Subclavian vessels injury:An underestimated complication of clavicular fractures

Clavicle fractures are frequent orthopedic injuries,often resulting from direct trauma or a fall.Most clavicle fractures are treated conservatively without any complications or adverse effects.Concomitant injuries of the subclavian vein or artery are rarely encountered and most commonly associated with high-energy trauma or comminuted clavicle fractures.They are potentially life-threatening conditions leading to hemorrhage,hematoma,pseudoaneurysm or upper limb ischemia.However,the clinical presentation might be obscure and easily missed,particularly in closed and minimally displaced clavicular fractures,and timely diagnosis relies on early clinical suspicion.Currently,computed tomography angiography has largely replaced conventional angiography for the assessment of subclavian vessel patency,as it demonstrates high accuracy and temporal resolution,acute turnaround time,and capability of multiplanar reconstruction.Depending on the hemodynamic stability of the patient and the severity of the injury,subclavian vessel lesions can be treated conservatively with observation and serial evaluation or operatively.Interventional vascular techniques should be considered in patients with serious hemorrhage and limb ischemia,followed by stabilization of the displaced clavicle fracture.This review aims to provide a comprehensive overview of the incidence,clinical presentation,diagnostic approaches,and current management strategies of clavicle fractures associated with subclavian vessel injuries.

Bilateral common carotid artery common trunk with aberrant right subclavian artery combined with right subclavian steal syndrome: A case report

BACKGROUND We report a rare case of numbness in the right hand,finally diagnosed as bilateral common carotid artery common trunk with aberrant right subclavian artery combined with right subclavian steal syndrome and explain the cause of these diseases.CASE SUMMARY The patient was a 65-year-old woman.She complained of dizziness,numbness and weakness of the right hand for 6 mo.She was diagnosed with bilateral common carotid artery common trunk with aberrant right subclavian artery combined with right subclavian steal syndrome by ultrasound,enhanced computed tomography,computed tomography angiography and other examinations.Considering the surgical risks,the patient refused the aberrant right subclavian artery stent implantation and was discharged.We hypothesize that these two kinds of deformity and right subclavian steal syndrome may not occur by accident and result from multiple malformations.CONCLUSION Bilateral common carotid artery common trunk with aberrant right subclavian artery combined with right subclavian steal syndrome is rare.This case reminds interventional radiologists of the possibility of these abnormalities before surgery.

Subclavian artery stenting via bilateral radial artery access:Four case reports

BACKGROUND Subclavian artery stenosis refers to the stenosis in the lumen caused by the presence of plaque or thrombus in the subclavian artery.It is a common problem in endovascular interventions.In fact,conventional subclavian artery stenting via the femoral artery approach is effective and safe.Nevertheless,because femoral artery puncture is not easy to stop bleeding,it requires longer femoral artery compression or more expensive hemostatic materials,such as staplers.Patients need to be catheterized and bedridden for a longer time,which may lead to many complications,such as pseudoaneurysm.CASE SUMMARY Herein,we reported a new interventional therapy of subclavian artery.From March 1,2020 to August 31,2021,we operated on four patients with subclavian artery stenting via bilateral radial artery access.CONCLUSION After reviewing four cases of successful placement of clavicular artery stents via bilateral radial arteries,we concluded that bilateral radial artery approach is feasible.Clavicular artery stenting is safe,effective,and timesaving.It is an excellent alternative to the traditional femoral artery procedure,with few complications and high comfort degree.

