World J Surg (2011) 35:962966 DOI 10.

1007/s00268-011-1008-8

Civilian Penetrating Axillary Artery Injuries

Hardeep Gill William Jenkins Sorin Edu Wanda Bekker Andrew J. Nicol Pradeep H. Navsaria

Published online: 1 March 2011 Societe Internationale de Chirurgie 2011

Abstract Background The surgical management and outcome of penetrating axillary artery (AA) injuries is presented. Patients and methods Patients presenting to Groote Schuur Hospital with penetrating AA injuries from January 2003 to December 2009 were reviewed. Demographic data, mechanism of injury, associated injuries, angiographic ndings, surgical treatment, complications, and mortality were noted. Results Sixty-eight patients with AA injuries were identied from an operating trauma database. Stab and gunshot wounds accounted for 54 (79.4%) and 14 injuries, respectively. The mean Revised Trauma Score was 7.5 (range: 3.87.8). Angiography was done in 49 patients; false aneurysms (32) and total occlusions (15) were the two commonest ndings. Primary repair of the injured AA was possible in 41 (60.3%) patients. Five AA (7.4%) injuries were ligated. Morbidity was restricted to associated brachial plexus injuries. The limb salvage rate was 100%. Conclusions Primary repair of AA injuries was possible in 60% of patients, and ligation was life-saving in critically ill patients. The associated brachial plexus injury was the cause of major long-term morbidity.

constitute less than 5% of all civilian vascular traumas. Limited clinical experience, complex local anatomy, and surgical exposure have rendered management of these injuries particularly difcult. In our urban trauma center with a high incidence of penetrating trauma, AA injury is the third commonest (15.3%) peripheral vascular injury seen; brachial (48.2%) arterial injuries [1] being the commonest, followed by femoral (18.8%) arterial injuries [2]. The purpose of the present study was therefore to review our management and outcome of patients with penetrating AA injuries.

Patients and methods The records of all patients undergoing surgery for a penetrating AA injury in the Trauma Center at Groote Schuur Hospital during the 7-year period January 2003 to December 2009 were retrieved from a prospective trauma operating room database and retrospectively reviewed. Blunt AA injuries were excluded. Standard demographic data, mechanism of injury, admission vital signs, neurological decit, hemoglobin concentration, blood transfusion requirements, and vascular investigations were recorded. Operation notes documented the location of the AA injury, method of repair, and local associated injuries. Hospital stay, complications, and mortality were noted. Initial management and resuscitation were conducted along standard Advanced Trauma and Life Support (ATLS) guidelines. Emergency room thoracotomy (ERT) was performed in patients with no signs of life or with imminent cardiac arrest and/or immediate drainage of 1,500 ml of blood from a tube thoracostomy. Patients in shock, with active bleeding, compartment syndrome, or limb ischemia, were resuscitated and expediently taken to the operating

Introduction Penetrating axillary arterial injuries (AA) occur infrequently. Together with subclavian arterial injuries, they

H. Gill W. Jenkins S. Edu W. Bekker A. J. Nicol P. H. Navsaria (&) Trauma CenterC14, Groote Schuur Hospital and University of Cape Town, Observatory, 7925 Cape Town, South Africa e-mail: pradeep.navsaria@uct.ac.za

