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Penetrating injuries to the subclavian artery carry a high mortality rate, especially when the patient presents in shock. Rapid and effective haemorrhage control is challenging due to the anatomical location at the thoracic outlet. Historically, vessel ligation has been used to control bleeding, but this is often performed late, when metabolic exhaustion is established, and is associated with upper-limb ischaemia and limb loss. Rapid proximal control through the chest with temporary intravascular shunting is the damage control technique of choice to temporise blood loss and restore perfusion until the patient is physiologically optimised for a delayed definitive vascular repair. We describe a case of vascular damage control in a patient after gunshot wound.

Background: A national analysis of clavicle fractures is lacking and the risk of concomitant axillosubclavian vessel injury (ASVI) in patients with clavicle fractures is unknown. A minority of patients may have a combined brachial plexus injury (BPI). We sought to describe risk factors for concomitant ASVI in patients with a clavicle fracture; hypothesizing patients with combined clavicle fracture and BPI has a higher risk of ASVI., Methods: The Trauma Quality Improvement Program (2010-2016) was queried for blunt trauma patients with a clavicle fracture. A multivariable logistic regression model was used to determine risk factors for ASVI. A subset analysis on patients with isolated clavicle fractures was additionally performed., Results: From 59 198 patients with clavicle fractures, 341 (.6%) had concomitant ASVI. Compared to patients without ASVI, patients with ASVI had a higher median injury severity score (24 vs. 17, P < .001) and rates of pulmonary contusions (43.4% vs. 37.7%, P = .029) and BPI (18.2% vs. .4%, P < .001). After controlling for associated chest wall injuries and humerus fracture, the BPI odds ratio (OR 49.17, 35.59-67.92, P < .001) was independently associated with risk for ASVI. In a subset analysis of isolated clavicle fractures, BPI remained associated with risk of ASVI (OR 60.01, confidence intervals 25.29-142.39, P < .001)., Conclusion: The rate of concomitant ASVI in patients with a clavicle fracture is <1%. Patients presenting with a clavicle fracture had a high rate of injuries including pulmonary contusion. Patients with findings suggestive of underlying BPI had a nearly 50 times increased associated risk of ASVI. Thus, a detailed physical exam in this setting including brachial-brachial index appears warranted.

Bicortical drilling of the clavicle is associated with risk of iatrogenic damage from plunging given the close proximity of neurovascular structures. This study determined plunge depth during superior-to-inferior clavicle drilling using a standard drill vs drill-sensing technology. Two orthopedic surgeons drilled 10 holes in a fresh cadaveric clavicle with drill-sensing technology in freehand mode (functions as standard orthopedic drill) and another 10 holes with drill-sensing technology in bicortical mode (drill motor stops when the second cortex is breached and depth is measured in real time). The drill-measured depths were compared with computed tomography-measured depths. Distances to the neurovascular structures were also measured. The surgeons' plunge depths were compared using an independent t test. With freehand (standard) drilling, the mean plunge depth was 8.8 mm. For surgeon 1, the range was 5.6 to 15.8 mm (mean, 10.9 mm). For surgeon 2, the range was 3.3 to 11.0 mm (mean, 6.4 mm). The surgeons' plunge depths were significantly different. In bicortical mode, the drill motor stopped when the second cortex was penetrated. Drill-measured depths were verified by computed tomography scan, with a mean difference of 0.8 mm. Mean distances from the clavicle to the neurovascular structures were 15.5 mm for the subclavian vein, 18.0 mm for the subclavian artery, and 8.0 mm for the brachial plexus. Plunge depths differed between surgeons. However, both surgeons' plunge depths were greater than distances to the neurovascular structures, indicating a risk of injury due to plunging. Although a nonspinning drill bit may still cause soft tissue damage, drill-sensing technology may decrease the risk of penetrating soft tissue structures due to plunging. [Orthopedics. 2021;44(1):e36-e42.]., (Copyright 2020, SLACK Incorporated.)

