ARTERIAL INJURIES OF THE THORACIC OUTLET - A 10-YEAR EXPERIENCE

Arterial injuries of the thoracic outlet are complex and require a pre cise plan for adequate management and prompt exposure of injured vesse ls. Our 10-year experience with 28 such injuries is reviewed. Arteriog raphy was performed whenever possible in stable patients (15) and aide d in planning the operative approach. Unstable patients with active bl eeding, pulsatile or expanding hematoma, or pulse deficit were taken t o the operating room without delay. A thoracic approach was required i n 15 patients, and the exposure was extrathoracic in 12 patients. Airw ay was secured with liberal use of emergency endotracheal intubation ( 16 patients). Primary repair was possible in 16 patients, with graftin g performed in eight and ligation in three. One vertebral artery injur y was successfully controlled with embolization. Venous injuries were repaired in six patients and ligation was necessary in eight; there wa s no significant morbidity. Two patients died in this series from comp lications of severe hemorrhage. Significant morbidity was encountered from associated neurologic injuries in 15 patients. Stroke was evident in two patients, both of whom were moribund preoperatively. Proximal subclavian artery injuries were particularly more problematic and freq uently required an interim anterior thoracotomy for early control of e xsanguinating hemorrhage. Our philosophy in the management of these in juries and choices of exposure are discussed in detail.