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Ann Thorac Surg 1996;61:851-853
© 1996 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Stab Wounds of the Innominate Artery

Department of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa

Accepted for publication November 7, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Innominate artery stab wounds are rarely encountered, and the optimal management of this injury is different from that of blunt innominate injury in that permanent bypass shunting should not be necessary.

Methods. The records of 19 patients with stab wounds of the innominate artery who were treated by our department from January 1982 to June 1995 were reviewed.

Results. Eighteen patients (95%) sustained zone 1 neck stabs, with a similar proportion having only a single stab wound. Seventeen (89%) of the 18 patients having chest roentgenograms had mediastinal widening. Thirteen patients (68%) were hemodynamically stable at admission; the remainder were unstable (26%) or moribund (5%). Fourteen patients (74%) underwent angiography, with no false-negative studies for arterial injury. Associated injuries to thoracic viscera occurred in 4 patients (21%). All injuries were repaired with either direct suture (18 of 19) or prosthetic interposition grafting (1 of 19). One patient required cardiopulmonary bypass to repair complex injuries. The overall mortality rate was 5% (1 of 19), and complications occurred in 2 patients (11%).

Conclusions. Innominate artery stab wounds can be managed successfully without permanent bypass shunting and with a low mortality rate.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Innominate arterial injuries are uncommon. None were documented in large series of vascular injuries in both World Wars I and II [1, 2], and Rich and colleagues [3] documented only three innominate artery injuries during the Vietnam War. In civilian practice in the United States, injuries to the innominate artery have been well documented, although infrequently. The most common mechanism of injury is low-velocity gunshot wounds, followed by stab wounds [4–16]. As a result, the experience with stab wounds to the innominate artery is limited, and so it is difficult to establish whether permanent bypass shunting, as recommended in two recent studies, should be performed in all of these injuries [4, 5]. We therefore evaluated our results to attempt to clarify this issue.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
We reviewed retrospectively all patients treated by the Department of Cardiothoracic Surgery at Groote Schuur Hospital between January 1, 1982, and June 30, 1995, for innominate artery injuries. We reviewed the hospital records with regard to the mechanism and external location of injury, clinical status on admission, radiologic features, vessels injured, operative approaches, method of repair, and outcome. Records of all patients treated by the department are kept on a computerized database.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Nineteen patients with innominate artery stab wounds were treated during this 13-year period. Their age ranged between 18 and 46 years (mean, 26 years); 17 were men (90%) and two were women (10%).

Clinical Status on Admission
Thirteen patients (69%) were hemodynamically stable on admission, 5 patients (26%) were in shock (defined as blood pressure less than 90/60 mm Hg and signs of hypovolemia), and 1 patient (5%) was moribund. All patients were assessed immediately and resuscitated by the trauma unit staff, and were referred to the Department of Cardiothoracic Surgery. No patient required resuscitative thoracotomy.

The site of entry of the stab wound was zone 1 of the neck in 18 patients (95%); another patient had an entry wound immediately adjacent to the left side of the manubrium. No patients had pulse deficits or neurologic impairment on admission.

All individuals except the moribund patient had chest roentgenograms before operation. A widened mediastinum was apparent in 18 patients (89%), including 6 patients with a hemothorax in addition to mediastinal widening. One patient (5%) had an isolated hemothorax without other abnormalities. Fourteen patients (73%) underwent angiography. All 14 angiograms were abnormal, revealing extravasation of contrast in 4 (29%), false aneurysm formation in 7 (50%), and arteriovenous fistula in 3 (21%). All patients underwent immediate operation.

Operative Approach and Findings
Median sternotomy alone was used in 12 patients (64%), median sternotomy with neck extension in 6 (32%), and a trapdoor incision (anterolateral thoracotomy combined with partial sternotomy and supraclavicular incision) in 1 patient (5%). Injuries to other vascular structures were noted in 9 patients (50%) (Fig 1).

View larger version (33K): [in this window] [in a new window]   Fig 1. . Twelve associated vascular injuries involving seven vessels, which occurred in 9 patients. One patient had three vessel injuries and another had two vessel injuries.

Associated injuries to the intrathoracic viscera occurred in 4 patients (20%). Penetration of the esophagus (n = 1) and trachea (n = 2) was noted during operation and repaired immediately, without morbidity. The lung was injured in 2 patients; this was not repaired, but was managed with tube thoracostomy only.

Death occurred in 1 patient who had suffered hypoxic brain injury from sustained hypotension before admission and did not regain consciousness postoperatively. The mortality rate was thus 5%.