Background: Central venous catheter (CVC) complication rates reflecting the application of modern insertion techniques to a clinically heterogeneous patient populations are needed to better understand procedural risk attributable to the 3 common anatomic insertion sites: internal jugular, subclavian, and femoral veins. We sought to define site-specific mechanical and duration-associated CVC complication rates across all hospital inpatients., Methods: A retrospective chart review was conducted over 9 months at Georgetown University Hospital and Washington Hospital Center. Peripherally inserted central catheters and tunneled or fluoroscopically placed CVC's were excluded. Mechanical complications (retained guidewire, arterial injury, and pneumothorax) and duration-associated complications (deep vein thrombosis or pulmonary embolism, and central line-associated bloodstream infections) were identified., Results: In all, 1179 CVC insertions in 801 adult patients were analyzed. Approximately 32% of patients had multiple lines placed. Of 1179 CVCs, 73 total complications were recorded, giving a total rate of one or more complications occurring per CVC of 5.9%. There was no statistically significant difference between site-specific complications. A total of 19 mechanical complications were documented, with a 1.5% complication rate of one or more mechanical complications occurring. A total of 54 delayed complications were documented, with a 4.4% complication rate of 1 or more delayed complications occurring. There were no statistically significant differences between anatomic sites for either total mechanical or total delayed complications., Conclusions: These results suggest that site-specific CVC complication rates may be less common than previously reported. These data further inform on the safety of modern CVC insertion techniques across all patient populations and clinical settings.

Competing Interests: Competing interests: None declared.

Purpose: Traumatic subclavian vascular injury (TSVI) is rare but often fatal. The precise diagnosis of TSVI remains challenging mainly because of its occult nature, less typical presentations, and being overlooked in the presence of polytrauma. Compared to penetrating injuries, it is even more difficult to identify TSVI in patients who have blunt injuries and no visible bleeding. The risk factors associated with TSVI in patients with thoracic trauma are unclear. The aims of this study were to identify risk factors for TSVI in a cohort of patients with thoracic vascular injuries and to report outcomes after clinical treatment., Methods: From January 2009 to June 2017, 39586 patients were admitted to our hospital (a level I trauma center) due to trauma, and 136 patients with thoracic vascular injury were enrolled in this study. We retrospectively reviewed data from medical records including demographic characteristics, injury scoring systems (RTS, ISS, NISS, TRISS and AIS), management and outcomes. Patients were further divided into the TSVI group (patients with TSVI) and the non-TSVI group (patients with thoracic vascular injuries other than TSVI). Univariate and multivariate analyses were used to identify independent risk factors., Results: The enrolled 136 patients suffered mostly from blunt trauma (89.0%) and 22 of them had TSVI. When compared to the non-TSVI group, the TSVI group had lower Glasgow Coma Scale (GCS) scores (p = 0.002; especially GCS ≤ 12), less concurrent abdominal injury (p < 0.001), lower Injury Severity Scales (ISS) (p = 0.007) and New Injury Severity Scales (NISS) (p < 0.002) but had higher Abbreviated Injury Scales (AIS) of the head ≥ 3 (p = 0.009) and rates of clavicular or scapular fractures (p = 0.013). No difference was detected between the two groups with regard to age, gender, trauma mechanism, vital signs on arrival, or rate of facial and extremities injury. In multivariate regression analyses, GCS ≤ 12, AIS of the head ≥ 3 and the presence of clavicular or scapular fractures were independent risk factors for TSVI (p = 0.026, p = 0.043 and p = 0.005, respectively) after adjustment for confounding factors. Open and endovascular repair were two surgical procedures utilized for these TSVI patients with an overall mortality rate of 18.2%. No difference was found between these groups with regard to mortality rate and the length of ICU stay, but the patients in the TSVI group had a shorter length of hospital stay., Conclusions: Our results suggest that GCS ≤ 12, AIS of the head ≥ 3 and the presence of clavicular or scapular fractures were independent risk factors for TSVI in patients with thoracic vascular injuries. For patients with thoracic trauma, TSVI should be considered for prompt management when patients exhibit concurrent injuries to the head, clavicle or scapula.

Our report demonstrates how Twiddler's syndrome associated with subclavian crush syndrome may result in a challenging transvenous lead extraction. Thus, it should be performed in centers with experience with the appropriate tools.

