Jurnal Kedokteran Syiah Kuala ISSN: 1412-1026

Volume 17, Number 2, Agustus 2017 E-ISSN: 2550-0112

Pages: 103-111 DOI: https://doi.org/10.24815/jks.v17i2.8989

LEFT SUBCLAVIAN ARTERY RUPTURE DUE TO BLUNT

THORACIC TRAUMA: A CASE REPORT
1
Yopie Afriandi Habibie, 2Ign Wuryantoro
Email: [email protected]

1
Division of Thoracic Cardiac & Vascular Surgery, Departement of Surgery,
Zainoel Abidin Hospital, Medical Faculty of Syiah Kuala University, Banda Aceh
2
Division of Thoracic Cardiac & Vascular Surgery, Departement of Surgery,
Cipto Mangunkusumo General Hospital, Medical Faculty of Indonesia University, Jakarta

Abstrak. Trauma tumpul toraks memiliki insiden yang sangat tinggi pada populasi dewasa, 20 – 50 % dari kasus dapat
mengakibatkan kematian. Cedera pada struktur pembuluh darah dari bagian dada atas, terutama pembuluh darah arteri
subklavia kiri, sangat jarang ditemukan dan biasanya disertai dengan “hematotoraks massif”. Observasi ketat dari tanda-
tanda vital dan foto toraks serial sangatlah penting. Kami paparkan sebuah kasus jarang dari seorang pasien yang
mengalami cedera traumatik arteri subklavia kiri. Tidak ditemukan gambaran klinis dari hematoma di supra klavikula,
pulsasi arteri radialis kiri tidak teraba, dan tidak ditemukan pelebaran dari mediastinum pada foto toraks. Tetapi didapatkan
hematotoraks massif kiri. Dilakukan posterolateral torakotomi kiri, dijumpai sumber perdarahan dari bagian apex paru kiri,
dicurigai terdapatnya robekan dari pembuluh darah arteri subklavia kiri. Tindakan dilanjutkan dengan insisi median
sternotomy yang diperluas ke arah supraklavikula kiri, ditemukan rupture total dari arteri subklavia kiri dengan jarak 1,5
cm proksimal dari arkus aorta. Tindakan repair (perbaikan) arteri secara primer (end to end anastomosis) dilakukan dengan
hasil baik. (JKS 2017; 2: 103-111)

Kata kunci : Trauma tumpul toraks, hematotoraks massif, cedera arteri subklavia kiri

Abstract. Blunt thoracic trauma highest incidence is in adult, 20% to 50 % of the trauma cause death. Injuries to the
vascular structures of the thoracic outlet, especially left subclavian artery, are rare and typically accompanied by massive
hemorrhage. Close observation of vital sign and serial chest x-ray are very important. We describe an unusual
presentation of a patient who suffered traumatic rupture of left subclavian artery. No clinical presentation of
supraclavicular hematoma, unilateral absence of radial artery pulse and mediastinal widening in chest x-ray was found,
but there is a massive hemothorax. Left posterolateral thoracotomy was performed, the source of bleeding was found in the
apex of the lung, suspected a rupture of the left subclavian artery. The procedure continued with median sternotomy
extended to left supraclavicular incision, a rupture was found in the left subclavian artery, 1,5 cm proximal to aortic arch.
Primary repair was done with a good result. (JKS 2017; 2: 103-111)

Key Words : Blunt thoracic trauma, massive hemothorax, left subclavian artery rupture

Introduction injuries. Injuries to the vascular structures of

Blunt thoracic trauma is seen frequently and it thoracic outlet, especially left subclavian
is one of the major injuries resulting in death in artery, are rare, accounting for only 1% to 2%
young people. The most frequent cause of of all vascular trauma and are typically
trauma is motor vehicle accident. If thoracic accompanied by massive hemorrhage.1-6
injury is suspected, treatment of potentially Associated organ injuries raise mortality.
fatal injuries must be prioritized. Involvement of heart, lung and great vessels
Approximately 20% to 25% of traumatic will increase mortality. Closed observation of
deaths at the scene of accident are caused by vital signs and serial chest radiographs are
isolated thoracic trauma. Twenty-five of every essential in monitoring such patients.
100.000 trauma victims die following the Sometimes chest tube maybe needed for
trauma. Deaths are often due to airway effective treatment. Hemodynamically unstable
obstruction, hemorrhage, flail chest, tension- patients with cardiac and great vessel injuries,
pneumothorax, cardiac tamponade, and massive intrathoracic haemorrhage, trachea-
associated intra-abdominal and skeletal bronchial or diaphragmatic rupture may need

