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Non-operative management of thoracic vascular Injury

Case Presentation
This was a 34 year old male who suffered a low velocity gunshot wound to the left upper chest, presenting with a 1cm wound just under the left midclavicle as a sucking chest wound. This wound was sutured close and a left tube thoracostomy placed, which initially put out 300cc blood. There was an apparent exit wound on the upper right back over the mid right scapula. Physical exam showed complete sensorimotor loss below the nipples and no rectal tone, consistent with a spinal cord injury at T4. Distal pulses were all present and equal in all 4 extremities.

Patient's vital signs initially were BP 110/70, Pulse 120, RR 30, O2 sat 97% room air. CXR showed bullet fragments across the upper right chest posteriorly, and a left pulmonary contusion.

After the chest tube was placed, BP intermittently dropped into the 80's, and over the course of the next 4 hours a total of 1000cc blood came out the left chest tube. Patient was intubated.

An arteriogram was performed showing a nonocclusive and non-extravasating intimal injury of the right innominate artery at the takeoff of the right subclavian and carotid arteries. Left great vessels were not injured. A flexible esophagoscopy showed no injury. It was decided to observe the patient nonoperatively. A right chest tube was placed which did not put out any blood. Over the next 5 days the blood from the left chest stopped, vital signs stabilized, and the patient was extubated. A repeat arteriogram showed complete resolution of the innominate artery intimal defect. The patient never required surgery. He was transferred to a spinal cord injury rehab center 10 days post injury.

Initial Angiogram

Repeat Angiogram

It was clear that the innominate artery injury was not responsible for the left chest bleeding (which was probably from the parenchymal injury of the lung), or the hemodynamic instability, and was an essentially incidental finding. Such nonocclusive "minimal" arterial injuries are well documented to have a benign natural history, and should be followed rather than being immediately operated upon when they are asymptomatic (i.e. no hard signs of vascular injury) with a vessel that is not occluded and has no gross extravasation, as the majority never require surgery. A patient such as this does not need unnecessary surgery, especially surgery as extensive as this procedure would have to have been. His bleeding from the left chest tube was borderline in terms of an indication to operate, which is generally suggested when output exceeds 200cc/hour for more than 4 hours. Fortunately it tapered off.


Frykberg ER, et al: 'Nonoperative Observation of Clinically Occult Arterial Injuries - A Prospective Evaluation.' Surgery 1991;109:85-96. (5:6) June 2000