The role of revascularization in a patient with scapulothoracic dissociation

The management of subclavian artery injury in scapulothoracic dissociation can be challenging. We describe a 28-year-old patient who presented with concurrent left subclavian artery hemorrhage and upper extremity ischemia following a high-speed motor vehicle accident. The left upper extremity was pulseless, cold, and paralyzed. Imaging confirmed scapulothoracic dissociation. Left carotid to axillary artery bypass was performed after failed endovascular recanalization. The left proximal subclavian artery was plugged endovascularly. When the hematoma was evacuated, we encountered bleeding from avulsed vertebral and internal mammary arteries which required open ligation. There was no neurological recovery of the left upper extremity in the postoperative period or at 1 year. Overlapping symptoms of ischemia, brachial plexus injury, and hematoma-associated compressive nerve palsy complicate the decision regarding revascularization in a patient with scapulothoracic dissociation.