Introduction: Cardiac implantable electronic device (CIED) trans venous lead extraction (TLE) is technically challenging. Whether the use of a laser sheath reduces complications and improves outcomes is still in debate. We therefore aimed at comparing our experience with and without laser in a large referral center., Methods: Information of all patients undergoing TLE was collected prospectively. We retrospectively compared procedural outcomes prior to the introduction of the laser sheath lead extraction technique to use of laser sheath., Results: During the years 2007-2017, there were 850 attempted lead removals in 407 pts. Of them, 339 (83%) were extracted due to infection, device upgrade/lead malfunction in 42 (10%) cases, and other (7%). Complete removal (radiological success) of all leads was achieved in (88%). Partial removal was achieved in another 6% of the patients. Comparison of cases prior to and after laser technique introduction, showed that with laser, a significantly smaller proportion of cases required conversion to femoral approach [31/275 (6%) laser vs. 40/132 (15%) non-laser; p<0.001]. However, success rates of removal [259/275 (94%) vs. 124/132 (94%) respectively; p = 0.83] and total complication rates [35 (13%) vs. 19 (14%) respectively; p = 0.86] did not differ prior to and after laser use. In multivariate analysis, laser-assisted extraction was an independent predictor for no need for femoral extraction (OR = 0.39; 95% CI 0.23-0.69; p = 0.01)., Conclusion: Introduction of laser lead removal resulted in decreased need to convert to femoral approach, albeit without improving success rates or preventing major complications., Competing Interests: The authors have declared that no competing interests exist.

Purpose: Clavicle fractures are common injuries in adults and children. Although neurovascular damage is rarely seen, acute subclavian artery pseudoaneurysms and injuries to subclavian vessels were reported for closed fractures of the clavicle. The aim of this study was to identify the morphological details of the subclavian vessels and their relation to the sternoclavicular joint and body of the clavicle., Methods: 127 patients (66 females and 61 males) were evaluated using reconstructed three-dimensional computed tomographic angiographies. The point at which the subclavian artery crossed posterior to the clavicle was detected as a landmark. The medio-lateral distance between the sternal end of the clavicle, landmark, antero-posterior distance between the clavicle and the subclavian artery, diameter of the artery and vein, angle between the subclavian artery and vein, distance of the subclavian vein to the subclavian artery and the clavicle at the landmark were measured. Measurements were compared according to gender and right and left sides, and age correlation was determined., Results: Morphometric relationship between the subclavian vessels and clavicle presented differences between genders. We measured the antero-posterior distance between the subclavian artery and the clavicle to be less than 1 cm (0.91 cm)., Conclusion: The subclavian artery travelled longer distances in men than women to reach the point that it crossed the clavicle. Our results demonstrated that the subclavian artery does not pass from the inferior margin of the clavicle, thus, superior plate osteosynthesis does not have any risk to injury against the subclavian vessels during the management of the clavicle fractures.

Background: Patients with stable blunt great vessel injury (GVI) can have poor outcomes if the injury is not identified early. With current pediatric trauma radiation reduction efforts, these injuries may be missed. As a known association between scapular fracture and GVI exists in adult blunt trauma patients, we examined whether that same association existed in pediatric blunt trauma patients., Methods: Bluntly injured patients younger than 18 years old were identified from 2012 to 2014 in the National Trauma Data Bank. Great vessel injury included all major thoracic vessels and carotid/jugular. Demographics of patients with and without scapular fracture were compared with descriptive statistics. The χ test was used to examine this association using SAS Version 9.4 (SAS Institute, Inc, Cary, NC)., Results: We found a significant association between pediatric scapular fracture and GVI. Of 291,632 children identified, 1,960 had scapular fractures. Children with scapular fracture were 10 times more likely to have GVI (1.2%) compared to those without (0.12%, p < 0.0001). Most common GVI seen were carotid artery, thoracic aorta, and brachiocephalic or subclavian artery or vein. Children with both scapular fracture and GVI were most commonly injured by motor vehicles (57% collision, 26% struck)., Conclusions: Injured children with blunt scapular fracture have a 10-fold greater risk of having a GVI when compared to children without scapular fracture. Presence of blunt traumatic scapular fracture should have appropriate index of suspicion for a significant GVI in pediatric trauma patients., Level of Evidence: Epidemiologic and prognostic study, level III; Therapeutic, level IV.