Carotid-subclavian bypass and endovascular aortic repair of Kommerell’s diverticulum with aberrant left subclavian artery:A case report

BACKGROUND Kommerell’s diverticulum(KD)with aberrant left subclavian artery is a rare congenital deformity and also has very little research literature about it(35%of case study).There are three types of aortic arch diverticulum.Even literature concerning the treatment options are limited.CASE SUMMARY We present a case report of a 50-year-old male with KD in the right aortic arch with aberrant left subclavian artery.We conducted a total endovascular repair procedure,which is innovative and will spread more light in the medical world.Our patient has no past medical history and is a non-smoker and non-alcoholic.Patient presented with shortness of breath,chest pain and dizziness for six months.Blood tests were done and computerized tomography(CT)angiogram of the chest confirmed the diagnosis,illustrating showed a 3.9 cm KD.On Day 1,the CT angiogram showed mild dilatation of the thoracic aorta,adjacent esophagus,trachea was compressed and displaced.Surgery was planned as the treatment modality.Carotid-Subclavian artery bypass and endovascular aortic repair was conducted.We used prolene 5-0 C1 sutures to precisely anastomose a 6-mm Dacron graft to the left subclavian artery.Haemostasis was secured and wounds were closed.Protamine was administered and patient was shifted to intensive care unit.Post-operative,patient responded favorably and was discharged.Regular follow-up is done.CONCLUSION The procedure we performed is novel.This will help the cardio-thoracic surgeons a better insight about the full procedures we conducted,thereby bringing more light and better treatment options in managing KD with aberrant subclavian artery.

Subclavian Artery Pseudoaneurysm following Stab Injury and Its Surgical Approach: A Case Report and Literature Review

Penetrating injuries to the subclavian arteries as well as post traumatic pseudoaneurysm involving Subclavian artery (SCA) are very much uncommon. We present one case of a 21 year-old male sustained a physical assault with a post stab injury left subclavian artery pseudoaneurysm. He was referred to our facility, two days after sustaining a penetrating chest trauma over left infraclavicular area of the chest. The presentation, diagnostic procedures and surgical approach for management of this very rare injury are discussed.

A rare case of non-ST-segment elevation myocardial infarction triggered by coronary subclavian steal syndrome

Coronary subclavian steal syndrome (CSSS) has been recognized lately as an unusual clinical entity,giving rise to angina but rarely causing an acute coronary syndrome (ACS). The prerequisites for the appearance of CSSS are both a patent left internal mammary artery (LIMA) graft and severe stenosis of the left subclavian artery (LSA). However,LSA is often overlooked in the diagnostic evaluation of patients with angina,who have underwent coronary artery bypass grafting (CABG). We report an unusual case of non-ST-segment elevation myocardial infarction (NSTEMI) caused by subtotal occlusion of proximal LSA.

Thoracic endovascular aortic repair with left subclavian artery reconstruction for blunt traumatic aortic injury in elderly patients

Introduction:Blunt thoracic aortic injury(BTAI)is rare in elderly patients.As the population ages and life expectancy increases,the frequency of this injury will increase,while the treatment and outcomes remain unclear.Methods:We retrospectively analyzed the collected data of patients>60 years old with BTAI to investigate the mechanism of trauma;time interval from injury to diagnosis;type and timing of surgical intervention;aortic arch pattern;choice of left subclavian artery reconstruction;endograft to treat BTAI;length of the endovascular procedure;endoleaks;complications including stroke,paraplegia,and renal failure;length of hospital stay(LOS)and intensive care unit stay(L.ICUS);and 30-day mortality.Results:Five elderly trauma patients were found to have BTAI.Four(80%)were males,the cohort mean age was68 years,the major mechanism of trauma was fall injury,and the associated injury was thoracic trauma.All patients were transferred to our hospital,and emergency computed tomography angiography showed BTAI in each patient.The average time interval from injury to diagnosis was 2.7 days.Two patients suddenly showed signs of instability in their vital signs and underwent immediate endovascular repair,while 3 patients underwent delayed endovascular repair.The injury site was located in the aortic isthmus just distal to the origin of the left subclavian artery;the aortic arch pattern was II(80.0%)in 4 cases and III in 1 case(20.0%).The choice of left subclavian artery reconstruction included chimney,double chimney,prefenestration,and chimney combined with in situ fenestration.Endografts to treat BTAI included the Ankura(Lifetech Scientific,Shenzhen,China)and the C-TAG(W.L.Gore&Associates,Flagstaff,AZ USA).The length of the endovascular procedure was 75.4 min;there were no endoleaks and no complications including stroke,paraplegia,or renal failure.The average LOS was25 days,and the average L.ICUS of 2 patients was 15 days,with no 30-day mortality.Conclusion:Elderly patients with fall injury should promptly exclude BTAI.Thoracic endovascular aortic repair(TEVAR)with a left subclavian artery reconstruction technique provided good results without procedure-related or neurological complications.Because of the low incidence of this type of injury,we are unable to provide any evidence to guide the treatment option for this life-threatening condition.

