Vascular Injuries of the Axilla

JOSEPH M. GRAHAM, M.D., KENNETH L. MATTOX, M.D., DAVID V. FELICIANO, M.D., MICHAEL E. DEBAKEY, M.D. &

Between January 1970 and December 1980, 65 patients sus-taining 85 vascular injuries of the axillary artery and/or veinwere managed at the Ben Taub General Hospital in Houston,Texas. Concomitant injuries of the subclavian and/or brachialvessels were noted in 34 per cent of patients. A variety ofexposure techniques was used in approaching the axillary ves-sels. Emphasis upon preservation of collateral vessels led to anincreased use of substitute vascular conduits over end-to-endanastomosis. The ready availability of prosthetic conduits, ab-sence of graft infection, and excellent short-term patency havemade them a primary choice for axillary arterial reconstructionin our recent experience. Associated brachial plexus injury(35%) accounted for the most significant long-term morbidity.The operative mortality was 3.1%, and one patient requiredupper extremity amputation following failure of repeated re-vascularization attempts.

)ENETRATING AND BLUNT INJURIES of the shoulder1 are frequent and often innocuous appearing wounds.In close proximity, however, lies the anatomic axillaand a host of neurovascular structures. Although pro-viding considerable coverage and protection, the sur-rounding bone and muscular girdle may obscure phys-ical signs of vascular injury and hinder rapid operativeexposure and vascular control. The intimate proximityof the brachial plexus and the presence of an extensivecollateral network to the upper extremity demand ac-curacy of dissection. A systematic approach to theevaluation and management of axillary vascular injuriesis required. In the following report, the managementand morbidity of axillary vascular injuries in a civilianpopulation are reviewed.

Materials and Methods

Between January 1970 and December 1980, 65 pa-tients sustaining 85 vascular injuries of the axillary ar-tery and/or vein were managed at the Ben Taub Gen-eral Hospital in Houston, Texas. Fifty-eight patientswere male and 17 were female. Their ages ranged from16 to 61, with an average age of 22.2 years. Axillaryvascular injuries were caused by gunshot wounds in 39

Reprint requests: Joseph M. Graham, M.D., 6535 Fannin, Houston,TX 77030.

Submitted for publication: July 14, 1981.

From the Cora and Webb Mading Department of Surgery,Baylor College of Medicine, and the Department of

Surgery, Ben- Taub General Hospital, Houston, Texas

patients, stab wounds in 16 patients, shotgun woundsin 7 patients, and blunt trauma in 3 patients (Table 1).

Results

Thirty-one arterial, 14 venous, and 20 combined ar-,teriovenous wounds were managed. The axillary arteryis defined as that continuation of the subclavian arteryfrom the lateral border of the first rib to the lateral.border of the teres major muscle. Its three anatomicdivisions are defined by the overlying pectoralis mintrtendon (Fig. 1). The 51 axillary arterial injuries wer%evenly distributed between the three divisions, with 13injuries involving multiple segments or the entire artery(Table 2). Complete or subtotal transection was presentin 47% of arterial and 24% of venous injuries. In 24patients (47%) with axillary artery injury, distal arterialpulses were absent or markedly diminished. In 19 p-tients, positive arteriograms were obtained, 14 via ret-rograde brachial and five via arch aortogram techbniques. Axillary artery injury was not initially recognizedin two patients. One patient was discovered to have atraumatic axillary arteriovenous fistula one week fol-lowing repair of a concomitant subclavian vein injury.A lateral axillary artery injury was missed in anotherpatient at the time of the original exploration. Re-ex'ploration and repair of the false aneurysm three weeksfollowing injury was required. Twenty-three patients(35%) in this series had evidence of injury to the bra-chial plexus, while two patients had injury to the spin\kcord. One patient was found to have a hemispheric ce-rebral neurologic deficit. Concomitant vascular woundikwere the most frequent associated injuries (Table 3)Subclavian or brachial arterial injuries were present in22 patients (34%), including one patient with simul-taneous subclavian, axillary, and brachial artery inju-

6ries.A variety of operative exposures was used (Table 4}

In most patients, the initial incision was in either the

0003-4932/82/0200/0232 $00.85 © J. B. Lippincott Company

232

VASCULAR INJURIES OF THE AXILLA

infraclavicular or anterior axillary region. Options forextension of either wound to attain proximal or distalvascular control or to expose adjacent concomitant vas-

cular wounds were frequently used. In addition, divisionof the pectoralis major and/or minor tendon(s) was

selectively performed to aid exposure. In one patient,the proximal axillary artery was exposed following tho-'racotomy by resecting the first and second ribs. Twopatients having large shotgun wounds were explored byextending the original wound defects. In more proximalaxillary vascular wounds, supraclavicular exposure ofthe subclavian artery was occasionally used for vascularcontrol.