Background: In cases of lead failure after implantation of pacemakers (PM) or implantable cardioverter defibrillators (ICD) early lead replacement may be challenging. Puncture of the subclavian vein bears possible complications such as pneumothorax, hematothorax, and damage of leads to be left in place. To avoid venous puncture PM or ICD leads were replaced using a flexible polypropylene sheath (Byrd-sheath)., Method: From January 2010 through December 2017, 55 patients underwent early lead exchange avoiding venous puncture. Early lead exchange for this study was defined as a reintervention within 14 days after the initial lead implantation. The connector of the malfunctioning lead was cut off, and stabilized by a stiff stylet. After having cut off the plastic knob of the stylet, the lead was passed through the polypropylene sheath and the latter advanced into the subclavian vein with gentle rotational movements to gain access to the subclavian vein. After lead removal the polypropylene sheath was replaced by a peel away sheath a new lead inserted., Results: Overall, 23 defibrillation leads and 34 pacing leads (16 right atrial leads, 17 right ventricular leads, and 1 left ventricular lead) were successfully explanted. Access to the subclavian vein was uneventful, and blood loss minimal. Radiation exposure and fluoroscopy time were also negligible., Conclusion: The Byrd-sheath technique proved to be safe and successful in providing vein access within 2 weeks after initial lead implantation using the previously implanted lead and thus avoiding puncture of the subclavian vein.

Background: This paper reviews our experience with penetrating cervical venous trauma and aims to validate the selective non-operative management (SNOM) of these injuries., Methods: This was a retrospective review of a prospectively maintained registry. All patients presenting alive with an injury to the internal jugular vein, subclavian vein or innominate vein following a PNI were reviewed for a 6-year period., Results: Among 817 patients admitted for the management of PNI, 76 (9.3%) had a venous injury. Of these, 37 (48.7%) patients were managed non-surgically, 20 (26.3%) required immediate surgical exploration, seven of whom had an associated arterial injury, and 19 (25%) underwent surgery following a diagnostic CTA, 16 of whom had an associated arterial or aero-digestive injury. In total, only 16 (21.1%) of the 76 patients required exploration for venous injury alone. The majority (63.2%) of patients had a history of severe bleeding or hemodynamic instability prior to arrival, but only 20 (26.3%) required immediate exploration. Two (2.6%) patients died as a result of venous injury. No patients developed complications related to the venous injury., Conclusions: SNOM is applicable to a well-defined subset of patients with isolated penetrating cervical venous trauma to the IJV and SCV identified on CTA.

BACKGROUND The persistence of a vein of Marshall (VoM) from the left subclavian vein to the coronary sinus is a rare cardiac anomaly known as a persistent left superior vena cava (PLVC). This anatomical variant is usually asymptomatic but can lead to serious complications during catheterization via the left subclavian or internal jugular vein, as described here. In our case, the patent vein of Marshall directly connected the coronary sinus with the left subclavian vein discovered in a cardiac arrest patient because of pericardial effusion during the insertion of a central venous catheter (CVC). CASE REPORT A 62-year-old patient required a central line insertion through a left internal jugular vein. The patient immediately went into cardiac arrest after CVC insertion with a pericardial effusion. The patient was successfully resuscitated with the drainage of a pericardial effusion. A chest X-ray revealed that the central venous catheter (CVC) was located along the left border of the mediastinum rather than the right border. It was evident that the central venous catheter was inadvertently placed into the pericardial space, resulting in tamponade. This complication occurred through inadvertent access of a small persistent vein of Marshall. CONCLUSIONS This case illustrates the importance of knowledge of anatomical variants of the persistent vein of Marshall to prevent or correctly interpret and manage procedural complications.

Different methods for venous access are used for permanent pacemaker or implantable cardioverter defibrillator (ICD), of which subclavian vein puncture technique is the most widely practised. Although this approach is relatively easy to learn, quick and offers high success rates, it may be associated with potential serious acute complications including pneumothorax, emopneumothorax, brachial plexus injury and longer-term complications such as lead fracture, loss of lead insulation and subclavian crush syndrome especially in young patients with ICD leads. Axillary vein approach seems to be a favourable technique not only for the prevention of acute complications but also to reduce lead failure including lead insulation and lead fracture prevention with a consequently better long-term lead survival compared with the classical subclavian approach. Although randomized studies are lacking, recent reports not only evaluated the safety and effectiveness of new fluoroscopic axillary venous puncture technique, but also compared it with the conventional intrathoracic subclavian venous puncture technique for the implantation of leads in permanent pacing. Various techniques of axillary vein puncture have been proposed ranging from a blind percutaneous puncture to the use of different tools such as contrast venography and ultrasound. In this article, we report a case of subclavian crush syndrome, the use of a modified Bellot's technique of axillary vein puncture that we currently use and the potential benefits of axillary vein puncture for pacemaker and ICD leads implantation compared with subclavian approach to avoid acute and long-term lead complications.

