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Home , Axillary artery, Axillary vein, Brachial veins, Lateral thoracic artery, Subscapular artery, Superior thoracic artery

Eur J Trauma Emerg Surg (2011) 37:451–457 DOI 10.1007/s00068-011-0134-1

REVIEW ARTICLE

Operative exposure and management of axillary vessel injuries

F. N. Mazzini • T. Vu • S. Prichayudh • J. D. Sciarretta • J. Chandler • H. Lieberman • C. Marini • J. A. Asensio

Received: 16 June 2011 / Accepted: 19 June 2011 / Published online: 29 July 2011 Ó Springer-Verlag 2011

Abstract and particularly from the axillary can be torrential Introduction Axillary vessel injuries are uncommon and and may lead to exsanguination if uncontrolled. This vessel challenging injuries encountered by trauma surgeons. is always difficult to expose and control, especially which Proximity of this vessel to other adjacent including it sustains a penetrating injury. Injury to the axillary vessels the axillary , and the osseous structures may lead to severe disability, limb loss, and even death [1]. of the and upper account for a large number of associated injuries. Materials and methods Systematic review of the literature, Historical perspective with emphasis on the diagnosis, treatment and outcomes of these injuries, incorporating the authors’ experience. In 1920 Makins [2] described the British WWI experience Conclusions Although uncommon, axillary arterial injuries with penetrating vascular injuries. He reviewed a total of can result in significant morbidity, limb loss and mortality. 1,191 arterial injuries, of which 108 were Early diagnosis and timely repair of the artery leads to good injuries, and calculated an incidence of 9.0%, although none outcomes. underwent repair. In 1946, DeBakey and Simeone [3]pub- lished the American WWII experience. In this series they Keywords Trauma Á Axillary Á Injury Á Exposure Á reported a total of 2,471 vascular injuries, of which 74 were Management Á Vascular axillary artery injuries, yielding an incidence of 2.9%, as well as a high rate of limb loss of 43.2%. During the Korean con- flict, Hughes [4] reported a total of 304 arterial injuries, of Introduction which 20 were axillary artery injuries, for an incidence of 6.5%. In 1970, Rich [5] reported 1,000 cases from the Vietnam Axillary vessel injuries are uncommon and challenging War who sustained vascular injuries, among which there were injuries encountered by trauma surgeons. The proximity of 59 axillary injuries, for an incidence of 2.6% (see Table 1). the axillary artery to adjacent veins including the , the brachial plexus and the osseous structures of the shoulder and upper arm account for a large number of Incidence and mechanism of injury associated injuries. Hemorrhage from the axillary vessels Reports of military experiences from the major conflicts reveal an incidence of axillary injuries ranging from 2.9 to F. N. Mazzini Á T. Vu Á S. Prichayudh Á J. D. Sciarretta Á J. Chandler Á H. Lieberman Á C. Marini Á J. A. Asensio (&) 9% of all arterial injuries sustained in combat [2–6]. This Division of Trauma Surgery and Surgical Critical Care, incidence is remarkably similar to that reported from the Dewitt-Daughtry Family Department of Surgery, civilian experience, which ranges from 1.5 to 8.6% [7–10]. University of Miami Miller School of Medicine, A review of recent civilian series reveals that axillary Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL 33136-1018, USA arterial injuries account for 4.7–42.9% of all upper e-mail: [email protected] extremity vascular injuries [7–10] (see Table 2). 123 452 F. N. Mazzini et al.

Table 1 Incidence of axillary Conflict Authors Total Axillary Incidence (%) artery injury in various military experiences WWI Makins [2] 1,191 108 9.0 WWII DeBakey and Simeone [3] 2,471 74 2.9 Korean Hughes [4] 304 20 6.6 Vietnam Rich [5] 1,000 59 5.9 Iraq Clouse [6] 163 10 6.1

