Exsanguinating upper extremity vascular injury: is an initial approach by clavicular resection adequate?

Clavicular resection has been recommended by some as an acceptable approach to the repair of subclavian and axillary vascular injuries. We believe this may not be the best approach in patients with severe trauma and exsanguinating injuries. During the last 5 years, we have treated 11 patients with trauma to the subclavian or axillary vessels, four of whom presented in shock from exsanguinating injuries. After initial fluid resuscitation, we operated on each patient by resecting the medial portion of the clavicle. Three of the four patients required further surgery or extension of the incision to control bleeding. In our experience, clavicular resection as a primary approach to exsanguinating injuries did not provide either adequate tamponade of bleeding or the exposure needed to repair injured vessels safely. Clavicular resection may be acceptable for hemodynamically-stable patients with minimal soft tissue damage and simple, right-sided vessel lacerations, but we cannot recommend it as an initial approach in patients with severe, exsanguinating injuries.