Emergency Approach to the Subclavian and Innominate Vessels

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1 Emergency Approach to the Subclavian and Innominate Vessels Joseph J. Amato, M.D., Robert M. Vanecko, M.D., See Tao Yao, M.D., and Milton Weinberg, Jr., M.D. T he operative approach to an acutely injured subclavian vesselprotected by clavicle, sternum, the costal cartilages, and ribs -is by no means an easy one in the presence of active bleeding. We wish to describe a new emergency approach to these vessels which provides rapid exposure for control of bleeding and excellent visualization for arterial and venous reconstruction. During a three-year period at the Cook County Hospital in Chicago, 25 cases of acute subclavian vessel injury were managed without operative mortality. In this series, 12 gunshot wounds and 13 stab wounds resulted in 14 arterial injuries and 13 venous injuries. One of the patients who had sustained combined arterial and venous injuries presented with an arteriovenous fistula. In 1 patient it was necessary to ligate the injured subclavian artery. In all the remaining patients, the subclavian arteries and veins were repaired by lateral sutures, end-to-end anastomosis, or, in 1 patient, by a vein patch. Preparation of the patient included sterile draping of the entire anterior chest wall as well as the cervical regions. Recently, we have included sterile draping of the femoral regions for access to the saphenous vein and to the femoral artery and vein for possible cardiopulmonary bypass. Initial exploration was carried out through a supraclavicular incision with subperiosteal removal of a middle segment of the clavicle. This limited approach provided adequate exposure in 15 patients. Early in our experience, when additional exposure was necessary it was obtained in 1 case by median sternotomy, in 3 cases by separate anterior thoracotomy through the third or fourth intercostal space, and in 2 cases by splitting the upper sternum and extending the original incision downward and laterally into the third interspace for development of a chest wall flap [4, 131. In the 4 later cases, ample additional exposure was achieved rapidly by removal of the medial clavicular remnant and sectioning of the first two costal cartilages. From tlle Department of Cardio-Thoracic Surgery of the Cook County Hospital, Chicago, Ill. Accepted for publication July 1, Address reprint requests to Maj. Joseph J. Amato, MC, Chief, Biomedical Department, Edgewood Arsenal, Md VOL. 8, NO. 6, DECEMBER,

2 AMATO ET AL. Of historical interest is the description of 17 approaches to the subclavian and innominate vessels by Greenough [2] in 1929, in which he credits V. Mott with performing, in 1818, the first ligation of the innominate artery through a V-shaped cervical incision along the sternomastoid and clavicle, and Cooper with the first removal of bony structures in Sencert [lo] in 1918 described an approach to these vessels in which a flap is raised by resecting the middle portion of the clavicle and incising the intercostal cartilages and manubrium. Kocher [6] in suggested a method of raising the manubrium by disarticulation of the clavicle, transection of the sternum, and incision of the first two costal cartilages. Other approaches have been described in the past, with emphasis on different aspects of the operations intended [l, 3, 5, 7, 9, 121. The approach to be described here is particularly applicable to the emergency situation in which the immediate threat of exsanguination demands swift and aggressive safe access to the area of injury. The excellent exposure afforded by the approach suggests its application to elective situations as well. OPERA TIVE TECHNIQUE The medial end of the initial supraclavicular incision is extended downward and parasternally to the third intercostal space (Fig. 1). Sternoclavicular disarticulation [S] is performed by incisions through the anterior and posterior sternoclavicular ligaments as well as through the costoclavicular ligaments and the articular disc (Fig. 2). The superior and anterior mediastinum is entered with blunt finger dissection, hugging the posterior surface of the sternum and costal cartilages and displacing the underlying structures laterally and posteriorly. Frequently, these structures already have been displaced by a hematoma. The first two cartilages are then transected with a knife, guided by two fingers under- FIG. 1. Extension of the original supraclavicular incision downward to the third intercostal space. 538 THE ANNALS OF THORACIC SURGERY