Table 2 Incidence of axillary artery injury among civilian upper circumflex humeral arteries. The is the extremity vascular injuries largest branch. It originates from the axillary artery at the level Authors Total upper Axillary Incidence (%) of the glenoid fossa and descends along the lower border of the extremity arteries to the muscles of the posterior axillary wall. It anas- Orcutt [13] 150 20 13.3 tomoses with the descending branch of the profunda brachii Oller [10] 361 17 4.7 artery beneath the , and contributes to the collateral Andreev [12] 50 6 12.0 supply of this area. The anterior and posterior circum- Pillai [14] 21 5 23.8 flex arteries form a ring around the neck of the . Anastomosis of the posterior circumflex humeral artery with Sriussadaporn [16] 28 12 42.9 the ascending branch of the profunda brachii artery provides Prichayudh [11] 52 3 5.8 another important contribution to the collateral circulation. Franz [15] 30 3 10.0 The axillary vein is formed by the joining of the two venae comitantes of the , the , Penetrating mechanisms account for the majority of all and the basilic vein. It courses into the and becomes axillary vascular injuries. Graham recently reported 65 the once it travels underneath the clavicle, patients with axillary vascular injuries; 95% were due to entering the thoracic cavity by the ligament of Halsted. The penetrating while only 5% were due to blunt trauma. Simi- axillary vein covers the axillary artery when the arm is larly, the experience from the Vietnam conflict revealed that abducted. This relationship may contribute to arteriovenous 98% of all axillary arterial injuries resulted from gunshots and fistula formation following penetrating injuries. fragment injuries (i.e., grenades or shrapnel), while only 2% The brachial plexus also lies in close proximity to the were caused by blunt trauma. axillary artery; as a matter of fact, they are invested in a common fascial sheath. The three major cords of the plexus (medial, lateral, and posterior) surround the axillary artery Anatomy in its proximal portion. The major peripheral nerves of the upper extremity derive directly from these cords. The The axillary artery measures approximately 15 cm in median nerve lies anteriorly, the ulnar nerve lies medially, length. It is the natural continuation of the subclavian and the lies posteriorly to the axillary artery. artery. It begins at the lateral border of the first and ends at the inferior border of the , where it transitions to become the brachial artery. Diagnosis The muscle divides the axillary artery into three parts. The first part is proximal to the muscle and gives All patients with periclavicular and/or axillary trauma should rise to one branch: the , which courses be evaluated for the presence of vascular trauma. Hard signs medially to supply the muscles of the first two intercostal that are classically diagnostic of vascular injury include sig- spaces. The second part courses under the muscle and gives nificant hemorrhage, large expanding hematoma, absent or rise to two branches: the thoracoacromial and lateral thoracic diminished peripheral pulses, and bruits on auscultation. Soft arteries. The is an important branch signs that are indicative of vascular trauma include stable that contributes to a very rich collateral circulation. It arises as hematomas, slow continuous bleeding, associated nerve a short trunk and divides into four branches to supply the injures, as well as proximity injury. The presence of peripheral deltoid and pectoral muscles as well as the acromioclavicular pulses distally does not reliably exclude a significant proximal region. The travels along the lower arterial injury given the excellent collateral circulation pre- border of the pectoralis minor muscle to supply the chest wall. valent for this vessel [1, 2]. The third part lies lateral to the muscle and gives rise to The brachial plexus should always be evaluated. Asso- three branches: the subscapular, anterior and posterior ciated injuries occur in approximately 33% of patients

123 Operative exposure and management of axillary vessel injuries 453 presenting with axillary vascular injuries. Attention should also be given to identifying associated thoracic injuries, such as pneumo- or hemothoraces secondary to associated pulmonary injuries, which are present in 28–30% of patients [1, 2]. In the presence of severe hypotension, major active bleeding or a threatened limb, the patient should be rapidly transported to the OR. A chest X-ray should be obtained if the hemodynamic condition of the patient allows it, since it may reveal an associated hemothorax, missiles, or a mediastinal hematoma that will need to be addressed [2]. The ankle brachial index or the brachio-brachial index (i.e., the ratio of the systolic blood pressure of an injured limb to that of an uninjured limb) are useful measurements Fig. 2 Intermediate-range shotgun injury to the left arm and axilla and should be obtained in all stable patients. An abnormal index (\0.9) is diagnostic or highly suspicious for the presence of an arterial injury [2, 18]. However, significant axillary arterial injuries may be associated with a normal index given the rich collateral circulation of this vessel [2]. Angiography should be reserved for stable patients presenting with soft signs of vascular trauma, and (rarely) the stable patient that presents with hard signs but an uncertain site of injury, such as patients sustaining multiple gunshot wounds, shotgun wounds, or multiple fractures (see Figs. 1, 2, 3)[11, 19]. Patients with a proximity injury to the axillary artery without completely defined indica- tions for operative exploration should also undergo angi- ography, since significant injuries could be present and can thus be identified in asymptomatic patients [1, 19]. False

