Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 27-30

Traumatic axillary artery repair: A single center experience


Department of Cardiothoracic and Vascular Surgery, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, India

Date of Submission24-Jun-2021
Date of Decision02-Jul-2021
Date of Acceptance10-Jul-2021
Date of Web Publication23-Mar-2022

Correspondence Address:
Subrata Pramanik
Department of Cardiothoracic and Vascular Surgery, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_70_21

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  Abstract 


Introduction: Only 15%–20% of the arterial injuries of the upper limbs are due traumatic axillary artery injury. Out of all ninety four percent are due to penetrating wounds, while the remaining 6% are caused by blunt traumas. Four cases with traumatic axillary artery injury are reported here. Materials and Methods: Four patients diagnosed with traumatic axillary artery injury underwent vascular repair presented between October 2019 and September 2020 are included in this study. Results: Fifty percent of patients presented with blunt trauma, whereas 50% with penetrating injury. Only one patient had associated bone injury. Hundred per cent of the patients had absent peripheral pulsation, while 50% of patients presented with warm upper extremity and normal capillary refill time. Seventy-five percent of patients involved had trauma to 1st part of axillary artery, whereas one patient suffered trauma to 2nd part. Two incisions, i.e. supraclavicular and infraclavicular incisions were taken to take proximal control of subclavian artery in two patients with trauma to 1st part of axillary artery. Only one patient underwent vascular repair with reverse saphenous vein graft, rest all patients underwent end-to-end axillary artery repair. Twenty-five percent of patients had associated brachial plexus injury and bone injury, respectively, which were taken care off along arterial repair. Hundred percent of the patients had good vascular outcome postoperatively. Conclusion: Patients presenting with trauma to periclavicular region must be thoroughly examined for associated axillary artery injury and if diagnosed with same must undergo prompt surgical exploration and arterial repair. For good proximal control, it is advisable to go for both supraclavicular and infraclavicular incisions in case of injury to 1st part of axillary artery.

Keywords: Axillary artery injury, reversed saphenous vein graft, trauma, vascular


How to cite this article:
Munjal R, Kisku N, Pramanik S, Gupta A. Traumatic axillary artery repair: A single center experience. Indian J Vasc Endovasc Surg 2022;9:27-30

How to cite this URL:
Munjal R, Kisku N, Pramanik S, Gupta A. Traumatic axillary artery repair: A single center experience. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 May 28];9:27-30. Available from: https://www.indjvascsurg.org/text.asp?2022/9/1/27/340506




  Introduction Top


Traumatic axillary artery injury represents 15%–20% of the arterial injuries of the upper limbs. Ninety-four percent of these are due to penetrating wounds, while the remaining 6% are caused by blunt traumas.[1] The injured axillary artery can cause distal ischemia. The axillary artery injury can be associated with brachial plexus injury whose incidence ranges between 27% and 44%.[2] Hence, axillary artery injury is a serious complication requiring urgent surgical exploration and repair to prevent irreversible limb ischemia.[3]

The present study reports four patients who suffered injuries to axillary artery following varied mechanism and their management and outcomes have been discussed.


  Materials and Methods Top


Four patients diagnosed with traumatic axillary artery injury underwent vascular repair between October 2019 and September 2020 are presented in this study. Thorough preoperative clinical and radiological assessment was done, which included X-ray of the involved limb, color Doppler, computed tomography angiography (CTA) following which all the patients underwent emergency vascular repair.


  Description of Cases Top


Patient 1

A 32-year-old male was referred to our institute for alleged history of 10 h old penetrating trauma to right pectoral region. Wound extending from right pectoral region to the right shoulder with exposed nerves and vessels.

Right upper limb was cold with delayed capillary filling time (Capillary Refill Time [CRT]) and absent brachial, radial, and ulnar artery pulsations. There was no evidence of any bony injury and CTA showed abrupt cutoff of first part of axillary artery and flow in brachial artery was maintained by collateral circulations.

Emergency exploration revealed transected pectoralis muscle with exposed brachial plexus and transected first part of axillary artery. Both proximal and distal ends of artery had brisk antegrade and backward flow. Revascularization was performed with an interposition reverse saphenous vein graft in end-to-side fashion. Brachial plexus was found to be intact. Postanastomosis distal pulses were present.

Postoperatively, limb was warm with palpable distal pulses, and the patient was discharged on 7th postoperative day.