Central venous catheters are usually positioned using the Seldinger technique with a guidewire. This article reports a case where the guidewire was inserted via the left subclavian vein with the landmark technique. The guidewire became kinked, pierced the vessel wall and became stuck forming several loops within the adjacent tissue of the vein. Several attempts were made to remove the guidewire by interventional radiology but were unsuccessful. Due to the critical condition of the patient an operation was considered too perilous and the guidewire was finally left in situ. No formation of local venous thrombosis could be detected.

Central vein stenosis is not uncommon in hemodialysis-dependent patients as a result of mechanical damage to the vessel walls from prior cannulation. It can cause ipsilateral upper limb swelling and pain, resulting in suboptimal hemodialysis. It is unfortunate for bilateral central vein stenosis to develop concomitantly, and rare in the setting of an in-situ pacemaker. This case illustrates the successful ligation of a nondependent left arteriovenous fistula and stenting of the right subclavian vein with functioning ipsilateral arteriovenous fistula, to overcome the problem of symptomatic bilateral upper limb swelling., (© The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

We report the case of a 51-year-old woman who underwent hemicolectomy for colon cancer and subsequent hepatic metastasectomy for liver metastases. Right percutaneous infraclavicular subclavian venous port catheterization was performed during the initial operation for chemotherapy. She received chemotherapy after each operation with no reported complications. During a right thoracotomy for lung metastases 2 years after the catheter placement, we noticed the catheter perforating the right subclavian vein and directly entering the superior vena cava. To prevent hemorrhaging during catheter removal, we initially performed the lung metastasectomy, after which we decided to intrathoracically remove the catheter. No complication was observed. To the best of our knowledge, this case is the first of its kind to be reported in the published literature., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Post-mortem imaging at autopsy is gradually increasing in popularity among forensic practitioners. The objective of the present paper was to demonstrate that it is essential to survey the cadaver using computed tomography (CT) before autopsy. This case report presents an iatrogenic tension pneumothorax caused by left subclavian vein puncture undertaken during treatment for a gunshot-related wound. The victim, a 64-year-old woman, was shot by her husband at home, and transferred to the hospital emergency unit. Before surgical procedures were carried out, left subclavian vein puncture was performed; however, during the operation, the victim experienced sudden cardiac arrest. Subsequent intensive resuscitation was unsuccessful. The clinical cause of death was recorded as traumatic shock caused by the gunshot injury. However, before the legal autopsy took place, CT clarified the existence of tension pneumothorax not on the same side as the gunshot wound, but on the side of the iatrogenic subclavian vein puncture. Because of this information gained prior to legal dissection, a typical dissection procedure for tension pneumothorax could be performed. Post-mortem imaging prior to regular dissection is essential as an adjunct diagnostic tool., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

A 30-year-old female with end-stage renal disease was a candidate for dual lumen catheter placement. After catheter insertion, O2 saturation measurement of the aspirated blood from the catheter was similar to that of arterial blood. They referred the patient to our hospital after 48 hours. Diagnostic procedures revealed that the tip of the catheter had entered the pleural cavity. Catheter removal in the CPR room resulted in hemorrhagic shock. The patient was resuscitated and stabilized and sent to the operating room. A laceration found at the junction of right jugular and right subclavian veins and was surgically repaired. The patient was discharged after ten days without any complication.

Haemodialysis catheters used in the treatment of renal failure can cause very serious complications. Therefore, selection of the appropriate vein, and application of the intervention under ultrasound (US) guidance, carry vital importance. In this study, we aimed to present a potentially fatal complication of temporary haemodialysis catheter.