103
 Habibie et al.- Left Subclavian Artery Ruptute Due

urgent surgical Emergency Thoracotomy and unilateral absence of radial artery pulse
(ET).3,7,8 was found. The patient complaint to felt pain
on his left hip joint, there is adduction, flexion,
This procedure (ET) is adopted from the endorotation, no shortening and neuro-vascular
Advanced Trauma Life Support (ATLS) distal disturbance. Closed reduction and skin
management of penetrating chest injuries and traction was done due to anterior hip joint
selected cases of blunt thoracic trauma. The displacement.
objectives of ET are to release pericardial
tamponade, prevent air embolism, control Left haemato-pneumothorax, 1st and 2nd ribs
massive intra-thoracic or intra-abdominal fractures in left hemithorax was demostrated on
haemorrage, and provide access for open chest radiographs. No sign of mediastinal
cardiac massage and descending thoracic aortic widening, scapular fracture and hematoma at
cross-clamping. Majority of the cases are the apex of the lung was found. Left acetabular
hemodynamically stable on the scene, or are fracture and left femoral head dislocation was
resuscitated using the ATLS protocol. seen in pelvic radiograph. Laboratory findings
Emergency thoracotomy is a life saving shows haemoglobin level of 12,8 gr/dl,
procedure in critically injured patients who haematocryte 38%, leucocyte 27.700/l. On
presents with no detectable pulse or blood observation period, instability of
pressure following chest trauma. 8 haemodynamic happened. The patient was
resuscitated with crystalloid and colloid
We present a case of 35 year-old-man with solution, 800 ml blood was drained from chest
blunt chest trauma, resulting in left traumatic tube. Sign of massive haemothorax and on
subclavian artery rupture with an unusual going bleeding intra thoracic cavity was found,
clinical presentation, whom underwent haemoglobin level was decreased to 5,5 gr/dl.
successful primary repair.
Emergency left posterolateral thoracotomy was
Case Report performed, intra thoracic cavity was entered
A 35-year-old man came to our emergency through 5th intercostal space. About 500 ml of
department unit, had a bajaj collision with a blood clot was found at the basis of the lung,
bus coming from the left opposite direction. and was also found at the apex of the lung.
The patient was conscious and well orientated Source of the bleeding was suspected in apex
on admission, with a normal Glasgow coma of the lung and rupture of the left subclavian
scale. On primary survey, shortness of breath, artery. The procedure continued with median
asymmetrical movement of hemithorax, sternotomy extended to left supraclavicular
decreased left fremitus, and hypersonor on incision. In exploration, aortic arch, innominate
percussion was found, tension pneumothorax artery, right and left carotid artery was intact,
was suspected. Needle thoracosintesis was but there was rupture with active bleeding from
performed, a large bore needle was inserted at left subclavian artery, 1,5 cm proximal to aortic
the 2nd intercostal space midclavicular line, arch. Primary repair was done with a good
followed by insertion of chest tube with initial result.
drainage of 200 ml blood and minor air leak.
Despite these injuries, the patient respiratory
status and blood pressure was remained stable.
On secondary survey, no bruise or
supraclavicular hematoma on anterior chest

104
 Jurnal Kedokteran Syiah Kuala 17 (2): 71-74, Agustus 2017

Figure 1. Chest radiograph demonstrating left haemato-pneumothorax with chest tube insertion.
Arrow; 1st and 2nd ribs fractures in the left hemithorax. No sign of mediastinal widening,
scapular fracture and no hematoma at the apex of the lung.

A B

Figure 2. Operative picture. (A) First step we do left posterolateral thoracotomy. Found blood clot at
the basis of the lung about 500 ml, also blood clot at the apex of the lung, suspected source
of bleeding in the apex of the lung and rupture from left subclavian artery, (B) continued
with median sternotomy extended to left supraclavicular incision. Arrow; Left subclavian
artery, found rupture 1,5 cm proximal to aortic arch.

Postoperative, the patient’s condition improved was discharged home on the 10th postoperative
dramatically. He was extubated on the 1st day, with the chest radiograph showing good
postoperative day in Cardiothoracic ICU, and lung expansion.

Figure 3. Post operative chest radiograph demonstrating good lung expansion. Chest drain already
took off.

105
 Habibie et al.- Left Subclavian Artery Ruptute Due

Figure 4. Post operative clinical picture. There is no wound dehiscence.

