O-166 - IN HOSPITAL AND LONGTERM OUTCOMES OF PATIENTS WHO UNDERWENT ENDO OR OPEN REPAIR OF AXILLOSUBCLAVIAN ARTERIAL INJURIES

TOPIC:
Vascular Trauma
AUTHORS:
Torres I. (Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo ~ Sao Paulo ~ Brazil) , Andrade R. (Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo ~ Sao Paulo ~ Brazil) , Apoloni R. (Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo ~ Sao Paulo ~ Brazil) , Da Silva E. (Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo ~ Sao Paulo ~ Brazil) , Puech-Leão P. (Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo ~ Sao Paulo ~ Brazil) , De Luccia N. (Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo ~ Sao Paulo ~ Brazil)
Introduction:
Blunt subclavian and axillary artery injuries are relatively rare, accounting for less than 9% of all vascular injuries. These injuries can contribute to significant morbidity and mortality and usually coexist with other injuries of adjacent structures (brachial plexus, aero-digestive tract, bone fractures, venous and lymphatic system). The optimal surgical treatment is a matter of debate, and in recent years endovascular surgery has become the first line of treatment in many centers around the globe, but there is concern with long term outcomes. This study aimed to evaluate in hospital and longterm outcomes after open or endo repair of axillosubclavian arterial injuries.
Methods:
This study was a retrospective analysis of data of the patients with axillosubclavian arterial injuries admitted at a high volume trauma center in Brazil (Hospital das Clínicas da Faculdade de Medicina da USP) from 2009 to 2020. We collected demographics, mechanism of injury, trauma scores, MESS score, time from trauma to treatment, ischemia time, surgical approach, transfusion requirements, complications, mortality, and limb salvage at discharge at hospital discharge. Independency for self-care, chronic pain and capacity to work were assessed during follow-up. Data underwent statistical analysis, p<0.05 was considered significant.
Results:
Fifty-seven patients suffered axillosubclavian trauma during the period of the study, mean follow-up time was 4.26  3.57 years. The mean age of the patients was 32.63+ 10.5 years; most patients were male (87.2%) and suffered from blunt trauma (51%). The median time to admission at our hospital after the trauma was 12 hours (IQR25-75% 1.4-30). The surgery was mainly due to ischemia (63.16%), median ischemia time was 13.5h (IQR 7.88-24) and most patients underwent endovascular repair (77.19%). The groups (open vs endo) were comparable analyzing age (33.61  10.09 vs 32.34  10.72, p=0.6973 Student t test), sex (masculine sex 84% vs 90.47%), type of trauma (blunt trauma 23% vs 56.82% p= 0.05629 Fisher Exact test), trauma Scores (ISS 13 IQR 9-34 vs 19 IQR 11-34, p=0.4535, TRISS 90 IQR 19-99 vs 98.3 IQR 79.5-99 p=0.247 Mann-Whitney test) and the Mangled Extremity Severity Score (4 IQR 4-5 vs 4 3-6 p=0.9489 Mann-Whitney test). Patients who underwent open repair arrived at the hospital in shorter time after the accident (4.8 hours IQR 3.02-9 vs 10.5 hours IQR 1.3-40.5), because they had axillary penetrating injuries and 24% were admitted with active bleeding. Comparing open and endo approach, there was no difference analyzing in-hospital complications (30% vs 43% respectively, p=0.53 Fisher Exact test), technical success rates (69.23% vs 93.19% p=0.57), amputation rate (0 vs 9% p=0.44 Fisher Exact test), need for blood components (median 2 packed red blood cells IQR 2-3 vs 4 IQR 2-4.75 p=0.7 Mann-Whitney test), days in ICU (2 IQR 0-4 vs 3.5 IQR 0.5-25 p=0.6453 Mann-Whitney test), days in-hospital (8.5 IQR 6-13.6 vs 8.5 IQR 3.75-16.5 p=0.6453 Mann-Whitney test), death (7.69% vs 6.8% 0.36 Fisher Exact test) and amputation free survival at hospital discharge (92.3% vs 81.82% p=0.66 Fisher Exact test) . The surgical time was longer for open procedures (382 minutes IQR 202-495 vs 180 minutes IQR 115-240 p=0.006 Mann-Whitney test) comparing to endovascular repair. Amputations was due to extensive injury in the arm (1/4), or irreversible ischemia at hospital admission (3/4). In-hospital complications were more common in patients who suffered polytrauma (53% of patients who had ISS>15 had complications, compared to 19% of patients with lower ISS p=0.01 Fisher Exact test). Most of the patients (52%) had some level of neurological impairment on the limb at hospital discharge, but it was related to brachial plexus injury and ischemia time, not to the modality of arterial treatment. This neurological impairment led to important limitations: 64% had to quit their jobs, 20% require help for selfcare. Additionally, 70% of the patients had chronic pain and needed to use medication almost daily, which was the main problem that affected their quality of life during follow-up.
Conclusion:
Endovascular is currently the first choice of treatment for patients with axillosubclavian trauma admitted at our hospital, but open repair was chosen in patient with axillary penetrating injuries admitted with active bleeding. In hospital and longterm complications were related with the severity of the trauma, associated injuries and ischemia time, rather than the modality of treatment of arterial injury.