Patient 2

A 40-year-old male presented with an alleged history of blunt trauma to right shoulder and right-sided anterior chest wall with ecchymosis over the same area following road traffic accident after 24 h. Right upper limb was warm but with delayed CRT and absent brachial, radial, and ulnar artery pulsation. Right upper limb movement was restricted, and sensation was reduced. There is no associated bony injury. CTA was suggestive of abrupt cutoff at the level of 1st part of right axillary artery.

The patient was taken for vascular repair. Through right supraclavicular approach, proximal control of right subclavian artery was taken. Right infraclavicular incision extending to right axilla was made to explore the injured site. On exploration, first part of axillary artery was found to be transected with 2 cm segment loss. Axillary artery was repaired with the resection of the injured part with end-to-end anastomosis. Concomitant brachial plexus injury repair was performed by plastic surgeon.

Postoperatively, distal pulses were palpable, and the patient was discharged on 10th postoperative day.

Patient 3

A 25-year-old male presented to emergency department with an alleged history of gunshot injury to right upper shoulder 12 h back. Entry wound was at the anterior aspect of right chest 2 cm below the mid-point of clavicle. Exit wound was on the back of right chest above scapula. On examination, limb was warm with normal CRT and normal limb movement but absent right brachial, radial, and ulnar artery pulsation. Color Doppler of right upper limb revealed the monophasic flow in brachial artery and axillary artery could not be assessed.

Proximal control of subclavian artery was taken through supraclavicular approach. Wound was explored by infraclavicular incision. First part of axillary artery was transected with associated rent in axillary vein. Primary repair of axillary vein was performed. Both ends of axillary artery margins were freshened. Brisk backflow and antegrade flow were present. End-to-end anastomosis of axillary artery was performed. Distal pulses were palpable postoperatively.

Postoperative period was uneventful, and the patient was discharged on 5th postoperative day.

Patient 4

A 37-year-old male was admitted with an alleged history of blunt trauma to left shoulder due to fall from height. On examination, limb was cold with delayed CRT. Left upper limb movement and sensation were present, but brachial, radial, and ulnar artery pulsation was absent. The patient had associated Grade III fracture of left humerus upper shaft, and Color Doppler was suggestive of monophasic flow distal to left axillary artery. CTA revealed that there is transection of 2nd part of left axillary artery [Figure 1].
Figure 1: CTA showing transected 2nd part of left axillary artery

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The patient was explored through left infraclavicular incision extending to axilla. Transection of 2nd part of axillary artery with loss of 2 cm segment was noted. Axillary artery repair was done with end-to-end anastomosis [Figure 2]. Bone fixation was done by orthopedic surgeon.
Figure 2: End-to-end anastomosis of left axillary artery

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Postoperatively, patient had palpable distal pulses.


  Results Top


All patients in the study are male with average of 33.5 years and were admitted with an alleged history of trauma. Seventy five percent of the patients suffered injury to right axillary artery and only one patient had injury to left side. Patients presented with variable clinical presentations and are tabulated in [Table 1].
Table 1: Clinical presentation

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CTA and color Doppler were used for diagnosis and revealed axillary artery injury in all the patients. Hence, all four patients underwent emergency axillary artery repair. Seventy-five percent of patients involved had trauma to 1st part of axillary artery, whereas one patient suffered trauma to 2nd part.

Two out of three patients with trauma to 1st part presented with closed wound and hence, two incisions, i.e., supraclavicular and infraclavicular incisions were taken to take proximal control of subclavian artery, whereas third patient presented with open wound and exposed vascular structures, hence, was approached through same wound and did not require an extra incision.

Intraoperative findings are compiled in [Table 2]. In the present case series, we achieved 100% successful vascular outcome.
Table 2: Intraoperative findings

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  Discussion Top


Vascular injuries involving upper extremity comprises 30%–50% of all vascular extremity trauma.[4] Out of these, only 5% of patients form a rare subgroup with axillary artery injury. Penetrating trauma is the most common cause of upper extremity vascular injury comprising 90%–95% of cases, followed by blunt trauma due to motor vehicle accidents, industrial accidents which accounts for 5%–10% of cases.[5] In our study, 50% of patients presented with blunt injury and 50% with penetrating injury. Axillary artery is surrounded by the bones and muscles of the shoulder girdle, and this explains the low incidence of trauma suffered by this arterial segment.