Discussion from 896 patients who sustained blunt thoracic

Trauma is the leading cause of death among trauma, the most common cause of mortality
people younger than 40 years of age. Blunt and major complication is acute respiratory
thoracic trauma is seen frequently in society distress syndrome (ARDS).1,3,9
and also one of the major injuries resulting in
death in younger people. Road traffic accidents Table 2. Mortality and major complication of
were the main cause of injury, followed by patient who suffered from blunt thoracic trauma
domestic falls and labour accidents. Outdoor
falls and sport accidents accounted for a small
number of injuries. The increasing incidence of
high-speed road accidents has important
repercussions on the number of thoracic
injuries admitted to hospital. It is widely
accepted that 25% of all traumatic deaths are
due to thoracic injuries and that significant The pathological pattern of blunt chest trauma
chest trauma is present in 50% of fatal traffic varies worldwide, and involvement of any
accidents. In a review of the management of thoracic organs leading to various
chest trauma, Adebonojol et all noted that 10% consequences. The diagnosis of blunt chest
of patients with chest injury died at the site of trauma is mainly by clinical assessment
the accident, and 5% died within 1 hour of supported by investigations such as chest
arrival at the hospital. He also found a 5% rate radiography and echocardiography. Chest
of thoracotomy in such patients. 1,3,9-11 radiography is routine for patients presenting
with chest trauma; however, beyond
Table 1. Type of causes of blunt thoracic resuscitation in emergency situations, specific
trauma treatment depends on the pathology detected.
The primary aims in the management of chest
trauma are prompt restoration of normal
cardiorespiratory function, control of
hemorrhage, treatment of associated injuries,
and prevention of sepsis. While the outcome of
chest trauma depends on early diagnosis and
urgent institution of care, resuscitative
measures and chest tube insertion are curative
in only 80% of cases.4,9
Two most common causes of death between Table 3. Etiology of blunt thoracic trauma.
the accident site and the casualty department The most common etiology is traffic
are respiratory distress and irreversible accidents. The most common organ injuries
hypovolemic shock. Thomas et all, describe are lung and chest wall.

106
 Jurnal Kedokteran Syiah Kuala 17 (2): 71-74, Agustus 2017

no rib fractures. Poole reviewed all series of

fractures of first and second ribs and found a
3% risk for aortic injury and a 4.5% risk for
injury of brachiocephalic and subclavian
vessels. Hospital mortality rate for isolated
chest injuries were reported to range from 4-
8%, and increased to 13–15% when another
organ system was involved, and to 30–35%
Table 4. Treatment of blunt thoracic trauma in when more than one organ system was
896 patient. The most common treatment is involved. Lee et all reported the mortality rate
tube thoracotomy drainage as 1.8% in all patients with blunt chest trauma.
An ISS of 16 or more has been taken as the
cut-off value defining major trauma. Death was
also occured due to associated head injury.9,11-
13

Associated organ injuries such as heart injuries

or ruptured of great vessel increase mortality.
The chest wall and the soft tissues are the Although nothing can be done for these
locations most commonly affected by blunt patients, many other arrive at hospital alive and
traumas. Although most of the fractures of can be saved if errors of evaluation and
bony thorax are benign entities and can be management can be avoided. Closed
treated without hospitalization, trauma limited observation of vital signs and serial chest
to the thoracic cage itself may cause profound radiographs are essential in monitoring such
pathophysiological alterations, which may be patients. Effective and urgent intervention were
fatal if not promptly treated. On the other hand, life saving, such as in hemodynamically
the accurate identification of patient at high unstable patients with cardiac and great vessel
risk for major chest trauma is essential for injuries, massive intrathoracic haemorrage,
regulation of over and under triage within a tracheobronchial or diaphragmatic rupture
trauma system. Chest pain and dyspnea were patients whom may need urgent surgical ET.1,3
the most common symptoms at presentation
whereas sensitivity over the chest wall, bone Table5. Pathologies of bony thorax in
crepitation and subcutaneous emphysema were blunt thoracic trauma
the most common findings on physical
examination. Soft tissue trauma and rib
fractures were the most common problems
observed following blunt thoracic traumas.
Non-penetrating chest injuries are seen
frequently in civil populations. Rib fractures
are reported as the most common pathologies
associated with chest trauma (35–40%).11
ET in blunt thoracic trauma is still a
The presence of 1st or 2nd ribs, or more than two controversial issue. Surgical indications for
rib fractures is a marker of severe injury and is thoracotomy, such as immediate or
the most common type of injury in blunt chest resuscitative thoracotomy, and early or late
trauma, and intra pleural collection is the most operations, are also well defined. Mortality in
frequently associated pathology. Chest tube chest trauma was more related to the clinical
insertion has significant role as the single most state of the patients and the type of injuries
important treatment modality for chest trauma. than to the form of treatment.(1) Urgent left
Mortality rate was 0.2% in patients with no rib thoracotomy is indicated for all patients who
fractures versus 4.7% in patients with more are not responsive to effective resuscitation.
than two rib fractures. Lee reported that Those with no vital signs on monitoring or
mortality doubles (1.8% vs 3.9%) for patients after the first 30 minutes following the trauma
with three or more rib fractures and those with may not require resuscitation. The most

