Endovascular Repair of Intraoperative Penetrating Injury to the Subclavian Vein: Case Report,Technical Considerations and Literature Review

Introduction

Penetrating injury to the subclavian vessels represents a small, but potentially life-threatening proportion of thoracic outlet vascular trauma. ¹ While subclavian arterial injuries (SAI) are well reported in literature, subclavian venous injuries (SVI) are much less commonly reported.^2,3 Penetrating injury to the subclavian vein, particularly at the level of the jugulo-subclavian venous confluence (venous angle), presents a unique challenge, given the vessel’s deep location beneath the clavicle, its large caliber, and its relatively high flow. ³ Mortality is high, primarily due to hemorrhagic shock before definitive control. ¹ Surgical repair often requires complex exposure, which is associated with significant morbidity, especially in hemodynamically unstable patients.^2,4 Over the past decades, endovascular techniques have been increasingly used for managing SAI, demonstrating high technical success and excellent postoperative outcomes.^4-6 Application of endovascular techniques to venous injuries is less well documented, but appears similarly promising.^7,8

The aim of this paper is to document the successful management of an exceptionally rare intraoperative penetrating injury to the subclavian vein, that occurred during cervical lymph node dissection (LND), with emergent endovascular deployment of a self-expanding stent-graft (SESG). Moreover, we performed a review of the available literature on SVI, to highlight the feasibility, technical considerations, and clinical advantages of endovascular repair in these anatomically challenging venous injuries. This work aims to contribute meaningful clinical insight, support the evolving role of minimally invasive techniques in vascular trauma, and provide guidance for clinicians that are confronted with similar life-threatening scenarios.

Case Report

A 60-year-old woman with the diagnosis of invasive differentiated thyroid carcinoma, and ultrasonographically confirmed left lateral cervical lymphadenopathy was admitted in our hospital for elective total thyroidectomy with left lateral cervical LND. She had a medical history of arterial hypertension, under medical treatment with angiotensin-converting enzyme inhibitor. Her preoperative laboratory blood tests were within normal limits. The procedure began uneventfully under general endotracheal anesthesia, with the patient in the supine position, her neck extended, her shoulders elevated using a shoulder roll, her head supported in neutral position, and her arms tucked at the patient’s sides. Following the completion of total thyroidectomy and removal of the specimen, the patient’s head was turned to the right, and the dissection of the left cervical lymph node basins was initiated.

During the dissection of level IV cervical lymph nodes, an enlarged, pathological lymph node, densely adherent to surrounding structures, was encountered deep in the lower cervical compartment. While mobilizing this lymph node from the thoracic outlet, brisk venous bleeding occurred. Immediate compression was applied, and direct visualization revealed that the hemorrhage originated from a large laceration in the left subclavian vein (LSV) at the level of the left venous angle. At that point, the vascular surgery team was called in the operating room. Because of the subclavian vein’s large caliber, the size of the laceration, and the relatively high blood flow at the level of the jugulo-subclavian venous confluence, attempts at hemostasis using direct pressure failed. Moreover, because of the subclavian vein’s deep location beneath the clavicle, the narrow operative field, and despite multiple maneuvers, direct open repair with precise placement of hemostatic sutures was ineffective. Therefore, given the difficulty of exposure, the risk of significant blood loss, and the need for definite control and repair, the decision was made to convert into an endovascular approach.

After extension, preparation and draping of the left upper extremity, ultrasound-guided percutaneous puncture of the left axillary vein was performed using the Seldinger technique, and an 8Fr, 11 cm introducer sheath was inserted. Under fluoroscopic guidance, a 0.035’’, 180 cm hydrophilic guidewire was advanced through the LSV into the superior vena cava. Next, the sheath was exchanged to a 10Fr, 45 cm flexible sheath, and venography was performed, showing substantial extravasation of contrast medium from the LSV at the level of its confluence with the left jugular vein, in accordance with the intraoperative findings (Figure 1A). An 11 × 50 mm Viabahn® SESG (W. L. Gore & Associates, DE, USA) was advanced over-the-wire and deployed in the LSV, at the level of contrast extravasation. The stent-graft was molded with a 12 × 60 mm Oceanus™ angioplasty balloon (iVascular, Spain), to ensure its full apposition to the venous wall. Final venography showed complete exclusion of the injury site, without residual contrast extravasation, and with excellent flow through the stent-graft (Figure 1B). The guidewire and sheath were then removed, and hemostasis was achieved with direct manual compression over the venous access site. Attention was then shifted to the neck wound. After proper irrigation, no further bleeding was observed. Hemostasis and lymphostasis were secured, and the surgical wound was closed in layers, leaving a closed negative-pressure drain near the left venous angle.