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room (OR) for emergency exploration. Hemodynamically stable patients and those who stabilized after simple resuscitation (less than 2 l crystalloids) underwent further evaluation. Foley-catheter balloon ination into the bleeding wound was used in actively bleeding patients in an attempt to establish temporary tamponade. If successful and the patient was stabilized, angiography was performed. Indications for angiography were as follows: ipsilateral distal pulse discrepancy, absent pulse in the presence of a viable limb, moderate to large hematoma, Foley-catheter balloon tamponade, and palpable thrill and/or audible bruit. Operative technique The axillary artery is dened as the continuation of the subclavian artery from the lateral border of the rst rib to the lateral border of the teres major muscle. Its three anatomic divisions are dened by the overlying pectoralis minor muscle tendon. The rst part, proximal to the pectoralis minor muscle, has one branch (superior thoracic artery); the second part, behind the pectoralis muscle, has two branches (lateral thoracic and thoracoacromial arteries); and the third part, distal to the pectoralis minor muscle, has three branches (anterior and posterior circumex humeral, and subscapular arteries) [3]. Surgical access to the axillary artery depends on the clinical presentation. Patients with no signs of life or imminent cardiac arrest require emergency room thoracotomy. Hemodynamically unstable patients are transferred to the OR immediately. In the presence of active bleeding, patients are placed in the Trendelenburg position to minimize the risk of air embolism, and control of external hemorrhage is achieved by simple digital pressure. Foley-catheter balloon tamponade (FCBT) can be used in an attempt to control bleeding. Also, a swab on a stick can be used to apply pressure to minimize bleeding during exposure. In the operating room all patients are positioned supine with a bolster beneath the shoulders; the head is placed in a head ring and turned to the opposite side with slight extension of the neck. Unlike elective axillary artery exploration for vascular disease where the ipsilateral arm is down at the side, with the elbow slightly exed (hand in imaginary pants pocket); the arm is fully abducted at 90 degrees to allow for the skin incision to be extended into the upper arm for adequate exposure of the third part of the axillary artery and proximal brachial artery. The groin is always prepared for harvesting the saphenous vein. For very proximal (subclavian-axillo) injuries, supraclavicular control of the subclavian artery is obtained. An infraclavicular incision is then made over the deltopectoral groove, beginning one nger breadth below the clavicle and ending about two nger breadths below the clavicle. The bers of the pectorals major muscle are split and the clavipectoral

fascia is encountered, with the pectoralis minor muscle in the lateral half of the wound. On opening of the clavipectoral fascia, branches of the thoracoacromial trunk will be seen and will lead to the rst part of the axillary artery. The pectoralis minor muscle is divided to expose the second part of the axillary artery. Distal control is mandatory because of the extensive collateral circulation in the neck and shoulder region [4]. Damage control surgery is reserved for the critically ill exsanguinating patient approaching the triad of death of hypothermia, coagulopathy,, and acidosis. An initial bail out operation for penetrating AA injuries will include temporary shunting with pieces of nasogastric tubes, suction catheters, and intravenous lines, or ligation of the artery with or without packing of the surgical dissection site with swabs. The patient is then resuscitated in the intensive care unit (ICU) and denitive arterial repair performed 2448 h later on a stable, rewarmed patient with an acceptable coagulation prole.

Results Sixty-eight patients with penetrating AA injuries comprised the study group. There were 66 men and two women with a mean age of 29.3 years (range: 1554 years). The mechanism of injury was a stab wound in 54 (79.40%) patients and a gunshot wound in 14 patients. Forty-ve patients (66.2%) sustained injuries to the left AA and 23 had right-sided injuries. Forty-seven patients (69.1%) presented within 24 h of their injury and 21 (30.9%) patients with more than a 24-h delay. The mean weighted revised trauma score (RTS) was 7.5 (range: 3.87.8) and the mean injury severity score (ISS) was 18.2 (range: 927). The mean nger-prick hemoglobin estimation on admission was 9.2 G% (range: 214 G%). Fifteen patients (22.1%) were hypotensive (systolic blood pressure \ 90 mmHg) on arrival in the emergency room, whereas 53 patients (77.96%) were hemodynamically normal on presentation (mean blood pressure 116/68 [range: 40/30170/104] and pulse rate 99.3 [range 54136]). In the former group, 7 (46.7%) patients underwent immediate transfer to the operating room for emergency surgery; 8 patients responded to simple resuscitation, allowing for further investigation. A pulse decit was present in 49 (72.1%) patients. Foley catheter balloon tamponade was used in ve patients; in three of them, bleeding was satisfactorily arrested and patients stabilized for formal angiography. The remaining two patients had persistent bleeding, requiring immediate surgical exploration. Admission clinical ndings are presented in Table 1. Angiography was performed in 49 (72.1%) patients; the commonest nding was a false aneurysm. Table 2 lists the