107
 Habibie et al.- Left Subclavian Artery Ruptute Due

frequent findings in blunt thoracic trauma were breath, was confirmed as tension
pneumothorax and haemothorax. These pneumothorax. Large bore needle was inserted,
complications can be treated successfully by continued with insertion of chest tube to drain
chest tube.3 blood. This management was based on ATLS
protocols. First and second rib fractures was
Table 6. Intra thoracic complication in blunt found in chest radiograph, but no mediastinal
thoracic trauma’s widening was found. Respiratory status and
blood pressure maintained stable. The
mechanism of the trauma was the same as in
the literature mentioned above.

This lethal injuries is due to combination of

direct compression, indirect compression and
deceleration forces, which typically cause a
transverse disruption of all three layers of the
great vessel wall and it’s branch, especially left
subclavian artery. The aortic isthmus (limited
in its mobility by the ligamentum arteriosum,
the paired intercostal arteries, and the left main
stem bronchus) is the site of disruption in 93%
to 95% of all blunt great vessel injuries who
Blunt thoracic trauma can lead to cardiac and
was survived. In contrast, survival after
great vessels injuries, frequently unsuspected
disruption of the aortic arch is extremely rare.
in patients with multiple systems injuries14.
The majority of patients sustaining aortic great
The absence of physical signs of thoracic
vessel injuries die at the scene of accident. Of
trauma, such as mediastinal widening in chest
approximately 15% of the patients who survive
radiograph, doesn’t mean that there is no
the initial injury, the leading cause of in-
internal thoracic injury. Pulmonary
hospital mortality is exsanguinating great
parenchymal injury following blunt thoracic
vessel rupture occurring in 20% of these
trauma have several mechanisms; (1)
patients. Survival depends upon prompt
deceleration effects on the unfixed structures in
diagnosis and repair.10
the chest; (2) bidirectional compression
Blunt injuries to branches of the great vessels,
between the sternum and vertebral bodies; (3)
which is subclavian artery, may be suspected
indirect force from the abdomen which
clinically, are not unusual and must be
increases intrathoracic pressure and produces
considered in any patient surviving
rupture; (4) laceration by fractured ribs and (5)
deceleration or crush injury. Hemodynamically
blast forces.(10,14) Mechanisms of vascular
stable patients should undergo a high resolution
injury of blunt thoracic trauma can include
contrast computed tomography(CT) of the
avulsion or traction injury from stretch or
chest which is the initial method of choice.15,16
rotational stress, compression, or contusion
Clinical presentation for patient with suspected
from a direct blow, and laceration from
of subclavian artery injuries are listed below. 18
fractures of adjacent ribs or clavicle.6

Most traumatic great vessel disruptions that  Bruishing over anterior chest
present for repair occur at the aortic isthmus  Limb ischemia
near the ligamentum arteriosum and just distal  Thoracic outlet hematoma
to the left subclavian artery. These injuries are  Discrepancies in pulses and blood
best approached through a posterolateral pressure between the two arms
thoracotomy in the 4th intercostal space.15
Sign of subclavian artery injuries or great
The patient in this case report had traffic vessel injuries in blunt thoracic trauma that can
accident, was councious and well oriented in be found in chest radiographs are also listed
admission, sustained bidirectional compression below. 18
on his chest. The patient had shortness of

