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Endovascular grafting as a complement to open surgery treatment for axillary and subclavian vascular injuries.

The most important step in evaluating a patient with upper extremity vascular trauma is the physical examination. Physical signs may be hard or soft. Hard signs include severe hemorrhage, expanding hematoma, arterial bruit, palpable thrill, or findings of acute ischemia. Soft signs include small nonexpanding hematoma, ipsilateral neurologic deficit or proximity of penetrating trauma to major vascular structures. Different anatomic types of arterial trauma include rupture of the arterial wall, intimal tear formation, dissection, pseudoaneurysm or arteriovenous fistula formation. Less frequent types of injury include compression with contusion, avulsion, and complete arterial transection. When firm indications for an operation are present, arteriograms or computed tomography (CT) angiographies are not only unnecessary but undesirable, and in some situations may be dangerous. Traditionally, axillosubclavian arterial trauma is managed through the use of a standard surgical approach (median sternotomy, left thoracotomy, clavicular resection, supraclavicular or infraclavicular approach), which is associated with 5 to 40% morbidity and mortality rates. Factors which contribute to these risks are difficult operative anatomic planes distorted by large hematomas, severe hemorrhage before arterial clamping, and associated neurovascular injuries during an emergent operation. The concept of endovascular treatment in the acute setting has theoretical and practical advantages. The patient is immediately transferred to the modern endovascular operating room, where mapping of the arterial injury through a transfemoral catheterization and an aortic arch aortography is performed. Inserting a wire along the arterial injury is the mandatory step. In the case of major bleeding due to a complete arterial transection or long arterial rupture, an occluding balloon can be deployed proximal to or along the bleeding point. Cessation of bleeding can be followed by endovascular or open surgical repair if anatomic characteristics of the damage make definite endovascular repair unfeasible. When appropriate anatomic factors are present (ie, intimal tears, dissections, pseudoaneurysms, arteriovenous fistulas, or focal arterial ruptures), a covered stent is immediately deployed to heal the lesion. Long segmental arterial injury, complete arterial transection and lack of an adequate proximal fixation zone are the most common contraindications for endografting, because of anatomic unsuitability. Coverage of the origin of the ipsilateral vertebral artery by the stent graft is contraindicated, whereas in life-threatening situations, the risk of obstruction of one vertebral artery may outweigh the risk of death. Less definite decisions for endografting can be made in cases with large hematomas and neurologic deficits. In the majority of cases, neurologic deficits more likely appear as a result of direct brachial plexus injury— which is repaired only by open surgery—rather than plexus compression from the hematoma. Even in the presence of compartment syndrome compressing the neurovascular bundle without direct plexus injury, surgical decompression is still indicated. Considering all the previous anatomic factors and clinical conditions, definite endovascular repair among all types of axillosubclavian injuries is feasible in between 30 to 40% of patients. In cases with soft signs or no signs of vascular injury, availability of time permits evaluation by detailed preoperative imaging (CT scan, angiography), which transforms the need for an emergent treatment to a more elective procedure. The feasibility of endovascular repair is higher, because the appropriate anatomic factors are more frequently present in these cases compared with cases with hard signs. A retrospective analysis of small series has proven that mortality and morbidity are dramatically lower in patients treated endovascularly (5%) versus patients treated by open repair (10–40%). Although no randomized and prospective evidence exists, it seems that a patient with axillosubclavian arterial trauma deserves the chance of endovascular repair when feasible. Cases which are not feasible–depending on anatomic factors or clinical conditions—have to be managed by open surgery without delay. Endovascular repair provides a less invasive means of treatment in patients who meet the anatomic criteria, and results in a dramatically better short-term outcome. Certainly, the durability of endovascular treatment is unclear and has to be defined by prospective trials. However, late stent graft complications like thrombosis or migration do not preclude future revascularization, which, if possible, may be done under less emergent circumstances after the acute injury has resolved. From the A’ Department of Propedeutic Surgery, Ippokrateion Hospital, University of Athens Medical School, Athens, Greece. Reprint requests to Konstantinos A. Filis, MD, 35, Kifisias Ave. 11523, Athens, Greece. Email: kfilis@hotmail.com Accepted October 23, 2007. Copyright © 2008 by The Southern Medical Association 0038-4348/