Operative management of penetrating vascular injuries of the thoracic outlet

A 5 yr experience with 20 patients who had penetrating vascular injuries of the thoracic outlet was reviewed. A median sternotomy with extension into the right neck was used to explore 6 patients with right subclavian vascular injuries. With injuries to the origin of the left common carotid artery, repair was accomplished through a median sternotomy combined with a left anterior thoracotomy in 1 patient and through a left posterolateral thoracotomy in the other. Injury to the left subclavian vessels occurred in 5 patients and was exposed through a left anterolateral thoracotomy combined with a supraclavicular incision in 4 patients and through a supraclavicular incision with clavicular resection in 1 patient. Axillary vessel trauma generally was managed with an extrathoracic incision only. The 2 deaths in this series were due to postoperative respiratory complications (mortality rate of 10%). Twenty arteries were repaired and all were patent on follow up examination. Associated neural and venous injury caused significant morbidity in 28% and 10% of patients, respectively. As a result of this experience the authors continue to recommend an extended median sternotomy for repair of right sided cervicothoracic vascular injury. Anterior or posterolateral thoracotomy combined with a supraclavicular incision is advocated for trauma to left sided vessels of the thoracic outlet. When possible, injured veins should be repaired rather than ligated.