Demetriades D, Chahwan S, Gomez H, Peng R, Velmahos G, Murray J, Asensio J, Bongard F
Department of Surgery, University of Southern California, Los Angeles 90033, USA.
J Am Coll Surg. 1999 Mar;188(3):290-5. doi: 10.1016/s1072-7515(98)00289-0.
Subclavian and axillary vascular injuries are notorious for their mortality and their difficult surgical exposure. In the present study we analyze our experience with 79 patients and describe the techniques used for surgical access to these vessels.
Retrospective review of the medical records of all patients with penetrating injuries to the subclavian or axillary vessels who had been admitted to 2 Los Angeles trauma centers during a 4-year, 3-month period.
Seventy-nine patients were admitted during the study period January 1993 to March 1997 (58 gunshot injuries, 21 other penetrating injuries). The artery was injured in 59 patients and the vein in 40 (20 patients had both arterial and venous injuries). Eighteen patients (23%) were admitted with no signs of life or were in extremis and underwent an emergency room thoracotomy without any survivors. Fifty-eight patients underwent exploration in the operating room, 1 patient with an arteriovenous subclavian fistula was successfully managed with a radiologically placed endovascular stent, and 2 patients with minimal subclavian artery injuries were managed nonoperatively. Overall mortality was 34.2%. Excluding the ER thoracotomies the overall mortality was 14.8%. The mortality for isolated arterial injuries was 20.5%, for isolated venous injuries 50%, and for both vessels 45.0%. The mortality in venous injuries was significantly higher than in arterial injuries (p < 0.05). The standard clavicular incision provided adequate exposure in 32 (50.0%) of the operating room cases. In the other 50% of operating room cases a combination of a clavicular incision with a median sternotomy or thoracotomy was necessary. Proximal subclavian injuries may be accessed through a clavicular incision combined with a median sternotomy irrespective of left or right site location.
Subclavian and axillary vascular injuries remain lethal. A clavicular incision provides satisfactory surgical exposure in about half the patients. In patients with proximal injuries addition of a median sternotomy provides adequate surgical access in both right and left subclavian vessels.
锁骨下血管和腋血管损伤因其高死亡率及手术暴露困难而声名狼藉。在本研究中，我们分析了79例患者的治疗经验，并描述了用于手术显露这些血管的技术。
回顾性分析在4年3个月期间入住洛杉矶2家创伤中心的所有锁骨下或腋血管穿透伤患者的病历。
在1993年1月至1997年3月的研究期间，共收治79例患者（58例枪伤，21例其他穿透伤）。59例患者动脉受伤，40例患者静脉受伤（20例患者动静脉均受伤）。18例患者（23%）入院时无生命体征或处于濒死状态，接受了急诊室开胸手术，无一例存活。58例患者在手术室接受探查，1例锁骨下动静脉瘘患者通过放射学放置的血管内支架成功治疗，2例锁骨下动脉损伤轻微的患者接受非手术治疗。总体死亡率为34.2%。排除急诊室开胸手术患者后，总体死亡率为14.8%。单纯动脉损伤的死亡率为20.5%，单纯静脉损伤的死亡率为50%，动静脉均损伤者死亡率为45.0%。静脉损伤的死亡率显著高于动脉损伤（p<0.05）。在58例手术室病例中，标准锁骨切口在32例（50.0%）中提供了充分的暴露。在另外50%的手术室病例中，需要将锁骨切口与正中胸骨切开术或开胸术联合使用。无论损伤位于左侧还是右侧，近端锁骨下损伤均可通过锁骨切口联合正中胸骨切开术进行显露。
锁骨下血管和腋血管损伤仍然致命。锁骨切口能为约半数患者提供满意的手术暴露。对于近端损伤患者，加用正中胸骨切开术可为双侧锁骨下血管提供充分的手术入路。