Short-term efficacy of unibody single-branched stent in the treatment of lesions involving the left subclavian artery:two-year follow-up outcomes

The development of thoracic endovascular aortic repair(TEVAR)technology avoids the risk of patients opening the chest and is widely used in Stanford B-type dissection.[1–3]However,because TEVAR technology has clear requirements for vascular anatomy of the lesion,it limits its application to some patients.In the shortcomings of the proximal anchor zone,coverage of the left subclavian artery(LSA)origin without revascularization during TEVAR appears to have increased risk of stroke,upper extremity ischemia and paraplegia.[4]

Interventional treatment of the left subclavian in 2 patients with coronary steal syndrome

In patients with history of coronary artery disease angina pectoris is usually attributed to the progression of atherosclerotic lesions. However,in patients with previous coronary artery bypass graft operation(CABG) using internal mammary artery grafts,great vessel disease should also be considered. Herein we present two patients with history of CABG whose symptoms were suspicious for coronary ischemia. During cardiac catheterization reverse blood flow was observed from the left artery disease to the left internal mammary artery(LIMA) graft in both cases. After angioplasty and stent implantation of the left subclavian artery antegrade flow was restored in the LIMA grafts and both patients had complete resolution of symptoms.

Mid-term outcomes of left subclavian artery revascularization with Castor stent graft in treatment of type B aortic dissection in left subclavian artery

Background:Here we analyzed mid-term data of thoracic endovascular aneurysm repair(TEVAR)surgery with Castor single-branched stent graft placement for the management of Stanford type B aortic dissection(STBAD)involving the left subclavian artery(LSA).Methods:Between April 2014 and February 2019,32 patients with STBAD involving a Castor single-branched stent graft were included.We analyzed their outcomes,including technical success rate(TSR),surgical duration(SD),presence of ischemia,perioperative complications,LSA patency,and survival rate(SR),using computed tomography angiography and clinical evaluation during mid-term follow-up.Results:The mean patient age was 54.63±12.37 years(range,36–83 years).The TSR was 96.88%(n=31/32).The mean SD was 87.44±10.89 with a mean contrast volume of 125.31±19.30 mL.No neurological complications or deaths occurred during the study period.The patients had a mean hospital stay of 7.84±3.20 days.At a mean follow-up of 68.78±11.26 months,four non-aortic deaths(12.5%)were observed.The LSA patency rate was 100%(n=28/28).There was only one case of type I endoleak immediately after surgery(3.12%)(type I from LSA).However,none of the patients experienced type II endoleaks,and there were no cases of retrograde type A aortic dissection or stent graft-driven new distal entry.Finally,all patients exhibited good LSA patency.Conclusion:TEVAR using a Castor single-branched stent graft may be a highly feasible and efficient procedure for the management of STBAD involving the LSA.

Total endovascular repair of aberrant right subclavian artery using caster branched stent-graft

A 57-year-old man has 20-year history of hypertension presented with intermittent chronic pain in the chest area and shoulder blades over the last three months.Computed tomographic angiography(CTA)on admission revealed a chronic type B aortic dissection(TBAD)with an aberrant right subclavian artery(ARSA)crossed behind the trachea and bovine aortic arch(Figure IB).