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World J Surg (2011) 35:962966 Table 3 Surgical management of 68 axillary artery injuries Management Resection and with endend repair Reverse saphenous vein graft Ligation Polytetrauorethylene Arteriorraphy Nil (intraoperative death unrelated to axillary artery injury) N (%) 38 (55.9) 17 (25.0) 5 (7.4) 4 (5.9) 3 (4.4) 1

indications for angiography and the ndings. A mean perioperative transfusion of 2.6 units (range: 012 units) of packed cells was administered. Eighteen patients (26.4%) required emergency exploration, the indications being active hemorrhage (7) and critical limb ischemia (11). The AA was injured in the rst, second, and third parts, 12 (17.6%), 31 (45.6%), and 25 (36.8%) times, respectively. Because most injuries were due to stab wounds (79.4%) with false aneurysms (65.3%), after adequate vessel debridement, either resection with end-to-end anastomosis or reverse saphenous vein interposition grafting was the commonest methods of arterial repair employed in 38 (55.9%) and 17 (25.0%) patients, respectively (Table 3). Polytetrauoroethylene (PTFE) interposition grafting was performed in 4 (5.9%) patients because of poor quality autogenous saphenous vein. Ligation of the AA was performed in ve patients (7.4%), all of whom had infected false aneurysms with delayed presentation ranging from 7 days to 6 weeks. Two patients; one who presented to a peripheral hospital in hypovolemic shock, was stabilized and transferred to our care intubated and ventilated, with a Glasgow Coma Score (GCS) of 3. Another patient was in advanced shock. Both had temporary shunts inserted, and these were later removed and denitive repair done at 48 h. 12 (17.6%) patients with stab wounds sustained concomitant axillary vein injuries, ten of which were ligated
Table 1 Clinical presentation of 68 patients with penetrating axillary artery injuries Clinical manifestation Pulse decit Large hematoma Limb ischemia Bleeding Bruit Pulsatile hematoma N (%) 47 (69.1) 21 (30.9) 11 (16.2) 9 (13.2) 8 (11.8) 8 (11.8)

Table 2 Indication for angiography and their ndings in 49 patients Number (%) Indications for angiogram Pulse discrepancy Bruit Moderate-large hematoma Pulsatile hematoma Delayed presentation with brachial plexus decit Angiographic nding False aneurysm Occlusion/transection Arteriovenous stula 32 (65.3) 15 (30.6) 2 (4.1) 5 (10.2) 12 (24.5) 2 (4.1) 2 28 (57.1)

because of complete transection requiring complex repair. The other two were repaired, both requiring simple lateral venorrhaphy. Mild limb swelling was documented postoperatively in the patients who underwent axillary vein ligation. 5 (7.3%) patients presented with signs of a compartment syndrome and underwent fasciotomy, whereas 3 (4.4%) patients with combined arterial and vein injury, had a prophylactic fasciotomy performed. Injuries to the brachial plexus were seen in 41 (60.3%) patients and accounted for long-term morbidity in 32 (47.1%) patients. No iatrogenic injury to the brachial plexus was seen. Brachial plexus repair (performed by the Hand Surgery Unit) was done in 18 (43.9%) of these cases, while the remaining injuries were considered to be minor (contusion with neuropraxia) and treated nonoperatively. Only nine (21.9%) of the 41 patients with brachial plexus injury had full neurological recovery at 6 months. Mild to moderate sensory motor dysfunction occurred in 23 (56.1%) patients, claw-hand in 5 (12.2%) patients; of which two had delayed extensor-carpi radialis longus tendon transfers. Four patients with extensive cord damage had a ail limb. In addition to the axillary vessel injuries, two patients underwent therapeutic laparotomy for abdominal penetrating injury. 29 (42.6%) patients had an associated hemopneumothorax. Infected hemothorax occurred in one (1.4%) case, requiring thoracotomy, pleural washout, and decortication. The limb salvage rate was 100% and there was one on-table death, unrelated to the axillary vessel injury, due to thoracoabdominal injuries.