Rapid resuscitation and early exposure of axillaryand associated vascular wounds permnitted repair of allarterial injuries (Table 5). In 61% of arterial wounds,a substitute vascular conduit of either autogenous sa-

phenous vein, Dacron velour, or Gore-Tex@* rangingfrom 2 to 6 cm in length was used. Axillary vein injtiries+were generally repaired by lateral venorrhaphy. Pros-thetic grafts were not used in the venous position, butthree injuries were treated by segmental resection andend-to-end anastomosis. Ligation was used only in pa-

tients with extensive venous wounds. One patient sus-

taining extensive brachial and axillary arteriovenousinjuries following a shotgun wound subsequently re-

quired amputation. Revascularization was attemptedused a saphenous vein graft from the axillary artery to

* W. L. Gore and Associates, Inc., 555 Paper Mill Road, Newark,DE 19711.

'.

FIG. 1. The three anatomicdivisions of the axillary ar-

tery and their branches.

TABLE 1. Mechanisms and Location of Axillary VascularInjuries in 65 Patients

ArteryEtiology Artery & Vein Vein Total

Gunshot wounds 19 12 8 39Stab wounds 8 2 6 16Shotgun wounds 1 6 0 7Blunt trauma 3 3

Total 31 20 14 65

the distal brachial artery. Recurrent graft thrombosis,despite repeated attempts at thrombectomy, and graftrevision ultimately led to distal extremity gangrene andinfection. Patients having axillary veinl repair or ligationexperienced minimal or only temporary problems witharm edema. Aside from the two previously describedinstances of delayed diagnosis, no additional vascularrelated complications occurred. There have been no

early or late graft infections. Graft failure or vascularocclusion has not been observed. Each patient had a

palpable distal pulse at the time of discharge and atfollow-up two weeks following discharge. Althoughlong-term follow-up has been incomplete, no instanceof late vascular occlusion Has been recorded.Two patients expired from complications of numer-

ous associated injuries. One patient died of respiratoryinsufficiency and pneumonia two weeks following sur-

gery for multiple gunshot wounds of the chest and ab-domen. The second patient died of complications ofcerebral injury incurred as a result of blunt trauma.

Supreme Thoracic A.

Thoraco-acromial A.

Lateral Thoracic A.

Subscapular A.

Anterior Humeral

~~Circumflex A.

Vol. 195 * No. 2 233

Ann. Surg. * February 1982

TABLE 2. Location of Axillary Artery Injuries

Number ofLocation Injuries

First division 12Second division 14Third division 12Combined divisions 13

Total 5 1

Pulmonary insufficiency developed in three survivingpatients, and severe cerebral sequelae of an associatedhead injury were noted in one patient. The most severeand permanent disability was experienced by 25 pa-tients (39%) having associated brachial plexus or spinalcord injury. Immediate repair of lacerated or transectednerve roots and cords was not performed. Proximal anddistal nerve ends were marked with nonabsorbable su-ture for possible future identification and when possiblethe nerve ends were approximated to prevent retraction.Three patients (12%) having brachial plexus contusionwere observed to regain appreciable neurologic func-tion. Delayed conventional epineural end-to-end unionwas performed in six patients, but without significantneurologic or functional return. Causalgia or persistentextremity pain led to repeat hospitalization or therapyin 20 patients (80%) and subsequent elective amputa-tion in one patient for a useless painful extremity.

Discussion

Although wounds to the axilla appear to be innocuousin many patients, axillary vascular injuries may leadto severe disability, loss of limb, or death. 3'8'9"4"9 The

TABLE 3. Associated Injuries Among 65 Patientswith Axillary Vascular Trauma

Number ofLocation Patients

VascularSubclavian artery 9Subclavian vein 5Brachial artery 13Brachial vein 7

NeurologicBrachial plexus 23Spinal cord 2Brain I

BonesClavicle 3Humerus 7Scapula 2

OtherThoracic duct ILung 19

TABLE 4. Operative Exposure in 65 Patients

Number of NIncision Patients

Infraclavicular 54*tAxillary 8Thoracotomy with first and

second rib resection IExtension of original wound 2

* Division of pectoralis major (10) and/or minor (19) muscle ten-,dons to aid exposure.

t Concomitant anterior thoracotomy and upper median sternotomyfor repair of subclavian vessels (9).

incidence of axillary artery trauma among major aswterial injuries has been similar in both civilian and mil-itary series, ranging from 2.9 to 9.0%.',34,1012,14,19 Withthe escalating use of firearms in our society, the occa-sional trauma surgeon needs to be familiar with therecognition and management of such injuries.The classic signs and symptoms of arterial injury ar*

usually well recognized and include (among others)pain, pulselessness, pallor, paresthesia, and paralysis.'"Following injury of the axillary artery, some or all ofthese "classic" signs may be absent.6'7 The explanationfor this apparent paradox lies in the extensive anasto-motic network of collateral vessels around the shoulderAs a result, patients having traumatic transection orsurgical ligation of the axillary artery may maintain notonly a viably extremity but a palpable distal pulse.4"2"3Other well-described manifestations of arterial injuryare usually present. These may include active arterialbleeding, expanding hematoma, continuous thrill, anda diminished pulse pressure when compared to the op-posite arm. Loss of peripheral pulse, a large or extpanding hematoma, or a positive arteriogram were thamajor indications for surgical exploration in this ex-.perience.

