The subclavian vein is a continuation of the axillary vein, extending from the outer aspect of the first rib to the manubrial head of the clavicle. Here it unites with the internal jugular vein to form the innominate vein behind the manubrio-clavicular joint. Its relations are as follows: anterior, the clavicle; posterosuperior, the subclavian artery separated by the phrenic nerve and the scalenus anterior muscle; and inferior, the first rib and the pleura.

Patients with subclavian vessel injuries can present in hypovolemic shock with active bleeding or in a stable condition with a Zone I or II neck or infraclavicular anterior chest wounds. Zone I is defined as the area between the clavicle and the cricoid cartilage and Zone II the area between the cricoid and the inferior border of the mandible. Resuscitation should be managed according to ATLS guidelines and adjunctive measures to control active bleeding include Foley catheter tamponade (Fig. 34.3) and manual compression. If local control cannot be achieved or if the patient bleeds into the pleural cavity as evidenced by continuous blood loss from a chest drain, the patient should be transferred to the operating room immediately. In this case, we prefer a midline sternotomy, with appropriate extension, if needed, to provide access to most mediastinal and thoracic outlet structures. Stable patients or patients that remain stable after resuscitation should be evaluated for arterial injury. In the stable or stabilized patient, you should proceed to diagnostic imaging. Controversy exists with regard to routine investigation of these surface wounds if no significant other signs of arterial injury are present. We currently favor routine CT angiography to exclude arterial injuries. When hard signs of arterial injury are present, it allows assessment of the extent of the injury and planning of intervention. When only soft signs are present, it acts as a low morbidity screening investigation to exclude arterial injuries. If an arterial injury is diagnosed in this case, you should note the exact position and extent of arterial injury and evaluate the patient for endovascular or open surgery.

In our practice, we prefer endovascular treatment by stent grafts whenever possible as we believe that it greatly benefits the patient by limiting surgical morbidity and mortality. The relative contraindications that can preclude endovascular management include clinical and angiographic factors. Clinical factors are active uncontrollable hemorrhage, critical limb ischemia, airway or brachial plexus compression, concomitant aero-digestive injuries, and infected wounds. Angiographic factors include excessive luminal discrepancy proximal and distal to the injury, an inability to traverse the lesion by guide wire, and a dominant vertebral artery on the injured side. Transfemoral endovascular management is our first choice if no contraindications are present.

If any of the above mentioned are present, consider open surgical repair. The basic approaches available for the exposure and proximal and distal control of subclavian vessel injuries include a full or limited upper median sternotomy, a supraclavicular incision, an infraclavicular incision, a limited anterolateral third-interspace thoracotomy, a full fifth-interspace posterolateral thoracotomy, a medial partial resection of the clavicle, and a trapdoor thoracotomy. The extent of the injury, pathology, the presence of a venous injury, the part of the vessel, and surgeon preference will dictate which approach or, more usually, combination of approaches to be used. In our practice, clavicle resection and trapdoor thoracotomy are very rarely used, only for subclavian vein injuries that cannot be controlled via any of the other approaches. This will usually be an extension of an existing sternotomy and supraclavicular or infraclavicular incision.