108
 Jurnal Kedokteran Syiah Kuala 17 (2): 71-74, Agustus 2017

 Abnormal thoracic contour/size radiograph was found, presented with massive

 “Widening” mediastinum haemato-pneumothorax and was
 First or second rib fractures hemodynamically unstable. ET was performed
 Scapular fracture without any suspicious of great vessel injury.
 Unstable sternum
Large amount of blood clot at the basis and at
 Opacification of aorto-pulmonary
window the apex of the lung was found, suspected left
 Depression of left main stem bronchus subclavian artery ruptured, continued with
 Tracheal shift to the right median sternotomy extended to left
 Deviation of NGT to the right supraclavicular incision.
 Widening of the right paratracheal
stripe Angiography should have been done first
 Presence of apical cap
before the surgery, if injuries to the great
 Widening of paraspinal line
vessels is suspected based on clinical
 Hemothorax
presentation in order to make a good plan for
the surgery. Since the patient had unusual
Such injury should always be suspected in
clinical presentation and was hemodynamically
major trauma where there are fractures of the
unstable, it was decided to performed ET for
first, second and third ribs. An early chest
live saving.
radiograph (antero-posterior view) is obtained
in the receiving area in all victims of either
Therapy is given based on priority when an
blunt chest trauma or decelerating trauma with
injury appears to be life-threatening, such as in
or without evidence of chest injury.
the event of airway obstruction, external or
Mediastinal widening is the most frequent
intraabdominal hemorrhage, or continuing
manifestation of great vessel injury, and is the
intracranial bleeding.(7,22) Medical therapy
key of diagnosis. Angiography is the next
include intravenous infusion of
diagnostic modality to perform when any
vasodilator(usually nitroprusside), attempted
mediastinal abnormality is seen on the chest
limitation of intravenous administration of
radiograph. Angiography remains the gold
fluids once the blood pressure exceeds
standard for the diagnosis of stable patients
90mmHg, and the administration of ß-blocker
with thoracic vascular injury. Angiography
when the pulse rate exceeds 85-90 beats/min.
provides the detailed anatomic information
Medical management is continued while
necessary for planning the operative approach.
diagnostic studies or other surgical procedures
However, they may remain undetected until the
performed, or until the patient with proven
fatal rupture of the mediastinal hematoma
rupture has been placed on cardiopulmonary
occur. Clinical presentation such as absent of
bypass.22
upper extremity pulses, sudden hemothorax,
left supraclavicular swelling and persistent
Successful repair was performed with
hypotension are also an indication for
autogenous saphenous vein. A high degree of
immediate angiography.17 Relative indications
clinical suspicion is necessary to detect
for angiography include brachial plexus palsy,
subclavian artery transection from blunt trauma
apical pleural hematoma, and fracture of 1st
because of the location of this injury, lack of
rib.(7) The use of angiography is to delineate
initial bleeding, and the rich collateral blood
the entire thoracic aorta; this will define the
supply to the arm.(17)Although prevention and
anatomy of the injury that may not always be
treatment of pulmonary damage have reduced
made clear on computerized
the mortality of patients with severe blunt
tomography.5,7,13,16,18,19-21
thoracic trauma, the mortality is still high when
multiple severe injuries, pulmonary contusion,
Clinical presentation in our patient was not
cardiovascular injury, diaphragmatic rupture
usual like stated in literature. The patient did
and brain damage are present.1
not have bruising on anterior chest, limb
ischemia, discrepancies in pulses and blood
Blunt injury of the brachiocephalic artery pose
pressure between the two arms, or widening of
diagnostic and management problems for
the mediastinum on chest radiograph, but
trauma and thoracic surgeon. Patients were
fractures of the first and second ribs on chest
stabilized and underwent repair through a