3 Emergency Approach to Great Vessels FIG. 2. Removal of the medial one-third of the clauicle by sternoclauicular.lisayticulation. lying the cartilages (Fig. 3). Care should be taken to make the incision lateral to the internal mammary vessels and to control the intercostal vessels as they are encountered. These vessels frequently have been involved in the initial injury. The right-sided approach exposes the subclavian, jugular, and innominate veins overlying the subclavian and innominate arteries. The origin of the common carotid artery is easily accessible. The trachea and even the esophagus can be approached by retracting the vena cava laterally and the aortic arch medially (Fig. 4). With the left-sided approach, there is easy exposure of the subclavian artery down to the arch of the aorta (Fig. 5). The origin of the carotid artery is seen, and the subclavian, jugular, and innominate veins can be reached easily. On either side, frequently, the lung is involved by the injury that has penetrated the pleural cavity. With this approach, it also was possible to inspect the lung, to evacuate the chest cavity of clots and other foreign materials, to place chest tubes, or to readjust previously placed chest tubes. FIG. 3. Transection of the first two costal cartilages with a knife while PYOtecting the underlying structures. VOL. 8, NO. 6, DECEMBER,

4 AMATO ET AL. FIG. 4. Right-sided exposure of subclavian, jugular, and innominate veins overlying the subclavian and innominate artery. Closure is accomplished by reapproximation of the costal cartilages with silk or wire. The clavicular segment that was removed is discarded, but the periosteal bed is closed with interrupted sutures. Postoperative pain and limitation of motion in the shoulder girdle and chest wall have been inconsequential, and residual deformity over the region from which the clavicle was removed is not significant [lll. SUMMARY Twenty-five consecutive patients were operated upon for control of acute gunshot or stab wounds of the subclavian artery or vein or FZG. 5. Left-sided exposure of the subclavian, jugular, and innominate veins overlying the subclavian artery and carotid artery down to the arch of the aorta. 540 THE ANNALS OF THORACIC SURGERY

5 Emergency Approach to Great Vessels both. There were no deaths in the series, and the subclavian arteries and veins were repaired in all but 1 patient, in whom ligation of the subclavian artery was necessary. In the majority of the patients the injuries were managed through a supraclavicular incision with excision of a middle segment of the clavicle. Early in this experience, when additional exposure was necessary, it was obtained by median sternotomy, anterior thoracotomy, or a combination of the two to reflect a thoracic wall flap. In our later experience, excellent exposure of the upper mediastinurn was accomplished rapidly and safely by removing the medial remnant of the clavicle and incising the first two costal cartilages. This technique is described and is suggested as the preferred approach in the exposure of acutely injured subclavian vessels. REFERENCES 1. Cook, F. W., and Haller, J. A., Jr. Penetrating injuries of the subclavian vessels with associated venous complications. Ann. Surg. 155: 370, Greenough, J. Operations on the innominate artery. Report of a successful ligation. Arch. Surg. 19: 1484, Halsted, W. Ligation of the first portion of the left subclavian artery and excision of a subclavio-axillary aneurysm. Bull. Hopkins Hosp. 3:93, Imamoglu, K., Read, R. C., and Huebl, H. C. Cervico-mediastinal vascular injury. Surgery 61:274, Jones, R. F., Terrell, J. C., and Salyer, K. E. Penetrating wounds of the neck: An analysis of 274 cases. J. Trauma 7:228, Kocher, T. Textbook of Operative Surgery, Vol. 11. New York: Macmillan, Mansberger, A. R., Jr., and Linberg, E. J. First rib resection for distal exposure of subclavian vessels. Surg. Gynec. Obstet. 120: 579, Nicola, T. Atlas of Orthopaedic Exposures. Baltimore: Williams & Wilkins, P Penn, I. The vascular complications of fractures of the clavicle. Brit. J. Surg. 50:819, Sencert, L. Wounds of the Vessels (Edited by F. F. Burghard). London: University of London Press, Chap Shumacker, H. B., Jr. Resection of the clavicle. Surg. Gynec. Obstet. 84:245, Shumacker, H. B., Jr. Operative exposure of the blood vessels in the superior anterior mediastinum. Ann. Surg. 127:464, Steenburg, R. W., and Ravitch, M. M. Cervico-thoracic approach for subclavian vessel injury from compound fracture of the clavicle: Considerations of subclavian-axillary exposures. Ann. Surg. 839:485, VOL. 8, NO. 6, DECEMSER,