Discussion Penetrating trauma accounts for the majority of AA injuries. Approximately 3% of all penetrating chest and neck trauma are associated with subclavian or axillary vascular injuries [3]. The incidence of AA trauma among major arterial injuries has been similar in both civilian and military series, ranging from 2.9 to 9% [4]. Pre-hospital mortality is about 23% and long-term morbidity is mainly attributed to brachial plexus injuries. Most reports of civilian penetrating AA injuries are usually described

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World J Surg (2011) 35:962966 Table 4 Literature review of axillary artery injuries showing paucity of reports Author (year) Reynolds et al. (1979) [17] Graham et al. (1982) [5] Shaw et al. (1995) [10] Degiannis et al. (1995) [18] Demetriades et al. (1999) [9] McKinley (2000) [6] Askoy (2005) [8] Current series Study design Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Study period (years) 8 10 10 4 4 20 13 7 Axillary or axillary/ subclavian Axillary Axillary Axillary/subclavian Axillary Axillary/subclavian Axillary/subclavian Axillary/subclavian Axillary No. of patients 14 65 15 32 59 123 26 68

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Penetrating mechanism (%) 71 95 26 100 100 96 66 100

together with subclavian arterial injuries [610] probably because of their low incidence (Table 4). All penetrating wounds in the periclavicular/shoulder girdle region must be clinically evaluated for a vascular injury. In addition to the usual hard (severe bleeding, shock, expanding hematoma, absent/diminished pulse and bruit) and soft (small stable hematoma, proximity injury) signs of a vascular injury, the axilla must always be examined for an occult hematoma, something that can be readily overlooked. Investigations are reserved for patients who are hemodynamically stable and those with hard signs with a viable limb. While there is some evidence that patients with hard signs of a vascular injury should undergo immediate exploration, we reserve emergency exploration for hemodynamically unstable and/or actively bleeding patients, those with acute limb ischemia and compartment syndrome. There is also evidence that a high negative exploration rate of up to 40% occurs when a protocol of routine exploration or angiography for a compendium of hard and soft signs is employed [11]. The constant shortage of emergency operating room time in public service hospitals is a major constraint to explore all patients with hard signs (moderate to large hematoma, bruit, thrill, and absent/diminished pulse on palpation) [12]. In our institution access to angiography is much quicker than getting a patient who is hemodynamically stable with a viable limb to the operating room. Angiography remains the gold standard of investigation, and if normal, reduces the negative exploration rate and allows for early discharge. Color ow duplex angiography has not gained favor in our center because of the poor visualization of the vessels in the periclavicular area. Damage-control surgery is reserved for the critically ill exsanguinating patient approaching the triad of death of hypothermia, coagulopathy, and acidosis. An initial bail out operation for penetrating AA injuries will include temporary shunting with pieces of nasogastric tubes, suction catheters, and intravenous lines. The patient is then resuscitated in the intensive care unit (ICU), and denitive

arterial repair is performed 2448 h later on a stable, rewarmed patient with an acceptable coagulation prole. Commonly associated injuries with AA injuries are brachial plexus, axillary vein, and intrathoracic (hemothorax and/or pneumothorax) injuries. Table 5 compares the reported incidence of these associated injuries with the current series. The current series had almost twice as many patients with brachial plexus and intrathoracic injuries, and half the number of patients with concomitant venous injury. Brachial plexus injury, despite current techniques of microvascular funicular repair, remains the cause of major long-term morbidity. In cases where patients can be adequately neurologically evaluated, the operation should be performed with consultation of the hand surgeon, who should explore and repair any nerve injury. In the case of an emergency exploration, where preoperative brachial plexus injury examination is precluded by shock and or ischaemia, the hand surgeon should be consulted, and if any brachial plexus injuries are identied, they should be repaired if the patients physiological status permits; otherwise, the nerve endings should be tagged with a nonabsorbable suture for easy recognition at re-exploration and repair at a later stage. Venous injury repair should be considered only if it can be performed by simple suturing without producing severe stenosis and without the use of any complex reconstruction techniques such as autologous grafts or patches. Ligation of the vein is very well tolerated by almost all patients, and there is no evidence that complex reconstruction reduces the probability of development

Table 5 Associated injuries and their incidence Injury Brachial plexus Axillary vein Intrathoracic Reported incidence (%) 3041 3043 1829 Current series (%) 60.3 17.6 42.6

Source of data: [5, 6, 810, 15, 18]

