From the Guidelines
Fracture of a subclavian artery stent is a medical emergency that requires immediate attention and evaluation by a vascular surgeon or interventional radiologist, with management prioritizing surgical repair due to its low morbidity and mortality and excellent long-term patency, as described in the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline 1. When a fracture of a subclavian artery stent is suspected, patients should proceed to the nearest emergency department for urgent imaging, typically CT angiography or angiography, to confirm the diagnosis. Symptoms that may indicate a stent fracture include recurrent arm pain, coldness, numbness, weakness, or a sudden decrease in blood pressure in the affected arm.
Management Considerations
- The management of a subclavian artery stent fracture depends on the severity of the fracture and may range from observation with antiplatelet therapy to urgent endovascular repair with placement of a new stent or open surgical repair.
- According to the guideline, surgical repair is associated with low morbidity and mortality and excellent long-term patency, with primary patency after surgical bypass being 100% at 1 year and 96% at 5 years 1.
- Endovascular therapy, including balloon angioplasty, atherectomy, and stenting, is also an option but has shown lower patency rates compared to surgical repair, with patency being 93% at 1 year and 70% at 5 years 1.
Prevention and Follow-Up
- Regular follow-up imaging is essential after initial stent placement to monitor for potential complications, including stent fracture, with recommendations for duplex ultrasound every 6 months for the first year, then annually.
- Patients with subclavian stents should be educated about symptoms of stent complications and advised to avoid extreme arm positions that might place additional stress on the stent, as stent fractures can occur due to mechanical stress from repetitive arm movement, compression between the clavicle and first rib, or material fatigue.
From the Research
Fracture of Subclavian Artery Stent
- A case of subclavian artery stent fracture was reported in a study published in 2009 2, where a 52-year-old dentist experienced stent fracture within one week of stent placement.
- The study highlights the occurrence of stent fractures as a serious complication of endovascular therapy.
- Another study published in 2008 3 discussed the long-term results of stent graft treatment of subclavian artery injuries, but did not specifically address stent fractures.
- However, the study found that endovascular repair is a feasible and safe treatment option for stable patients with selected penetrating subclavian artery injuries, with acceptable long-term follow-up results.
Complications and Management
- A review published in 2024 4 discussed the incidence, clinical presentation, diagnostic approaches, and management strategies of clavicle fractures associated with subclavian vessel injuries.
- The review highlights the importance of early clinical suspicion and timely diagnosis, as well as the use of computed tomography angiography for assessing subclavian vessel patency.
- A study published in 2024 5 investigated the optimal antiplatelet therapy after revascularization of the left subclavian artery during thoracic endovascular aortic repair (TEVAR).
- The study found that single antiplatelet therapy (SAPT) was associated with a lower risk of bleeding compared to dual antiplatelet therapy (DAPT).
Endovascular Repair
- A systematic review published in 2018 6 summarized the available data on subclavian artery true and false aneurysm stenting.
- The review found that endovascular SA aneurysm repair is a technically feasible technique, useful in both elective and emergency cases, with a mortality rate of 10.6% and a reintervention rate of 8.5%.
- The review highlights the need for larger cohort studies to elucidate the benefits of endovascular repair in treating SA aneurysms.