Unlabelled: The detachment of subclavian artery from brachiocephalic trunk and subclavian vein from right brachiocephalic vein with brachial plexus injury., Introduction: Traumas of large vessels of mediastinal and shoulder girdle cause significant life risk and constitute serious diagnostic and therapeutic problems because of lack of time for accurate treatment planning. Particularly difficult to treat are blunt trauma of large arteries in patients under the influence of drugs or with a progressive hypovolemic shock., Aim: The aim of this dissertation is presenting my own experience in treating a seventeen-year-old motorcyclist who was under the influence of alcohol suffered a detachment of subclavian artery and subclavian vein from mediastinal large vessels following a traffic accident., Material and Methods: Seventeen-year-old motorcyclist who was under the influence of alcohol alcohol hit a concrete pole at a speed of 130 km/h. The patient was brought to the hospital in a state of hypovolemic shock, pulse 126/min, blood pressure 80/60 mmHg, without pulse on the right upper limb. The right upper limb was cold, without active movements, pressure and pain sense. The right shoulder was tumid. The right lung without audible murmurs. Pulses on carotid arteries were perceptible. The thoracic plain film x-ray showed a shading on right half of thorax, widening of the upper mediastinum, fracture of right clavicle and the rear right shoulder sprain. Passive movements in the right elbow were correct. The patient was taken to the operating theatre because of progressive hypovolemic shock and was operated in emergency regimen. The transverse thoracotomy was made by both the intercostals spaces between the second and third rib. The thoracotomy showed that subclavian artery from brachiocephalic trunk and subclavian vein from right brachiocephalic vein were detachment. The subclavian vein was ligated and the brachiocephalic vein was sewn (phleborrhaphy). The subclavian artery was connected with brachiocephalic trunk by a synthetic vascular graft so that the received pulse at the periphery of the upper limb. The thyrocervical trunk, costocervical trunk and damaged intercostal vessels at the first, second and third rib were also ligated. The sprained shoulder was set. During the operation, there was no sight that even one of fascicles of brachial plexus was interrupted. The next day pateint was reoperated because of hemorrhage to right pleura. The rest of intercostal vessels at the first, second and third rib were ligated., Results: The postoperative course was uneventful surgery. After operation was found that ulnar and radial nerve were demaged. The right lung expansion was achieved, upper limb had pulse, wounds healed as needed. The patient was transferred to the neurosurgical treatment., Conclusion: The quick decision to conduct operations without accurate diagnosis was the only factor for patient survival.

Background: Fractures of the clavicle are extremely common, representing 2.6-12% of all fractures and 35-44% of all shoulder girdle injuries; 69-82% of these fractures occur in the middle third of the clavicle. Vascular injuries relating to clavicle fracture are usually due to extreme force applied to the clavicle in an acute setting. No other reports of delayed subclavian vein laceration were found on literature search., Objectives: We present this case to increase awareness among emergency physicians of the potential delayed presentation of this rare condition., Case Report: A 21-year-old man presented to the Emergency Department with acute swelling of the base of the neck after carrying a heavy load on his left shoulder the night before. He had been recovering from a clavicle fracture for 2 months. Malunion of his left midshaft clavicle fracture led to subclavian vein injury and formation of a large hematoma secondary to reinjury that occurred at work the night before presentation. Computed tomography revealed a 9-cm hematoma at the fracture site. The patient was found to have a subclavian vein injury without evidence of arterial injury or nervous system involvement. The patient was admitted for observation and subsequently discharged without need for surgical intervention., Conclusion: Subclavian vein laceration is a rare complication of clavicle fracture. Patient education at discharge after conservative management is important due to the risk of vascular complications from malunion and reinjury., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Noncompressible hemorrhage is the leading cause of preventable death caused by hemorrhage on the battlefield. Currently, there are no hemostatic agents with the ability to control noncompressible hemorrhage. A wound stasis dressing based upon rapidly expanding cellulose minisponges (MS) was developed and tested in a lethal noncompressible model in swine, by fully transecting subclavian artery and vein. MS were compared with conventional hemostasis dressings, Combat Gauze (CG), in a randomized comparison., Methods: Sixteen 40-kg swine underwent transection of the subclavian artery and vein through a 4.5-cm aperture. After 30-second free bleeding, randomly selected MS or CG (n = 8 per group) were administered by an independent medical officer. The wound cavity was filled with either MS + no external pressure or one CG + one KERLIX gauze with 3 minutes of external pressure. One reapplication was allowed for CG. Mean arterial pressure was maintained at 60 mm Hg with 500-mL Hextend and lactated Ringer's solution intravenously administered up to a maximum of 10-L until study termination at 1 hour., Results: Mean pretreatment blood loss was similar for MS (719 mL) and CG (702 mL). Primary end points, namely, hemostasis at 4 minutes (MS, 75%; CG, 25%; p = 0.13), hemostasis at 60 minutes (MS, 100%; CG, 25%; p = 0.007), and survival at 60 minutes (MS, 100%; CG, 37.5%; p = 0.026), were improved with MS as were secondary end points, namely, total blood loss (MS, 118 mL; CG 1,242 mL; p = 0.021) and length of application time (MS, 25 seconds; CG, 420 seconds; p = 0.004)., Conclusion: The use of MS is a novel approach for the rapid, simple treatment of severe noncompressible hemorrhage, which provided statistically significant improvement in hemostasis and survival 60 minutes after injury and a large reduction in blood loss, resuscitation fluid requirement, and medic treatment time compared with conventional hemorrhage control dressings in a swine model.