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World J Surg (2011) 35:962966 3. Demetriades D, Asensio JA (2001) Subclavian and axillary vascular injuries. Surg Clin North Am 81:13571373 4. Rutherford RB (1993) Atlas of Vascular Surgery: Basic Techniques and Exposures, Section 2, Infraclavicular exposure. W. B. Saunders Company, Philadelphia, pp 250253 5. Graham JM, Mattox KL, Feliciano DV et al (1982) Vascular injuries of the axilla. Ann Surg 195:232238 6. McKinley AG, Abdool Carrim ATO, Robbs JV (2000) Management of proximal axillary and subclavian artery injuries. Br J Surg 87:7985 7. Franga DL, Hawkins ML, Mondy JS (2005) Management of subclavian and axillary artery injuries: spanning the range of current therapy. Am Surg 71:303307 8. Aksoy M, Tunca F, Yanar H et al (2005) Traumatic injuries to the subclavian and axillary arteries: a thirteen year experience. Surg Today 35:561565 9. Demetriades D, Chahwan S, Gomez H et al (1999) Penetrating injuries to the subclavian and axillary vessels. J Am Coll Surg 188:290295 10. Shaw AD, Milne AA, Christie J et al (1995) Vascular trauma of the upper limb and associated nerve injuries. Injury 26:515518 11. Richardson JD, Vitale GC, Flint LM Jr (1987) Penetrating arterial trauma. Arch Surg 122:678683 12. Frykberg ER, Dennis JW, Bishop K et al (1991) The reliability of physical examination in the evaluation of penetrating extremity trauma for vascular injury: results at one year. J Trauma 31:502511 13. Knottenbelt JD, Van der Spuy JW (1994) Traumatic haemothoraxexperience of a protocol for rapid turnover in 1, 845 cases. S Afr J Surg 32:58 14. Knottenbelt JD, van der Spuy JW (1990) Traumatic pneumothorax: a scheme for rapid patient turnover. Injury 21:7780 15. du Toit DF, Lambrechts AV, Stark H et al (2008) Long-term results of stent graft treatment of subclavian artery injuries: management of choice for stable patients? J Vasc Surg 47:739743 16. Danetz JS, Cassano AD, Stoner MC et al (2005) Feasibility of endovascular repair in penetrating axillosubclavian injuries: a retrospective review. J Vasc Surg 41:246254 17. Reynolds RR, McDowell HA, Diethelm AG (1979) The surgical treatment of arterial injuries in the civilian population. Ann Surg 189:700707 18. Degiannis E, Levy RD, Potokar T et al (1995) Penetrating injuries of the axillary artery. Aust N Z J Surg 65:327330

of compartment syndrome [3]. Ligation is associated with minimal morbidity, with most post-ligation swelling being mild and temporary in nature. The standard principles of management should be adhered to with patients with hemothorax and/or pneumothorax; namely, sterile insertion of tube thoracostomy, early mobilization, and aggressive physiotherapy [13, 14]. Endovascular repair of selected penetrating subclavian arterial injuries has been shown to be a safe, feasible option with acceptable long-term follow-up [15]. It has been reported that approximately 50% of all axillo subclavian vascular injuries may be endofeasible [16]. The ideal candidates are patients with false aneurysms, arteriovenous stulae, or arterial stenosis away from the origin of the carotid artery. Lesions that may not be amenable to endovascular repair include arterial occlusions where a guidewire cannot be made to traverse the injured segment. Also, centers with a high incidence of gunshot injuries to the axillary artery where patients present with hemodynamic instability, would make endovascular repair non feasible. Our own experience with AA stenting is nonexistent because of the major budget constraints in statefunded hospitals in South Africa. The advantage of this is that trauma surgeons can retain and teach surgical vascular skills. The present study obviously was limited by its retrospective nature and focuses only on the operative outcome of patients with AA injuries. The results are excellent, with no deaths related to the axillary artery repair and a limb salvage rate of 100%. Planning the surgical approach using preoperative angiography, rapid exposure to gain vascular control, and reconstruction to re-establish perfusion and ligation in carefully selected cases has contributed to the successful vascular outcome of patients in this study. Brachial plexus injury remains the cause of major morbidity.

References
1. Zellweger R, Hess F, Nicol A et al (2004) An analysis of 124 surgically managed brachial artery injuries. Am J Surg 188:240245 2. Murugan N, Navsaria PH, Edu S et al (2008) Femoral vessel injury: an audit of 64 patients. South Afr J Surg 46:128

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