109
 Habibie et al.- Left Subclavian Artery Ruptute Due

median sternotomy with extension of the 2. Wong, et all, Combined Blunt Aortic and
incision anterior to the sternocleidomastoid Bronchial Injury, Ann Thorax Surg,
muscle. Median sternotomy is the best 2004;78:2157–9
approach of choice in both controlling 3. Kahraman, et all, Blunt Thoracic Trauma:
hemorrhage and repairing the arterial Analysis of 1730 Patients, Asian Cardiovasc
injury.23,24 All patients had restoration of flow Thorax Ann 1998;6:308–312
to the subclavian and carotid arteries utilizing 4. Iyer, et all, Profile of Chest Trauma in a
Refferal Hospital; A Five Year Experience,
bypass grafts or primary repair. All patients
Asian Cardiovasc Thorac Ann 1999;7:124–7
survived leave the hospital with no
5. Hayn, et all, Intrathoracic jugular vein avulsion
complications related to the procedure. Patients after blunt chest trauma, J Thorax Cardiovasc
with blunt injuries of the brachiocephalic artery Surg 2002;123:190-1
should be stabilized, and circulation of the 6. Kapetanakis, et all, Traumatic Partial Avulsion
subclavian and carotid arteries should be of a Single Right Subclavian Artery from the
restored with graft placement or primary repair. Aortic Arch and Definitive Repair, Ann Thorax
23
Surg, 2006;81:348 –50
7. Strums, et all, The management of subclavian
Median sternotomy with extension of the left artery injuries following blunt thoracic trauma,
supraclavicular incision, anterior to the The Annals of Thoracic Surgery, Vol 38,
sternocleidomastoid muscle was performed on 1984;188-191
the patient in this case report, primary repair of 8. Athanasiou, et all, Emergency thoracotomy in
the ruptured site is also done, as the literature the pre-hospital setting: a procedure requiring
clarification, European Journal of Cardio-
mentioned above, with a good result.
thoracic Surgery 26,2004;377–386
9. Thomas, et all, Etiopathology and Management
Conclusion Challenges of Blunt Chest Trauma in Nigeria,
Clinical presentation in the patient presented in Asian Cardiovasc Thorax Ann 2009;17:608–11
this case report was unusual as what is 10. Balci, et all, Blunt thoracic trauma in children:
mentioned in the literature mentioned. The review of 137 cases, European Journal of
patient only had fractures of the first and Cardio-thoracic Surgery 26, 2004;387–392
second ribs on chest radiograph, massive 11. Liman, et all, Chest injury due to blunt trauma,
haematopneumothorax and was European Journal of Cardio-thoracic Surgery
hemodynamically unstable. ET was performed 23, 2003; 374–378
for live saving without any suspicion of great 12. Smith, et all, The management of trauma
vessel injury. Left subclavian artery ruptured victims in England and Wales: a study by the
then suspected, the procedure continued with National Confidential Enquiry into Patient
median sternotomy extended to left Outcome and Death, European Journal of
supraclavicular incision with good result. The Cardio-thoracic Surgery 36, 2009; 340—343
key word of diagnosis for great vessel injuries 13. Castagna, et all, Blunt injuries to branches of
the aortic arch, The Journal of Thoracic and
in blunt thoracic trauma is mediastinal Cardiovascular Surgery, Vol 69, 1975; 521-532
widening in chest radiograph. Angiography 14. Guyader, et all, Blunt chest trauma: a right
should be done first before the surgery if the pulmonary vein rupture, a case report,
patient was stable and if there is a suspicious of European Journal of Cardio-thoracic Surgery
great vessel injuries. 20, 2001;1054–1056
15. Leashnower, et all, Anterior Approach to
Acknowledgments Traumatic Mid Aortic Arch Transection, Ann
The authors would like to thank the Dr. Ign. Thorac Surg 2006;81:343–5
Wuryantoro, Cardiothoracic Surgeon for his 16. Tsui, et all, Combined subclavian artery rupture
expert surgical and editorial advice. and delayed bronchial stenosis from blunt chest
trauma, Eur J Cardio-thorax Surg, 1991; 610-
References 6121
17. Cunningham, Subclavian Artery Transection
1. Galan, et all, Blunt chest injuries in 1696 Due to Blunt Trauma, Vascular and
patients, Eur J Cardio-thorax Surg, 1992;6: Endovascular Surgery Journal, Vol. 18, No. 6,
284-2871 1984; 386-390

110
 Jurnal Kedokteran Syiah Kuala 17 (2): 71-74, Agustus 2017

18. Eslami, et all, Injury to the Thoracic Great

Vessel, Thoracic Surgery Secret Text Book,
Jaypee Brother’s Publisher, 2001, 238-40
19. Ipaktchi, et all, Subclavian artery and jugular
vein rupture after a blunt thoracic trauma due to
a BMX handlebar, European Journal of Cardio-
thoracic Surgery 37, 2010; 235
20. Rubin, et all, Transection of left common
carotid artery with arch extension after blunt
chest trauma, a case report, Interactive
CardioVascular and Thoracic Surgery 3, 2004;
608–611
21. Veerasingam, et all, Traumatic transection of
the innominate artery, a case report, Interactive
Cardiovascular and Thoracic Surgery,2, 2003;
569–571
22. Pate, et all, Acute Traumatic Rupture of the
Aortic Isthmus: Repair with Cardio-pulmonary
Bypass, Ann Thorax Surg1995; 59:90-98
23. Jones, et all, Traumatic rupture of the
innominate artery, European Journal of Cardio-
thoracic Surgery, 23, 2003; 782–787
24. Weiman, et all, Blunt injuries of the
brachiocephalic artery, Am Surgery Journal,
1998;64(5):383-7

111