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Figure 1.

(A) Intraoperative digital subtraction venography demonstrating substantial extravasation of contrast medium from the left subclavian vein to the cervical area, (B). Intraoperative digital subtraction venography after the deployment of the stent-graft demonstrating complete exclusion of the injury, without residual contrast extravasation, and with excellent flow through the stent-graft

After surgery, the patient was transferred to the intensive care unit for hemodynamic monitoring, where she remained for 24h, in stable condition. Her postoperative course was uneventful, without clinical evidence of recurrent bleeding, neck or arm swelling, respiratory compromise, access site complications, or any neurological deficit. Moreover, her hemoglobin levels remained stable. She was discharged from the hospital in excellent condition on the third postoperative day, under anticoagulation with rivaroxaban 20 mg once daily to reduce the risk of stent-graft thrombosis. Follow-up colored Duplex ultrasonography (cDUS) at 1 and 6 months demonstrated a widely patent subclavian stent-graft, with preserved venous flow, and no signs of thrombosis or stenosis. At 12 months, we performed a contrast-enhanced direct computed tomography venography (CTV), demonstrating a fully patent subclavian stent-graft, with good wall apposition, and without evidence of kinking, migration, intraluminal thrombus, focal stenosis, or neointimal hyperplasia (Figure 2). The patient remains up to date, 2 years later, asymptomatic, without thromboembolic events, and a patent stent-graft, under routine clinical and ultrasound surveillance every 6 months.

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Figure 2.

Postoperative contrast-enhanced computed tomography venography demonstrating a fully patent stent-graft in the left subclavian vein, with good wall apposition, and without evidence of kinking, migration, stenosis, or intraluminal thrombus

Discussion

Penetrating injury to the subclavian vein is a distinctly rare, but highly consequential event. ¹ Compared to its arterial counterpart, the subclavian vein is less commonly the focus of vascular trauma literature, and thus likely remain underreported.^2,3 In 1 retrospective series of penetrating cervico-mediastinal venous trauma, among 49 patients, only 15 had SVI. ³ However, when a SVI does occur, particularly in an intraoperative setting, it presents unique challenges. ¹ Our case, involving an iatrogenic laceration of the LSV during cervical LND, exemplifies those challenges, and underscores the potential of endovascular strategies for rapid and effective hemorrhage control.

Penetrating injuries to the subclavian vein typically occur due to penetrating cervico-thoracic trauma (eg, knife wounds, gunshots), central venous catheterization, or fractures of the clavicle and first rib.^3,9-11 Intraoperative iatrogenic injury is extremely rare, like in our case. ¹² The restricted space at the thoracic outlet, and the presence of critical structures, like the brachial plexus, the phrenic nerve, the thoracic duct or the lung apex, make surgical exposure difficult. ¹³ Conventional repair techniques include lateral venorrhaphy, patch venoplasty, or interposition grafting. ¹³ Such open approaches are demanding, time-consuming, and often require extensive exposure; supraclavicular incision, thoracotomy, clavicular division, or even median sternotomy, depending on the site of injury. ¹³ These techniques can carry considerable risk, especially in an unstable patient, or in the context of dense scarring (eg, previous surgery, malignancy).^2,4 In some cases, especially when the injury lies beneath the clavicle, surgical exposure can be inadequate to permit safe repair, and so the ultimate solution of venous ligation is chosen.^13,14

In recent decades, endovascular techniques have revolutionized the treatment of SAI.^4,5 Successful deployment of covered stents in subclavian or axillary arterial injuries has been steadily described, with favorable outcomes.^15-17 Data from the PROspective Observational Vascular Injury Treatment (PROOVIT) registry suggest that endovascular management of axillo-subclavian vessel injuries is technically feasible, safe and effective, with low rates of infection, reintervention, or limb loss. ¹⁸