This case report illustrates the case of a patient who developed recurrent strokes after a pace maker lead was inserted into his left ventricle. It was removed successfully by the cardiothoracic surgeons but he remained very dependent functionally. This case highlights the importance of always reviewing the electrocardiogram and chest radiograph after the insertion of a pacemaker as late diagnosis of this complication can leave the patient with significant morbidity.

Many mechanical complications associated with insertion, maintenance, and removal of the hemodialysis catheters have been reported in the literature. A 47-year-old man was consulted to our hospital because of an entrapped hemodialysis catheter guidewire. Computed tomographic scan revealed that the right subclavian vein was perforated by the guidewire and the wire was knotted over itself, one loop inside the vein and two loops in the extravascular site. Guidewire is pulled out from a 3-cm incision over the wire loops lateral to the right sternocleidomastoid muscle. He was discharged home on postoperative day 2 without any complication. Our suggestion is that any abnormal resistance should be immediately evaluated for the presence of any potential knots using the most appropriate imaging technique., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Vascular Ehlers-Danlos (VED) represents a rare disorder in which a defect in collagen synthesis renders vessels to be extremely fragile. We report the successful repair of a subclavian artery pseudoaneurysm via a hybrid technique employing delivery of a covered stent along with video-assisted thoracoscopic ligation of the internal mammary artery in a patient with VED., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: A port-A catheter implantation for cancer patients is popular as a route for chemotherapy. Potential complications exist, such as perforation during chemotherapeutic agent infusion, especially when the port-A tip is incorrectly positioned or when it is in long-term use., Case Report: We report on a patient who presented with hoarseness as a result of port-A catheter perforation-related mediastinitis subsequent to chemotherapeutic agent infusion through the catheter., Conclusions: Hoarseness is a rare complication of port-A perforation and extravasation. To avoid perforation, the tip of the catheter should be located in a high-flow vessel, such as the distal superior vena cava rather than higher in the caval vein, to prevent a locally increased concentration of drugs. We also recommend that a venogram be arranged if extravasation is suspected., (Copyright © 2012 S. Karger AG, Basel.)

Endovascular treatment options have evolved in many ways and become an important alternative for open surgical repairs in various vascular territories. Herein, we present a case of an 18-year-old man with complex injury to the left subclavian artery and vein caused by a gunshot 4 months ago. After the gunshot, a high-flow fistula between the left subclavian artery and the vein occurred with pseudoaneurysm formation. This fistula led to a significant left subclavian steal phenomenon. A stent-graft was deployed along the injured left subclavian artery after embolization of the left vertebral artery by Amplatzer vascular plug 4 (AVP-4) in order to prevent subsequent endoleak due to the subclavian steal syndrome.

Mediastinal haematoma is a rare complication following insertion of central venous catheter, with few cases reported in the literature. We report a case of mediastinal haematoma in a 33-year-old male patient with end-stage renal disease. In this patient central venous catheter insertion through the right subclavian vein was attempted on the operation table for renal transplantation but the procedure was abandoned as the attempt was unsuccessful. Post-procedure chest radiograph showed a large mediastinal haematoma occupying right hemithorax that developed as a result of injury to the subclavian vein. Patient was managed conservatively and haematoma completely resolved in four weeks time. This case is being reported to signify the importance of routine obtaining a post-procedure chest radiograph and to state that even large mediastinal haematoma can be managed conservatively in asymptomatic patients.