Fig. 3 Angiogram revealing segmental injury to the left axillary artery

aneurysms, arteriovenous fistulas and intimal disruption of the axillary artery have been managed successfully with endovascular stenting, but this experience remains quite limited [20, 23]. Computed tomographic angiography (CTA) is another promising diagnostic modality that may eventually replace or become complementary to angiography. The adoption of helical multidetector CT scanners (64 sections) and three- dimensional reconstruction has increased the resolution and decreased scanning time. Studies investigating CTA in upper and lower extremity injuries have demonstrated that the sensitivity and specificity of CTA are 95–100% and 87%, respectively [24, 25]. Limitations of CTA include Fig. 1 Gunshot wound to the left axillary artery. Angiogram reveals difficulty differentiating spasm from occlusion, and the injury to the second portion of the axillary artery presence of artifacts from high-attenuation structures such 123 454 F. N. Mazzini et al. as missile fragments or other foreign matter, which may make 13. If there is no distal back bleeding, pass Fogarty rendering a definitive diagnosis difficult at times [24, 26]. catheters of the appropriate size and length gently, and—if possible—under the direct vision of the vessels being thrombectomized. Do not hyperinflate the balloon and do not pass the catheter more than Surgical management necessary to achieve good back bleeding as this will increase the risk of intimal damage. If there is no Basic principles for the management of vascular arterial flow return, papaverine may be instilled to injuries break vasospasm. 14. Arterial injuries may be repaired by primary arteri- There are number of critical surgical maneuvers that are orrhaphy or by end-to-end anastomosis. They may standard in the management of all vascular injuries, and also require a bypass or interposition graft with either these are also applicable to the management of axillary an autogenous reverse saphenous vein graft or with a vessel injuries. They include: prosthetic graft. Repairs and/or bypasses should never 1. Applying direct pressure to control active bleeding. be under tension. They also should not be excessively 2. Prepping the person holding pressure into the oper- long in order to prevent kinking. The length of a ative field. bypass placed across a joint must be properly selected 3. Choosing the appropriate surgical exposure and with due consideration of the range of motion planning to expose the injured vessel widely. (flexion) of the joint to prevent kinking or graft 4. Obtaining proximal and distal control of both arteries occlusion. All anastomoses should be performed end and veins, as combined injuries are common. to end with double armed polypropylene sutures 5. Isolating the injured vessels with meticulous preferably in a running fashion. Although it has been dissection. commonly thought that a straight anastomosis can 6. The retraction of injured or uninjured vessels can be eventually develop stenosis, this is not the case. carried out by looping them with vessel loops or 15. Vessel discrepancies may be addressed by spatulating Cushing vein retractors. and/or fish-mouthing the graft. For small end-to-end 7. To retract nerves, utilize gentle dissection and place vessel anastomoses, simple interrupted sutures of two vessel loops at distal points for retraction to polypropylene may be used circumferentially, and the distribute the pressure required to retract the nerve tripartite suture technique of Carrel may be used for evenly. difficult anastomoses. 8. Identify the injury and approach directly after 16. Bypasses performed to smaller vessels such as distal proximal and distal control have been obtained. radial and ulnar arteries may require the distal 9. Expose the injured vessel widely with meticulous anastomosis to be end to side, which increases both surgical dissection. This may require taking down the size of the anastomosis as well as its flow some of its branches and/or collaterals, although care characteristics. must be exercised to preserve as many as possible. 17. Venous injuries may be ligated or primarily repaired. 10. Except for some stab wounds and/or lacerations in Double ligation with silk sutures is preferred for all which the vessel can be directly repaired and/or veins. Primary venorrhaphy should be carried out anastomosed, resect an appropriate length of the with fine monofilament polypropylene sutures, pre- injured vessel until a normal proximal and distal venting the repaired vein from being narrowed. Very vessel is obtained. In the case of arteries, resection rarely, a veno-venous bypass will be required. should avoid raising intimal flaps. 18. Fasciotomies should be performed early, expediently, 11. Inspect the transected edges of the artery. Re-resect if and when indicated. The more soft tissue injury there there are intimal flaps. In cases in which there is an is, the shorter the amount of ischemic time tolerated. extensive flap and further resection is not possible, We recommend utilizing cadaveric skin grafts as tack the intimal flap with internal horizontal mattress biological dressings. sutures of Halsted, placing the sutures from the inside 19. At the completion of the arterial repair and/or bypass, of the vessel lumen and tying the knots outside of the pulses should be checked by digital palpation and vessel. This should be done utilizing the finest interrogated by a hand-held Doppler probe, including monofilament polypropylene sutures. the proximal and distal anastomosis of the bypass, the 12. Flush the proximal and distal ends of the transected bypass itself, and all distal vessels. vessel with heparinized saline. Check for distal back 20. The use of completion angiography should be indi- bleeding. Flush frequently and gently. vidualized, but it is highly recommended that 123 Operative exposure and management of axillary vessel injuries 455