Anatomically, axillary artery is divided into three segments by pectoralis minor. First and second parts are injured due to hyperabduction and traction of shoulder. Reports suggest that 89% of injuries occur at 3rd segment,[6] but in our study, 75% of patients had trauma to 1st part of axillary artery and one patient suffered trauma to 2nd part. Delayed recognition of a vascular injury may compromise the viability of limb. Injury to brachial plexus can occur by compression by and expanding hematoma/false aneurysm and can result in severe irreversible neurologic damage.[7]

Due to extensive network of collaterals around the shoulder, the classic signs of ischemia may be absent in axillary artery injury. Yagubyan et al. had reported in their series that pulses were abnormal in 89% and 75% had no distal pulse, whereas 14% had decreased pulse on presentation.[5] Temperature of limb is also an important physical sign in arterial injuries with majority of patients with axillary artery injuries reported previously had cold upper extremities and poor capillary refill.[8],[9],[10],[11] Similarly, all four patients in our study had absent peripheral pulsation but warm upper extremity and normal capillary refill in 50% of the patients. Hence, high index of suspicion is necessary so as to provide appropriate treatment to patients and avoid complications.

There is no doubt that the time since injury carries an utmost importance for the outcome in limb ischemia; as reported in upper limb injuries, initial 4 h for proximal lesions and 12 h for more distal lesions are considered as vital periods.[12],[13]

Definitive diagnosis can be made by noninvasive methods which have evolved since the last decade. Doppler ultrasound is a convenient and cheap diagnostic modality, hence it is commonly used modality to localize site of arterial injury followed by CTA and digital substraction angiography.[5],[9],[11] Arteriography is usually not indicated all the time because it can cause delaying of the procedure.

Following diagnosis and localization, it is considered necessary to repair artery as soon as possible even in those patients presenting with adequate distal perfusion, as it is seen that arterial repair is likely to improve long-term outcome.[14] Conservative management is not advisable in an ischemic limb.[15]

An adequate incision is essential for managing these injuries. We preferred to make two incisions, i.e., supraclavicular and infraclavicular incisions in patients with closed wounds with injury to first part of axillary artery so as to avoid uncontrolled bleeding from proximal end. Same approach was not followed in 1st patient as he presented with an open wound with exposed vascular structures, hence, did not require an extra incision for proximal control. “Hybrid approaches” may prove to be very helpful in the treatment of vascular injury. Endovascular balloons can be utilized for proximal occlusion for hemorrhage control before a definitive repair.[16] Although, this technique has not been used in any of our cases.

Vascular repair can be of two types, i.e. direct anastomosis or interposition graft placement. Direct repair can be done if the damaged segment is no longer than 2 cm and interposition graft is used in case of long segment loss. Case 2nd, 3rd, and 4th presented here had 1–2 cm segment loss, and hence in these cases, direct repair, i.e. end-to-end anastomosis of axillary artery was performed. Autologous vein grafts were first used successfully during Korean war.[17] In our series, only one patient had long segment axillary artery injury and was repaired with reversed saphenous vein interposition graft with good postoperative result.

A notable feature of axillary artery trauma is associated brachial plexus injury.[5],[10] Johnson et al. reported a 43.5% incidence of brachial plexus injury occurring in patients with subclavian and axillary artery vascular trauma.[18] In the present series, 25% of patients had brachial plexus injury which was taken care off along with arterial injury and postoperatively patient had sensory deficit.

Patients presenting with trauma to periclavicular region can present with axillary artery injury along with shaft of humerus fracture. Menendez et al. reported that there was only 0.09% of patients with proximal humeral fractures with concomitant axillary artery injury.[19] In the presenting case series, only one patient presented with associated fracture shaft of humerus and axillary artery repair was prioritized followed by fracture fixation.


  Conclusion Top


Diagnosing arterial injury in periclavicular region trauma can be difficult as patients can present with normal CRT and palpable pulses or monophasic flow in Color Doppler due to good collateral blood supply. Certain mechanisms of injury should alert clinician for the possibility of such injuries. If vascular injury is suspected, then early diagnosis and prompt surgical exploration must be the norm to prevent limb ischemia. Choice of incision for exploration should be decided accordingly so as to prevent excessive blood loss. Hence, both supraclavicular and infraclavicular incisions should be made in case of injury to 1st part of axillary for safe proximal control.

