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Supra-aortic vessel injuries are uncommon but can be life-threatening and surgically challenging. Trauma to these vessels may be blunt or penetrating, including iatrogenic trauma following the insertion of central venous lines, which may be preventable. Recent advances in technology have resulted in endovascular therapy becoming a common first-line treatment, and interventional radiologists now play a major role in the management of these vascular injuries. We review the literature on the endovascular management of these types of injuries and describe a spectrum of case-based extra-cranial supra-aortic vascular injuries managed at our institution and the range of imaging appearances, including active contrast extravasation, traumatic vessel occlusion, true aneurysms, pseudoaneurysms, and arteriovenous fistulae.

The treatment of posttraumatic aneurysms of peripheral arteries using covered stents is increasingly commonplace. We present the case of a 10-year-old girl with a pseudoaneurysm of the subclavian artery complicated by an arteriobronchial fistula with hemorrhaging into the bronchial tree and distal subclavian artery occlusion. Despite the lack of artery patency, endovascular stent graft implantation was successful. Pseudoaneurysm exclusion and involution was achieved, together with a patent implant and maintained collateral circulation patency.

Injuries of great vessels, such as the subclavian or vertebral arteries in childhood are rare. More frequent and therefore better described are dissections of the vertebral artery, which frequently occur following low energy trauma. The combination of dissection of the vertebral and subclavian arteries described in this case study led to sensory affections of the left arm. Therapeutic anticoagulation is the therapy of choice to avoid possible ischemic insults. The therapeutic approach of injuries to the subclavian artery remains unclear and is in the focus of discussions.

Central venous cannulation through the right internal jugular vein is a widely used technique, and complications due to this procedure are very rare. We report two cases of right massive hemothorax due to inadvertent puncture of a right subclavian artery. Digital subtraction angiography demonstrated a perforated subclavian artery in both cases. These were successfully treated with transcatheter arterial embolization for the bleeding points of the right subclavian arteries.

We report a case of massive hemothorax due to inadvertent puncture of an aberrant right subclavian artery during central venous access. Iatrogenic laceration at the origin of the right internal thoracic artery was successfully treated with coil embolization of the internal thoracic artery followed by stent-graft placement into the subclavian artery. Due to its elongated and abnormal course, an aberrant right subclavian artery may predispose to inadvertent puncture during vein catheterization and should be recognized as a potential threat for such procedures. Our case emphasizes that ultrasound guidance should be used routinely for central venous lines wherever possible.

Penetrating injury to the subclavian arteries is one of the most taxing arterial injuries a trauma surgeon can encounter. Operative access for repair is difficult, crossing two separate anatomical areas-superior mediastinum and base of the neck. The artery runs well protected behind sternum and clavicle and tears easily if clamped. Physiologically unstable patients must be rushed to theatre in an attempt to control exanguinating haemorrhage and to repair the injury. In the rare circumastance of being confronted with it, it is imperative for the occasional trauma surgeon to have a practical operative concept for dealing with this type of injury. This tutorial describes a practical approach for penetrating subclavian injuries, and it discusses alternative surgical strategies when supraclavicular expanding hematomas deny straightforward access.

Penetrating injuries such as gunshot wounds have traditionally been rare in Europe, with the result that European surgeons have only limited experience in their management. Socio-economic changes in the last decade have led to an increase in the frequency of injuries of this type, partly due to the expansion of organized crime and partly because of involvement of the European military in peace-keeping missions in Europe and elsewhere in the world. The purpose of this article is to offer some guidelines in the management of extremely serious or rarely encountered injuries to the neck, chest and peripheral arteries and discuss controversies and possible future changes in their management as a result of the extensive experience of treating penetrating trauma in our hospital.

We report a case of scapulothoracic dissociation with right subclavian artery traumatic injury that was managed by endovascular treatment. Particular features are the use of a flexible self-expandable noncovered stent and simultaneous protection of the right common carotid artery from distal embolization by inflating a balloon catheter.

In peacetime, injuries to the subclavian artery are now very rare. Even more rare are posttraumatic aneurysms and indirect damage to the brachial plexus as a result of injury. The clinical findings, diagnosis and treatment of such a case are described and discussed. Consideration of all the clinical symptoms as a whole is of the outmost importance in the diagnostic process. The development of neurological symptoms in the course of injury with a topographic relationship to the corresponding anatomical structures gave rise to the preliminary diagnosis in this particular case. CT and DSA confirmed the diagnosis. Although surgical treatment is urgently indicated in such cases, resection of the aneurysm as an elective surgical procedure was preferred.

We report three patients in whom arteriovenous fistulas probably occurred following placement of central venous catheters. Two fistulas apparently followed internal jugular vein catheterization (or attempts), and one was demonstrated angiographically following subclavian vein cannulation. One fistula was repaired operatively, and in this case two separate fistulas in the same anatomical region were found. One patient refused surgery but remained asymptomatic after 6 months of follow-up. In the third patient the fistula probably spontaneously disappeared within one week of its appearance. We discuss two methods of central vein cannulation which should decrease the occurrence of complications following the procedure.

11 cases of subclavian vessel injuries are reported. The problems of operative approach are discussed. Two out of 11 cases have been operated on by extraanatomical bypass from the common carotid artery to the subclavian or axillary artery. There resulted no problems by temporarily clamping the common carotid artery, no postoperative carotid steal syndrome was seen. In our opinion carotid-subclavian bypass - well known as standard procedure in chronical disease of the proximal subclavian artery - can also be applied in case of acute trauma of the subclavian artery. Thus the direct riskfull approach for these often polytraumatized patients can be avoided.

During a 16-months prospective study the frequency of displacements and complications of superior vena catheter has been investigated. The study showed, that the right jugular catheter has the lowest frequency of complications, and should be of primary choice. Pneumothoraces are rare with jugular vena catheters (0,05%), more frequently with subclavian catheters. Setting of superior vena catheter displacement in large veins is quite common. More important are catheter displacements in small veins, which are more frequent with jugular than with subclavian vena catheter (vena thoracica interna, vena pericardiacophrenica). Adequate X-ray control (high KV technic, sufficient amount of contrast medium) is necessary to recognize these complications. Correction of displaced catheter should be done under fluoroscopy. Serious complications s.e. tension pneumothorax and haematothorax are rare and should be treated surgically. In some cases no recognized extravasal catheterposition is followed by infusions into the pleural cavity or the mediastinum.