injuries in 15 patients. Stroke was evident in two patients, both of whom were moribund preoperatively. Proximal subclavian artery injuries were particularly more problematic and frequently required an interim anterior thoracotomy for early control of exsanguinating hemorrhage. Our philosophy in the management of these injuries and choices of exposure are discussed in detail.