correctable defects should be detected intraopera- proximal axillary and the , especially in tively, thus preventing a vessel and/or bypass failure. bleeding patients. The exposure of the axillary vessels requires the sepa- ration of the muscle fibers and the Specific management of axillary vessel injuries retraction of the underlying pectoralis minor muscle. In the presence of active bleeding, and where rapid and extensive Preoperatively, external bleeding is controlled by direct exposure is required, the muscles should be divided. The pressure over the wound; however, bleeding from vessels pectoralis major is divided about 2 cm from its attachment behind the clavicle is difficult if not impossible to control to the humerus and retracted inferomedially. The under- by direct compression. In these patients, balloon tampon- lying pectoralis minor then is divided near its insertion on ade with a Foley catheter may be effective. the coracoid process and retracted inferiorly. The axillary In the operating room (OR), the patient should be placed vessels are thus exposed fully. During dissection, all efforts in the supine position with the arm abducted at 90° and the should be made to preserve collateral branches and avoid head turned to the opposite side. Excessive abduction iatrogenic brachial plexus injury. should be avoided, as it distorts the anatomy and makes the After obtaining proximal and distal control, the injured exposure more difficult. The entire anterior chest, abdo- segment of the artery should be carefully examined to men, and neck should be prepped and draped within the delineate the extent of the injury. Simple arteriorrhaphy operative field to allow for possible thoracic and cervical may be performed if the injury allows for approximation exploration. The whole arm should also be prepared to without tension. However, the injured segments usually allow for repositioning, extension of the incision, and the palpation of the brachial, radial and ulnar pulses. Exposure of the axillary artery via an infraclavicular approach provides an excellent exposure (see Fig. 4). The incision begins inferior to the middle of the clavicle and is carried laterally to the deltopectoral groove. This incision can be extended onto the proximal arm into the medial bicipital sulcus to obtain additional exposure of the distal axillary and brachial artery. If exposure of the subclavian artery or proximal axillary artery is required to obtain proximal control, an incision can be made at the sterno- clavicular junction, extending it over the medial half of the clavicle at the middle of the clavicle, where it curves downward over the deltopectoral groove to join the infra- clavicular incision. Furthermore, the medial half of the clavicle may be divided and excised to gain exposure to the Fig. 5 Autogenous reverse saphenous vein bypass graft

Fig. 6 Resected right axillary artery post gunshot wound in antici- Fig. 4 Incision for the exposure of axillary vessel injuries pation of bypass. Please note axillary vein 123 456 F. N. Mazzini et al.

require resection and debridement before operative repair. Thrombectomy with a Fogarty catheter should be gently performed with the endpoint of obtaining good inflow and back-bleeding before repairing the injured vessels. End-to- end anastomosis may be possible in some injuries; how- ever, in most gunshot wounds, an interposition graft is usually required. The choice of graft—autogenous vein versus prosthetic graft—is a matter of personal preference, availability, and the general condition of the patient (see Figs. 5, 6, 7) There is no evidence of superiority for any of them. In critically ill patients that cannot tolerate definitive repair, ligation or temporary intravascular shunting with an Argyle ShuntTM are viable damage control options, but ligation of the acutely injured axillary artery has been associated with an amputation rate ranging from 9.0 to Fig. 7 Polytetrafluoroethylene (PTFE) 6 mm bypass graft 43.2% [1, 4]. Axillary venous injuries can be repaired by simple venorrhaphy, more complex repairs including vein–vein bypass or the use of grafts should not be attempted, as ligation of the vein is well tolerated by almost all patients (see Fig. 8). Furthermore, there is no evidence suggesting that complex reconstruction has a superior outcome. Fol- lowing axillary vein ligation, the patient may develop transient edema that subsides within a few days. Close observation and fasciotomy of the upper arm when indi- cated may provide a safe approach.