Subclavian Impella 5.0 to the rescue in a non-ST elevation myocardial infarction patient requiring unprotected left main rotablation: A case report

BACKGROUND Often in patients with significant three-vessel or left main disease there is coexistent significant peripheral disease rendering them poor candidates for percutaneous left ventricular support during revascularization.Evidence on the management of such cases is limited.CASE SUMMARY We describe a case of such a patient with critical distal left main disease and chronically occluded right coronary artery who presented with chest pain and a non-ST elevation myocardial infarction and had significantly impaired left ventricular function.With the aid of our cardiothoracic surgeons a cut down subclavian Impella 5.0 was inserted and high risk rotablation percutaneous coronary intervention carried out successfully.CONCLUSION This case highlights the need for cross-specialty collaborations in such high-risk cases were alternative access is needed for insertion of large bore mechanical circulatory support devices.

Life-threatening subclavian artery bleeding following percutaneous coronary intervention with stent implantation:A case report and review of literature

BACKGROUND Vascular complications of transradial percutaneous coronary intervention(PCI)are rare and usually occur at the access site below the elbow.Life-threatening vascular complications during transradial PCI therapy,such as vessel perforation and dissection in the brachiocephalic,subclavian,internal mammary,and thyrocervical arteries,are rarely reported.Subclavian artery bleeding is a potentially serious complication of vascular interventional procedures leading to tracheal obstruction,hemothorax,respiratory failure,hemorrhagic shock,and death if not diagnosed early and treated promptly.CASE SUMMARY A male patient with typical angina pectoris underwent coronary angiography and stent implantation.During the procedure,the patient felt pharyngeal pain and tightness,which we mistook for myocardial ischemia.After PCI,swelling in the right neck and supraclavicular area was observed.The patient experienced dyspnea,emergency endotracheal intubation was performed,and then a sudden drop in blood pressure was observed.Ultrasound and contrast-enhanced computed tomography scans demonstrated a cervical hematoma severely compressing the trachea due to subclavian artery bleeding.Brachiocephalic angiography revealed a vascular injury site at the root of the right subclavian artery at the intersection of the right common carotid artery.A covered stent was deployed to the right subclavian artery with successful sealing of the perforation,and a bare stent was implanted in the junction of the right common carotid and brachiocephalic arteries to prevent obstruction of blood flow to the brain.CONCLUSION Subclavian artery bleeding is a lifethreatening complication of PCI.Early prevention,rapid recognition,and prompt treatment may improve the prognosis.

Focal intramural hematoma as a potential pitfall for iatrogenic aortic dissection during subclavian artery stenting: A case report

BACKGROUND Iatrogenic aortic dissection(IAD)is a rare but fatal complication of interventional treatment for the proximal supra-aortic large vessels.Several cases of IAD after endovascular treatment of subclavian artery have been reported.Nevertheless,the pathogenesis of IAD is still unclear.Here we report a patient with IAD following a balloon expandable stent implanted into the left subclavian artery(LSA).CASE SUMMARY An 84-year-old man with a history of hypertension was admitted to the Neurology Department of our hospital complaining of dizziness and gait disturbance for more than 1 mo.Computed tomography angiography of the head and neck showed severe stenosis at the proximal LSA and the origin of the left vertebral artery.Magnetic resonance diffusion-weighted imaging of the brain revealed subacute infarctions in cerebellum,occipital lobe and medulla oblongata.He suffered a Stanford type B aortic dissection after the proximal LSA angioplasty with a balloon expandable stent.Thoracic endovascular aortic repair was performed immediately with the chimney technique and he was discharged 20 d later.After exploring the pathogenesis with multimodal imaging analysis,an easily neglected focal intramural hematoma(IMH)in the aorta near the junction of the LSA was found to be the main cause of the IAD.The risk of IAD should be sufficiently evaluated according to the characteristics of aortic arch lesions before the proximal LSA angioplasty.CONCLUSION Focal aortic IMH is a potential risk factor for IAD during a seemingly simple stenting of the proximal LSA.