Background: The epidemiology of vascular injuries in the geriatric patient population has not been described. The purpose of this study was to examine nationwide data on vascular injuries in the geriatric patients and to compare this with the nongeriatric adult patients with respect to the incidence, injury mechanisms, and outcomes., Methods: Geriatric patients aged 65 or older with at least one traumatic vascular injury were compared with an adult cohort aged 16 years to 64 years with a vascular injury using the National Trauma Databank version 7.0., Results: During the study period, 29,736 (1.6%) patients with a vascular injury were identified. Of those, geriatric patients accounted for 7.6% (2,268) and the nongeriatric adult patients accounted for 83.1% (n=24,703). Compared with the nongeriatric adult patients, the geriatric vascular patients had a significantly higher Injury Severity Score (26.6±17.0 vs. 21.3±16.7; p<0.001) and less frequently sustained penetrating injuries (16.1% vs. 54.1%; p<0.001). The most commonly injured vessels in the elderly were vessels of the chest (n=637, 40.2%), including the thoracic aorta and innominate and subclavian vessels. The overall incidence of thoracic aorta injuries was significantly higher in geriatric patients (33.0% vs. 13.9%; p<0.001) and increased linearly with progressing age. After adjusting for confounding factors, geriatric patients demonstrated a fourfold increase in mortality following vascular injuries (adjusted odds ratio, 3.9; 95% confidence interval, 3.32-4.58; p<0.001)., Conclusion: Vascular trauma is rare in the geriatric patient population. These injuries are predominantly blunt, with the thoracic aorta being the most commonly injured vessel. Although vascular injuries occur less frequently than in the nongeriatric cohort, in the geriatric patient, vascular injury is associated with a fourfold increase in adjusted mortality.

Background: Cardiovascular injuries after trauma present with high mortality. The aim of the study was to present our experience in cardiac and great vessel injuries after chest trauma., Methods: During the 10-year period, 104 patients with cardiac (n=94) and great vessel (n=10) injuries presented to our hospital. The demographic data, mechanism of injury, location of injury, other associated injuries, timing of surgical intervention, surgical approach, and clinical outcome were reviewed., Results: Eighty-eight (84.6%) males presented after chest trauma. The mean age of the patients was 32.5±8.2 years (range: 12-76). Penetrating injuries (62.5%) were the most common cause of trauma. Computed tomography was performed in most cases and echocardiography was used in some stable cases. Cardiac injuries mostly included the right ventricle (58.5%). Great vessel injuries involved the subclavian vein in 6, innominate vein in 1, vena cava in 1, and descending aorta in 2 patients. Early operations after admission to the emergency were performed in 75.9% of the patients. Thoracotomy was performed in 89.5% of the patients. Operative mortality was significantly high in penetrating injuries (p=0.01)., Conclusion: Clinicians should suspect cardiac and great vessel trauma in every patient presenting to the emergency unit after chest trauma. Computed tomography and echocardiography are beneficial in the management of chest trauma. Operative timing depends on hemodynamic status, and a multidisciplinary team approach improves the patient's prognosis.

A 48-year-old male with a symptomatic 2:1 atrio-ventricular block and a dual-chamber pacemaker, implanted one year previously, was admitted due to a syncopal episode. Pacemaker malfunction was identified as the cause of syncope. Subclavian crush syndrome was the cause of the pacemaker malfunction. Its incidence, consequences and management are discussed in this report.

In the case presented an intravenous line for large volume infusion rates was to be placed in a patient with an aortic aneurysm during clinical preoperative care. After a high-flow catheter had been placed without any problems retraction of the guide wire was found to be impossible. Computer tomography revealed that the reason was a kink in the catheter resulting in the guide wire being nipped off. Fortunately both catheter and guide wire could be removed completely without any further complications.

Subclavian arteriovenous fistula (AVF) is a rare complication of implantable cardioverter-defibrillator (ICD) implantation. This report illustrates the case of a subclavian AVF after ICD implantation in a patient with nonischemic cardiomyopathy and the successful closure of this AVF using an Amplatzer vascular occlusion plug. Given the increasing number of ICD implantations, physicians should be made aware of this uncommon complication. In addition, as more percutaneous endovascular techniques are developed to treat peripheral vascular and structural heart disease, iatrogenic AVFs may occur more frequently. The Amplatzer vascular plug should be considered as a potential treatment strategy for AVFs alongside other endovascular and surgical techniques., (Copyright © 2011 Wiley-Liss, Inc.)