Outcomes and mortality

Amputation rates for axillary artery injuries in recent civilian series have ranged from 0 to 3% [1, 19, 28], Fig. 8 Ligated axillary vein which is much lower than the 8.5–43.2% incidence

Table 3 Outcomes of axillary artery injuries in recent civilian series Authors (year) Number of patients Treatments Amputation Brachial Mortality (%) (%) plexus injury (%)

Graham (1982) 65 (31 arteries, 14 veins, 20 Arterial ligation 0, venous 2 (3%) 23 (35.4%) 2 (3%) [7] combined) ligation 9, arterial repair 51, venous repair 25 Degiannis (1995) 32 (penetrating axillary artery Repair 31 (died before 0 (0%) 11 (34.4%) 2 (6.3%) [19] injuries) repair 1) Demetriades and 79 (penetrating subclavian and Arterial ligation 0, venous N/A 26 (32.9%) 27 (34.2%); excluding Asensio (1999) axillary; 39 arteries, 20 veins, 20 ligation 26, arterial repair ED thoracotomy 9 [1] combined) 59 (endovascular repair (14.8%) 1), venous repair 14, ED thoracotomy 18 (all expired) McKinley (2000) 260 (proximal axillary and Repair 236, ligation 5, no N/A 79 (30.4%) 10 (11.5%) [29] subclavian artery injuries) surgery 19 Aksoy (2005) 38 (axillary and subclavian artery Repair 33, ligation 5 1 (2.6%) 12 (31.5%) 2 (5.2%) [28] injuries)

123 Operative exposure and management of axillary vessel injuries 457 reported during early military experiences [4, 6]. Associ- 11. Prichayudh S, Verananvattna A, Sriussadaporn S, Kritayakirana ated brachial plexus injury remains the major determinant K, Pak-art R, Capin A, et al. Management of upper extremity vascular injury: outcome related to the Mangled Extremity of long-term functional outcome. These injuries are Severity Score. World J Surg. 2009;33(4):857–63. present in between 30.4 and 35.4% of cases. 12. Andreev A, Kavrakov T, Karakolev J, Penkov P. Management of after arterial repair has been reported to range from 1.5 to acute arterial trauma of the upper extremity. Eur J Vasc Surg. 10%, while infectious complications have been reported to 1992;6(6):593–8. 13. Orcutt MB, Levine BA, Gaskill HV, Sirinek KR. Civilian vas- range from 0 to 21%. The mortality rates in recent civilian cular trauma of the upper extremity. J Trauma. 1986;26(1):63–7. series have ranged from 3 to 14.8% [1, 19, 27–29] (see 14. Pillai L, Luchette FA, Romano KS, Ricotta JJ. Upper-extremity Table 3). arterial injury. Am Surg. 1997;63(3):224–7. 15. Franz RW, Goodwin RB, Hartman JF, Wright ML. Management of upper extremity arterial injuries at an urban level I trauma center. Ann Vasc Surg. 2009;23(1):8–16. Conclusions 16. Sriussadaporn S. Vascular injuries of the upper arm. J Med Assoc Thai. 1997;80(3):160–8. Although uncommon, axillary arterial injuries can result in 17. Gallen J, Wiss DA, Cantelmo N, Menzoin JO. Traumatic pseu- doaneurysm of the axillary artery:report of three cases and lit- significant morbidity, limb loss and mortality. Early diag- erature review. J Trauma. 1984;24(4):350–4. nosis and timely repair of the artery leads to good out- 18. Levy BA, Zlowodzki MP, Graves M, Cole PA. Screening for comes. Selection of an appropriate extensile incision and extermity arterial injury with the arterial pressure index. 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