A case of acquired right-sided subclavian steal syndrome successfully treated with stenting using brachial approach

Subclavian steal syndrome (SSS) is defined as a group of symptoms that arise from reversed blood flow in the ipsilateral vertebral artery. It is the consequence of proximal occlusion or high-grade stenosis of the subclavian artery. The subclavian obstructive lesions are mostly located in the proximal segment of the subclavian artery and predominantly on the left side. In contrast, there are only a small number of patients that present with right-sided symptoms and even fewer with bilateral symptoms. Endovascular therapy of occlusions and high-grade stenosis of subclavian artery proximal to the origin of the vertebral artery becomes an established therapy in last two decades. We report a case of successful endovascular treatment of right-sided subclavian steal and high-grade (80%) right subclavian artery stenosis due to atherosclerotic occlusive disease with balloon-expandable stent using brachial approach.

Subclavian artery angioplasty in elderly patients with coronary-subclavian steal syndrome: preliminary comparison between a modified brachial technique and the standard femoral approach

Background and Objective Elderly patients who have been submitted to coronary bypass grafting with the left internal mammary artery (LIMA) may develop a coronary-subclavian steal syndrome because of a left subclavian artery (LSA) stenosis. Usually stenting of LSA is performed by the standard femoral route with guiding catheter technique, but this technique can be particularly difficult in elderly patients who often have iliac-femoral kinking and aortic tortuosity. We compared a new “ad hoc” brachial artery approach technique with the standard guiding catheter technique through the femoral access. Methods Between January 2005 and September 2006, four patients underwent LSA stenting using the left brachial artery access obtained with a 6F or 7F 45-cm-long valved anti-kinking sheath as the Super Arrow Flex sheath (Arrow International, PA, USA). The sheath was positioned just before the LIMA graft ostium and a 0.035 inch 260-cm-long Storq guidewire (Cordis Inc., Johnson & Johnson, Warren, NJ) was advanced across the lesion to the descending aorta. A balloon-expandable Genesis (Cordis Inc., Johnson & Johnson, Warren, NJ) endovascular stent was easily deployed, and the correct position was checked by direct contrast injection through the long sheath. This small group of patients has been compared to a group of 5 age-matched patients with coronary steal syndrome in whom the procedure has been performed with standard technique including femoral approach and guide catheter. Results The procedure was successful in all patients; vertebral and LIMA ostia remained patent in all cases. In the control group, cannulation of the subclavian artery was difficult in two cases, while one patient developed a groin hematoma. Mean pretreatment gradient was 32 mm Hg with a range of 25 to 40 mm Hg (34 mmHg, range 26- 43, in the control group, P=0.87) and fell to 2 mm Hg with a range of 0 to 4 mm Hg (3.1 mmHg, range 0 to 5, P=0.89) posttreatment. Mean contrast dose was 60±16 ml (138±26 ml in the control group, P>0.01), whereas mean fluoroscopy and procedural time were 5.7±1.6 minutes (10.8±1.0 minutes in the control group, P>0.01) and 15.7±6.3 minutes (28±7.1 minutes in the control group, P>0.01). At a mean follow-up of 10±3.2 months all patients are alive and free from angina and residual induced ischemia. Conclusions Our brief study suggested that brachial artery access be considered the optimal route to treat coronary-subclavian steal syndrome in elderly patients because of clear advantages; these included no manipulation of catheter to cannulate the artery, perfect coaxial position of the catheter at the site of LSA stenosis, clear visualization of the LIMA and vertebral ostia, and easy access to these vessels in case of plaque shifting or embolic protection device deployment.