In 1 patient, a transient left hemiparesis developed after repair of his transected innominate artery; he subsequently recovered completely. Otherwise, all patients made an uncomplicated recovery.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Penetrating innominate artery injury is rarely encountered clinically because of the small target area, the protective barrier of the skeletal structures of the thoracic inlet, and the lethal nature of such injuries. Stab wounds of the innominate artery were responsible for only 8 of 5,760 vascular injuries over a 30-year period as reported by Mattox and associates [17]. We report a large group of 19 patients with stab wounds of the innominate artery. Johnston and colleagues [5] reported stab wounds in 7 patients with 3 deaths, for a mortality rate of 42.9% compared with a mortality rate of 24% for gunshot wounds and 14.3% for blunt trauma. These results suggest that stab wounds carry a higher mortality rate than other mechanisms of injury. Low-velocity gunshot wounds tend to cause more severe arterial injury (ie, transection) and resultant vasospasm, preventing exsanguination [6]. Stab wounds result in local incised injury and less vasospasm, with consequent ongoing bleeding. Our mortality rate of 5% is low, and several factors could account for our discrepant experience. The poor availability of rapid transport and early resuscitation facilities results in deaths before some patients reach the hospital. In addition, most bullet wounds in our experience are of medium or high velocity and are rapidly fatal when there is mediastinal penetration. Furthermore, a lower incidence of hemodynamic instability (31%, compared with 43% to 76% in other studies [5, 7]) in our patients suggests that the less severely injured patients reach the hospital.

Zone 1 neck stabs should alert the surgeon to the possibility of innominate artery injury, as this was the case in 95% of our patients. Other clinical signs such as pulse deficit and neurologic fallout are unreliable indicators of major thoracic vascular injury [7]. The high incidence of associated vascular and visceral injury with these wounds is not surprising given the proximity of these structures to one another at the thoracic inlet. Our findings of associated tracheal, esophageal, pulmonary, and vascular injury in 60% of patients are consistent with others' experience [5, 7, 8, 16]. This mandates that the surgeon meticulously explore the tract of the wounding instrument to avoid missing occult injury. Preoperative esophagograms are not necessary if operative exploration is indicated and only delay definitive management.

Ninety percent of our patients had a widened mediastinum with or without other abnormalities on chest roentgenogram. Although this is a nonspecific finding, it should alert one to the presence of possible substantial vascular injury. All 14 patients undergoing angiography had recognized vascular injury. Although a false-negative rate for arteriography studies of up to 23% has been reported in penetrating arterial injury, it remains an essential investigation in the stable patient to plan the operation [13, 15].

The operative approach advocated for repair of these injuries is median sternotomy with or without neck extension [4–6, 7–16]. This incision was used in all but 1 patient, with excellent exposure, and allows repair of both vascular and visceral injuries. In addition, cardiopulmonary bypass can be instituted through the same incision in the event of complex vascular injuries. We discourage the use of a partial sternotomy as advocated by some authors [6]. Although there may be increased morbidity with a full sternotomy, all patients were still discharged within 10 days of admission.

When the surgeon is faced with a large mediastinal hematoma and ongoing bleeding, we recommend applying digital pressure, simultaneously opening the pericardium, and following the ascending aorta cephalad to locate the innominate artery at its origin from the aortic arch and to provide proximal vascular control [9].

Ninety-five percent of the injuries were repaired with direct suture using a nonabsorbable monofilament suture. The cleanly incised injuries to the vessels encountered in stab wounds are usually identified and repaired easily with this method. In a single patient with a transected innominate artery, an interposition graft of polytetrafluoroethylene was used. This patient had a transient hemiparesis but recovered completely. We were unable to be certain that this deficit did not exist preoperatively, owing to the shocked and intoxicated state of the patient. In no case did we use temporary shunting to the common carotid artery, as is advocated by some authors [4, 12]. The use of shunts for cerebral perfusion is attractive, but in cases of copious hemorrhage, time may be wasted inserting a shunt. We agree with Graham and co-workers [8] that intraarterial shunting should be reserved for those cases that may require simultaneous occlusion of both the innominate and left carotid arteries. A policy of routine use of permanent bypass shunting for repair of all innominate artery injuries is not necessary for stab wounds. In stab wounds with involvement of the innominate artery close to its origin from the aortic arch, this approach is useful, but cardiopulmonary bypass with hypothermia could be used in preference if the location of injury is known preoperatively [4]. In most patients, we have encountered active bleeding on opening the chest, and rapid control of hemorrhage is required. Once vascular control is obtained, the injury can be repaired in an orderly manner.

In conclusion, an individualized approach to this uncommon injury is essential. The surgeon must take into account the mechanism and site of injury, the patient's hemodynamic status, and associated injuries to manage innominate artery injuries safely. He or she should also be familiar with all of the adjunctive modalities available for operative management of these rare injuries to select the most appropriate one.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Fulton, Department of Cardiothoracic Surgery, University of Cape Town, 7925 Observatory, Cape Town, South Africa.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James O. Fulton Ulrich O. von Oppell Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fulton, J. O. Articles by von Oppell, U. O. Search for Related Content PubMed PubMed Citation Articles by Fulton, J. O. Articles by von Oppell, U. O.