Concomitant brachial plexus and soft-tissue injury dictate neurologic morbidity and play major role in recovery and outcome of the limb.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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2.
Birch R, Bonney G. Compound nerve injuries: The vascular lesion. In: Birch R, Bonney G, Wynn Parry CB, editors. Surgical Disorders of the Peripheral Nerves. 1st ed. London: Churchill Livingstone; 1998. p. 125-34.  Back to cited text no. 2
    
3.
Karita Y, Kimura Y, Sasaki S, Nitobe T, Tsuda E, Ishibashi Y. Axillary artery and brachial plexus injury secondary to proximal humeral fractures: A report of 2 cases. Int J Surg Case Rep 2018;50:106-10.  Back to cited text no. 3
    
4.
Ender Topal A, Nesimi Eren M. Management of axillo-subclavian arterial injuries and predictors of outcome. Minerva Chir 2011;66:307-15.  Back to cited text no. 4
    
5.
Yagubyan M, Panneton JM. Axillary artery injury from humeral neck fracture: A rare but disabling traumatic event. Vasc Endovascular Surg 2004;38:175-84.  Back to cited text no. 5
    
6.
Hayes JM, Van Winkle GN. Axillary artery injury with minimal displaced fracture of neck of the humerus. J Trauma 1983;23:431-3.  Back to cited text no. 6
    
7.
Raju S, Carner DV. Brachial plexus compression: Complication of delayed recognition of arterial injuries of the shoulder girdle. Arch Surg 1981;116:175-8.  Back to cited text no. 7
    
8.
Zarkadas PC, Throckmorton TW, Steinmann SP. Neurovascular injuries in shoulder trauma. Orthop Clin North Am 2008;39:483-90, vii.  Back to cited text no. 8
    
9.
Modi CS, Nnene CO, Godsiff SP, Esler CN. Axillary artery injury secondary to displaced proximal humeral fractures: A report of two cases. J Orthop Surg (Hong Kong) 2008;16:243-6.  Back to cited text no. 9
    
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Stenning M, Drew S, Birch R. Low-energy arterial injury at the shoulder with progressive or delayed nerve palsy. J Bone Joint Surg Br 2005;87:1102-6.  Back to cited text no. 10
    
11.
Seagger RM, Kitson J. A rare combination of an axillary artery and brachial plexus injury due to a proximal humeral fracture. J Shoulder Surg 2009;3:71-3.  Back to cited text no. 11
    
12.
Murata K, Maeda M, Yoshida A, Yajima H, Okuchi K. Axillary artery injury combined with delayed brachial plexus palsy due to compressive hematoma in a young patient: A case report. J Brachial Plex Peripher Nerve Inj 2008;3:9.  Back to cited text no. 12
    
13.
Palm DS, Parikh PP, Schoonover B, Lebamoff D, McCarthy MC. Axillary arterial entrapment and brachial plexus injury due to proximal humeral fracture. Inj Extra 2013;44:67-9.  Back to cited text no. 13
    
14.
Klocker J, Peter T, Pellegrini L, Mattesich M, Loescher W, Sieb M, et al. Incidence and predisposing factors of cold intolerance after arterial repair in upper extremity injuries. J Vasc Surg 2012;56:410-4.  Back to cited text no. 14
    
15.
Jensen BV, Jacobsen J, Andreasen H. Late appearance of arterial injury caused by fracture of the neck of the humerus. J Trauma 1987;27:1368-9.  Back to cited text no. 15
    
16.
Carrick MM, Morrison CA, Pham HQ, Norman MA, Marvin B, Lee J, et al. Modern management of traumatic subclavian artery injuries: A single institution's experience in the evolution of endovascular repair. Am J Surg 2010;199:28-34.  Back to cited text no. 16
    
17.
Hughes CW. Arterial repair during the Korean war. Ann Surg 1958;147:555-61.  Back to cited text no. 17
    
18.
Johnson SF, Johnson SB, Strodel WE, Barker DE, Kearney PA. Brachial plexus injury: Association with subclavian and axillary vascular trauma. J Trauma 1991;31:1546-50.  Back to cited text no. 18
    
19.
Menendez ME, Ring D, Heng M. Proximal humerus fracture with injury to the axillary artery: A population-based study. Injury 2015;46:1367-71.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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