In this context, slowly but steadily, endovascular methods have increasingly been used to manage central venous injuries, with promising outcomes.^7,8,19 Some case reports have described the successful application of stent-grafts in cases with venous perforation during catheter placement, or with traumatic ruptures of the axillary or subclavian veins.^7,8,20-22 Emergent endovascular repair has demonstrated rapid hemorrhage control, reduced blood loss, shorter procedure time, minimal invasiveness, and rapid patient recovery. ¹⁸ These observations are consistent with our experience. Indeed, our case demonstrates that endovascular repair of SVI is not only feasible, but can be life-saving. Traditional methods, like compression or hemostatic suturing, proved ineffective, due to the depth, the narrow operative field, the size of the injury, and the profound bleeding. Attempting to enlarge the incision, or dissect further downward demanded clavicular division, and would have risked catastrophic bleeding, nerve injury, or entry into the mediastinum. These anatomical limitations and the advanced surgical risk justified our decision to convert and proceed with an endovascular solution, which, in the end, offered the fastest, safest, and least invasive means of achieving rapid and definitive hemostasis.When applying endovascular techniques and technology in the deep venous system, several technical factors must be carefully considered. ²³ Choosing the correct venous access is critical, as in our case, where we used the ipsilateral axillary vein, which allowed stable wire and sheath placement, rapid stent-graft advancement, with minimum navigation through the venous system. Appropriate device selection and sizing are essential to ensure adequate sealing, and prevent complications such as migration or endoleak. ²⁴ Mild oversizing (approximately 10-15%) is generally recommended to achieve proper wall apposition without compromising luminal integrity. ²⁴ In our case, the selected stent-graft provided satisfactory coverage of the injured segment, and maintained excellent flow, without evidence of stenosis or thrombosis during follow-up. While intravascular ultrasound may enhance accuracy in device sizing and positioning, it was not required in this emergency setting, where rapid intervention was prioritized. ²⁵

In venous stenting for trauma cases, careful balancing of bleeding risk vs thrombosis is required. ²⁶ Postoperative antithrombotic management remains a key consideration in venous stenting. The low-pressure venous system predisposes to thrombosis, particularly in the presence of a covered stent.^27,28 However, there is no consensus regarding the optimal anticoagulation strategy in such cases. In our patient, a direct oral anticoagulant at therapeutic dosage was initiated, after achieving stable hemostasis. This approach provided effective thromboprophylaxis, while avoiding the need for intensive monitoring. The absence of thrombotic complications during follow-up supports the safety of this strategy, although larger studies are needed to establish a standardized protocol.

Although endovascular repair can offer clear advantages in the acute management of SVI, it is not without potential postoperative complications, thus underscoring the importance of rigorous postoperative surveillance. ²⁹ Long-term durability of venous stent-grafts in the subclavian position remains uncertain. The thoracic outlet is a dynamic anatomical region subject to repetitive mechanical stress from clavicular and shoulder motion, which may predispose to stent fatigue, kinking, or fracture. ¹⁰ Furthermore, currently available covered stents are designed for arterial use, and are applied off-label in the venous system. These factors underscore the importance of structured postoperative surveillance. In our case, serial Duplex ultrasonography and cross-sectional imaging demonstrated sustained patency and structural integrity of the stent-graft over a 2-year period, confirming the durability of the repair in this patient.

The successful management of this vascular injury highlights the critical role of interdisciplinary collaboration between surgical specialties. Rapid communication between the general and the vascular surgery teams allowed for immediate assessment of the bleeding source, formulation of a feasible strategy, and swift execution, without compromising the patient’s safety. Such coordination requires not only clinical expertise, but institutional readiness, including readily available imaging, endovascular equipment, and personnel familiar with emergent interventions. As surgeons are increasingly faced with complex surgical cases, interdisciplinary teamwork becomes essential for achieving optimal outcomes in unexpected intraoperative emergencies.

This report has inherent limitations, as it describes a single case. The rarity of SVI and the limited number of reported endovascular treatments restrict the ability to draw definitive conclusions regarding the long-term outcomes and optimal management strategies. Additionally, the use of an arterial stent-graft in a venous application introduces uncertainty, regarding long-term device performance. Despite these limitations, detailed reporting of such cases is essential to expand the current evidence base and guide future practice.

In summary, isolated SVI during elective surgery are exceedingly rare. Endovascular stent-graft repair represents an effective, safe, rapid, and minimally invasive alternative to open surgery for penetrating SVI, particularly at the level of the thoracic outlet, where extensive exposure can be hazardous, and carries significant risk.Rapid recognition of the injury, timely conversion to an endovascular strategy, and coordinated interdisciplinary management were key factors contributing to the successful outcome in our case. Careful attention to technical execution, appropriate anticoagulation, and structured follow-up is essential to ensure long-term success. This case contributes meaningful evidence to a field where standardized guidelines are lacking, and underscores that, when executed properly, endovascular repair may be a superior option in selected venous injuries, offering an effective and durable solution in life-threatening scenarios.

Ethical Considerations

Ethical approval for the operation was not obtained, since it involved an emergent, life-threatening case of major hemorrhage during surgery. Approval to report this case was obtained from by the Institutional Review Board of “G. Gennimatas” General Hospital of Thessaloniki (approval no. 27/2025).