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 artery 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 veins including it sustains a penetrating injury. Injury to the axillary vessels the axillary vein, brachial plexus and the osseous structures may lead to severe disability, limb loss, and even death [1]. of the shoulder and upper arm 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 axillary artery 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 axillary vein, 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 arteries 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 subscapular artery 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 scapula 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 triceps, and contributes to the collateral Andreev [12] 50 6 12.0 blood 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 humerus. 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 brachial artery, the brachial veins, Penetrating mechanisms account for the majority of all and the basilic vein. It courses into the axilla and becomes axillary vascular injuries. Graham recently reported 65 the subclavian vein 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 radial nerve lies posteriorly to the axillary artery. artery. It begins at the lateral border of the first rib and ends at the inferior border of the teres major muscle, where it transitions to become the brachial artery. Diagnosis The pectoralis minor 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 superior thoracic artery, 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 thoracoacromial artery 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 lateral thoracic artery 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].