c l i n i c a l f o l i o s : d i s c u s s i o n

Subclavian Artery Injury



Related narrative: Right Subclavian Artery Injury

Blunt injuries of the subclavian artery are distinctly uncommon, accounting for less than 0.03% of all acute vascular injuries (1,2). The subclavian vessels are well protected by surrounding soft tissue and bony structures of the thoracic inlet, so it is not surprising that blunt vascular injuries imply severe trauma. Blunt subclavian artery injuries are usually the result of rapid deceleration forces applied to the neck, chest, and upper extremities (1). As in the present case, injures of associated structures in the thoracic inlet are common. Frequent associated injuries include fractures of the first rib or clavicle, subclavian vein disruption, pneumothorax, pulmonary contusion, bronchial disruption, and brachial plexus injury. The most debilitating injury occurs in scapulothoracic dissociation, a condition in which severe traction to the shoulder girdle results in avulsion of the brachial plexus and subclavian artery (3).

Recognition of subclavian artery injuries is usually based on indirect physical findings in a patient who has sustained rapid deceleration in a motor vehicle accident or a fall. Vascular findings such as pulse deficits, bruits, or thrills may be absent due to the abundant shoulder collaterals. Brachial plexus injury in the setting of severe deceleration trauma should raise suspicion and prompt urgent artreiography (1). Chest x-ray findings such as first rib fracture, mediastinal widening, apical cap, or ill defined aortic knobs should also raise concern for vascular injury, although these findings are not specific for subclavian artery injury per se. Arteriography remains the gold standard for identification of arch and great vessel trauma, and stable patients should be transported to the arteriogram suite as soon as possible (4). In addition to confirming the injury, arteriography is important to help plan the proper approach for repair.

Operative exposure of the subclavian arteries has been well described elsewhere (5). Briefly, the proximal subclavian arteries cannot be easily exposed in the supraclavicular area. Proximal vascular control of the right subclavian artery is achieved most conveniently through a median sternotomy. However, median sternotomy is not adequate for exposure of the left subclavian artery owing to its posterior location in the mediastinum. Proximal control is best obtained through an anterior thoracotomy in the third intercostals space or through a "book" thoracotomy (5).

The outcome of blunt subclavian artery trauma is largely determined by the associated injuries. While most patients who do not sustain nerve injuries can be expected to make full recoveries, more than 50% of individuals become permanently disabled after severe neural and vascular injuries of the upper extremity (6).


1. Posner MP, Deitrick J, McGrath P, et al. Nonpenetrtaing vascular injury to the subclavian artery. J Vasc Surg 1988; 8: 611-7.

2. Costa MC, Robbs JV. Nonpenetrating subclavian artery trauma. J Vasc Surg 1988; 8: 71-5.

3. Sampson LN, Britton JC, Eldrup-Jorgensen J, et al. The neurovascular outcome of scapulothoracic dissociation. J Vasc Surg 1993; 17: 1083-9.

4. McIntyre WB, Ballard JL. Cervicothoracic vascular injuries. Semin Vasc Surg 1998; 11: 232-242.

5. Wind GG, Valentine RJ. Thoracic aorta. In: Wind GG, Valentine RJ. Anatomic Exposure in Vascular Surgery. Baltimore: Williams & Wilkens, 1991: 73-103.

6. Manord JD, Garrard CL, Kline DG. Management of severe proximal vascular and neural injuries of the upper extremity. J Vasc Surg 1998; 27: 43-9.

This page was last modified on 4-Sep-2001.