[논문]다발성 외상환자에서 혈관계 접근을 통해 치료한 쇄골하동맥 손상 2례

조자윤; 정희경; 김형기; 임경훈; 박진영; 허승

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Introduction: Surgical treatment of subclavian artery (SA) injury is challenging because approaching the lesion directly and clamping the proximal artery is difficult. This can be overcome by using an endovascular technique. Case 1: A 37-year-old male was drawn into the concrete mixer truck. He had ...

Introduction: Surgical treatment of subclavian artery (SA) injury is challenging because approaching the lesion directly and clamping the proximal artery is difficult. This can be overcome by using an endovascular technique. Case 1: A 37-year-old male was drawn into the concrete mixer truck. He had a right SA injury with multiple traumatic injuries: an open fracture of the right leg with posterior tibial artery (PTA) injury, a right hemothorax, and fractures of the clavicle, scapula, ribs, cervical spine and nasal bone. The injury severity score (ISS) was 27. Computed tomography (CT) showed a 30-mm-length thrombotic occlusion in the right SA, which was 15 mm distal to the vertebral artery (VA). A self-expandable stent($8mm{\times}40mm$ in size) was deployed through the right femoral artery while preserving VA flow, and the radial pulse was palpable after deployment. Other operations were performed sequentially. He had a viable right arm during a 13-month follow-up period. Case 2: A 25-year-old male was admitted to our hospital due to a motorcycle accident. The ISS was 34 because of a hemothorax and open fractures of the mandible and the left hand. Intraoperative angiography was done through a right femoral artery puncture. Contrast extravasation of the SA was detected just outside the left rib cage. After balloon catheter had been inflated just proximal to the bleeding site, direct surgical exploration was performed through infraclavicular skin incision. The transected SA was identified, and an interposition graft was performed using a saphenous vein graft. Other operations were performed sequentially. He had a viable left arm during a 15-month follow-up period. Conclusion: The challenge of repairing an SA injury can be overcome by using an endovascular approach.

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문제 정의

(2) In the Republic of Korea where gun control is very strict, penetrating trauma is so fewer than western countries that SA injury itself is rare. In this report, we describe the endovascular approach in the treatment of blunt SA injury and the review of literature.

제안 방법

And radial artery pulse was palpable after stent deployment. Other operations were performed sequentially which were interposition graft in the transected paramalleolar PTA lesion using saphenous vein, open reduction and internal fixation (OR/IF) of tibia and closed reduction of nasal bone. The surgeries lasted 11 hours in aggregate, during which the patient received 3 units of packed red blood cells.

대상 데이터

A 25-year-old previously healthy male patient was injured by motorcycle accident and had blunt trauma on the left shoulder. CT showed that left SA was ruptured and extravasated which was 20 mm distal to VA (Fig.
A 37-year-old schizophrenic male patient was drawn into the concrete mixer truck and had blunt trauma on the right shoulder. He had right SA injury with multiple traumatic injuries which was open fracture of right distal lower leg with posterior tibial artery (PTA) injury, right hemothorax and fractures of clavicle, scapula, ribs, cervical spine and nasal bone.

성능/효과

In the western data, penetrating trauma is the most common in the SA injury, while blunt trauma is extremely rare.(2) In the Republic of Korea where gun control is very strict, penetrating trauma is so fewer than western countries that SA injury itself is rare. In this report, we describe the endovascular approach in the treatment of blunt SA injury and the review of literature.
(5) Brachial plexus injury is more common in the blunt trauma and is the significant morbidity in the long term.(6) Intimal disruption and dissection which is not flow limiting can be treated conservatively, while thrombotic occlusion, perforation, transection, pseudoaneurysm and arteriovenous fistula should be considered to repair.(7)

참고문헌 (15)

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Demetriades D, Rabinowitz B, Pezikis A, Franklin J, Palexas G. Subclavian vascular injuries. Br J Surg. 1987 Nov; 74(11): 1001-3.

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Johnson SF, Johnson SB, Strodel WE, Barker DE, Kearney PA. Brachial plexus injury: association with subclavian and axillary vascular trauma. J Trauma. 1991 Nov; 31(11): 1546- 50.

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DuBose JJ, Rajani R, Gilani R, Arthurs ZA, Morrison JJ, Clouse WD, et al. Endovascular management of axillo-subclavian arterial injury: A review of published experience. Injury. 2012 Nov; 43(11): 1785-92.

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Xenos ES, Freeman M, Stevens S, Cassada D, Pacanowski J, Goldman M. Covered stents for injuries of subclavian and axillary arteries. Journal of Vascular Surgery. 2003 Sep; 38(3): 451-4.

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Shalhub S, Starnes BW, Hatsukami TS, Karmy-Jones R, Tran NT. Repair of blunt thoracic outlet arterial injuries: an evolution from open to endovascular approach. J Trauma. 2011 Nov; 71(5): E114-121.

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Danetz JS, Cassano AD, Stoner MC, Ivatury RR, Levy MM. Feasibility of endovascular repair in penetrating axillosubclavian injuries: A retrospective review. Journal of Vascular Surgery. 2005 Feb; 41(2): 246-54.

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Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011 Dec; 71(6): 1869-72.

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Carrick MM, Morrison CA, Pham HQ, Norman MA, Marvin B, Lee J, et al. Modern management of traumatic subclavian artery injuries: a single institution's experience in the evolution of endovascular repair. Am J Surg. 2010 Jan; 199(1): 28- 34.

상세보기
Mousa A, Chong B, AbuRahma AF. Endovascular repair of subclavian/axillary artery injury with a covered stent. A case report and review of literature. Vascular [Internet]. 2013 May 7 [cited 2013 Jul 28]; Available from: http://vas.sagepub.com/ content/early/2013/05/03/1708538113478754.

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다발성 외상환자에서 혈관계 접근을 통해 치료한 쇄골하동맥 손상 2례
Treatment of Subclavian Artery Injury in Multiple Trauma Patients by Using an Endovascular Approach: Two Cases 원문보기

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다발성 외상환자에서 혈관계 접근을 통해 치료한 쇄골하동맥 손상 2례 Treatment of Subclavian Artery Injury in Multiple Trauma Patients by Using an Endovascular Approach: Two Cases 원문보기

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다발성 외상환자에서 혈관계 접근을 통해 치료한 쇄골하동맥 손상 2례
Treatment of Subclavian Artery Injury in Multiple Trauma Patients by Using an Endovascular Approach: Two Cases 원문보기

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