Intervantional management in a patient with subclavian artery stenosis: case report

DAI Jiong, WEN Jie-qing, LI Shan-quan. Department of Neurosurgery, Renji Hospital, Shanghai 200001, China The patient is a 79 years old male. He was admitted for recurrent dizziness accompanied tinnitus during the last 2 weeks. These symptoms were aggravated during the last 4 days. He had a history of hypertension. Murmur was detected on the left subclavian artery. Left upper limb had IVth grade muscle force. The pulse of left radial artery was reduced. The systolic blood pressure of left upper limb was 30 mmHg lower than the right counter part. The Doppler sonography of vertebral artery revealed that there was inverse blood flow in the left vertebral artery. The angiography of left subclavian artery revealed that the left subclavian artery near the opening site(proximal to vertebral artery) was stenosed by approximatel 90%. Left vertebral artery was not detected. The angiography of right vertebral artery revealed that there was partial cerebral bolld flow steal to left subclavian artery via left vertebral artery. We treated this patient with percutaneous transluminal angiogrplasty(PTA)and stent implantation. Detailed description: Femoral artery was punctured, 8F artery theca was introduced. The 8F guiding catheter was introduced to the opening site of left subclavian artery. The 0.014 microwire was passed through the stenosis. The 3*30mm and 6*30mm balloon was introduced subsequently to widen the stenosis to guarantee the stent can pass the stenosis. Finally the 9*30mm Wallstent was introduced. Postoperative angioaphy revealed that there was approximately 5% stenosis remained and the left vertebral artery was patent. The patient’s symptoms and signs were all improved. From literatures, PTA and stent implantation is a safe and effective treatment and a first-line management in foreign countries for the subclavian artery stenosis. This is our first case. We feel that the most appropriate position of the guiding catheter is the key issue in successful treatment. We also think how to reduce the risk of stroke and upper limb ischemia more effectively.

MDCT of right aortic arch with aberrant left subclavian artery associated with kommerell diverticulum and calcified ligamentum arteriosum

We present a case of the right aortic arch with kommerell diverticulum (KD) and aberrant left subclavian artery in a symptomatic 50-year-old patient with a calcification in the presumed attachment site of the ligamentum arteriosum (LA) to the KD. In another 30-year-old male patient, the entire course of a calcified LA was demonstrated using multidetector row computed tomography.

Repair of an aberrant subclavian arterioesophageal fistula following esophageal stent placement

A fistula formation between the esophagus and an aberrant right subclavian artery is a rare but fatal com-plication that has been mostly described in the setting of prolonged nasogastric intubation and foreign body erosion. We report a case of a young morbidly obese patient who underwent sleeve gastrectomy that was complicated by a postoperative leak at the level of the gastroesophageal junction. A covered esophageal stent was placed endoscopically to treat the leak. The pa-tient developed massive upper gastrointestinal bleeding secondary to the erosion of the stent into an aberrant retroesophageal right subclavian artery twelve days after stent placement. She was ultimately treated by endovascular stenting of the aberrant right subclavian artery followed by thoracotomy and esophageal repair over a T-tube. This case report highlights the multidis-ciplinary approach needed to diagnose and managesuch a devastating complication. It also emphasizes the need for imaging studies prior to stent deployment to delineate the vascular anatomy and rule out the possi-bility of such an anomaly in view of the growing popu-larity of esophageal stents, especially in the setting of a leak.

Catastrophic vertebral artery and subclavian artery pseudoaneurysms caused by a fishbone:A case report

BACKGROUND Fishbone is the most common esophageal foreign body and tends to migrate after piercing the esophagus to nearby structures.Vascular injury around the esophagus is a serious complication and has a high mortality rate,especially in the case of multiple vascular injuries.CASE SUMMARY We report an extremely rare case of successive vertebral artery and subclavian artery pseudoaneurysms caused by swallowing a fishbone in a previously healthy 29-year-old female.She was transferred to the emergency department of our hospital because of hemorrhagic shock due to a vertebral artery pseudoaneurysm.We successfully managed the vertebral artery pseudoaneurysm with endovascular stent implantation and the patient's vital signs as well as hemodynamics once became stable.However,the patient died of the second subclavian artery pseudoaneurysm occurring within a short time,which was thought be related to the obvious displacement of the fishbone in the mediastinum.CONCLUSION Surgery and endovascular stent implantation may be the best choice for treating such complications.Early removal of the fishbone is of great significance in improving the survival of such patients.