Patients with penetrating wounds in proximity to theaxillary vessels should undergo arteriography if othercriteria for operative exploration are absent. In thl'experience, no false negative study was obtained; how-ever, one false positive arteriogram was seen. The ac-curacy of arteriography in the diagnosis of arterial in-jury has been documented elsewhere and depends upon

TABLE 5. Operative Repair of 85 Axillary Vascular Injuries

Surgical Procedure Artery Vein

Ligation 0 9Primary repair 10 22Segmental resection and repair with

End-to-end anastomosis 10Saphenous vein graft 13Dacron graft 14 0Gore-TexR 4 0

234 GRAHAM AND OTHERS

VASCULAR INJURIES OF THE AXILLA

,the quality of the study and the experience of theviewer. 6,17 In most instances, a retrograde brachial ar-

teriogram was performed by the surgeon himself shortlyafter initial evaluation and resuscitation (Fig. 2).Equally as important are arteriograms obtained in pa-

tients suspected of having concomitant subclavian vas-

,cular injuries.6 Associated proximal vascular injuryshould be considered when supraclavicular hematomaformation or extension is present. Arteriograms delin-eating anatomy in this area usually require transfer toan arteriographic suite with percutaneous Seldinger se-

lective techniques. Many patients are too unstable to,permit such detailed evaluations. In these cases, thesurgeon must immediately proceed to exploration andbe ready to achieve adequate proximal vascular control.

Approximately 22-27% of reported vascular injuriesoccur in the venous system.5'5 Although venous injuriesrepresented 40% of axillary vascular trauma in this se-

,ries, they probably occur more frequently than clinicallyrecognized. It may be hypothesized that many isolatedvenous injuries may not produce sufficient evidence ofvascular injury to warrant exploration, and the sequelaeof small unrepaired injuries are negligible. Fifty-nineper cent of the venous injuries in this series were en-

yountered at the time of exploration and repair of an

arterial injury. Venous injury alone may produce suf-,ficient hematoma formation or external bleeding towarrant operative exploration. In these patients, thepresence or absence of an associated arterial injury maynot be known until full exposure and exploration hasbeen performed. Many suspected axillary venous inju-ries, however, require only careful observation and may*3nly cause problems when associated arterial injurycannot be ruled out.

J

FIG. 3. Incision for infraclavicular exploration of the axilla (solid line)and possible extension (dotted line) for additional exposure of thedistal axillary and brachial vessels.

The operative management of axillary vascular in-juries begins with the placement of intravenous linesand the proper positioning of the patient for exploration.Peripheral or central venous lines on the side of sus-

pected vascular injury are contraindicated. In most in-stances, a lower extremity intravenous line should beplaced. The patient should be positioned supine withthe involved extremity abducted 90°. The entire ante-rior chest, abdomen, and neck should be prepped anddraped within the operative field to allow for possiblethoracic and cervical exploration. The arm should be

f

a

FIG. 2. Retrograde brachial axillary arteriogram demonstrating ax-

illary artery injury.

FIG. 4. Exposure of the axillary artery following separation of the

pectoralis major muscle fibers and lateral retraction of the pectoralisminor tendon.

235VOl. 195.- NO. 2

...,.mjllmpwwr,"M.. ......4m, -.1.

I

GRAHAM AND OTHERS236

/,~

FIG. 5. Lateral exposure of the axilla via an anterior axillary incision(solid line) with possible infraclavicular and brachial extension (dottedlines).

similarly prepared to the wrist to allow for repositioningand palpation of brachial pulses.

Exposure of the axilla via an infraclavicular approachaffords the widest exposure. The incision begins inferiorto the medial third of the clavicle and is carried laterallyto the delto-pectoral groove. The incision may be ex-

tended onto the proximal arm to gain additional ex-

posure of the third portion of the axillary artery andthe brachial artery (Fig. 3). Fibers of the pectoralis

K~~~~~~~~~~~~~~~~~~~~~~~

FIG. 6. Exposure of the axillary artery following medial retraction ofthe pectoralis muscle tendons.

major muscle are then separated, and the underlyingNpectoralis minor muscle tendon retracted medially orlaterally (Fig. 4). When additional exposure is needed,the pectoralis major and/or minor tendons may be di-vided near insertion, and the muscles retracted inferi-orly. Patients having distal axillary artery injury maybe approached laterally via an incision in the axilla.along the delto-pectoral groove. Options for medial ordistal wound extension exist (Fig. 5). The pectoralismuscle tendons are then retracted medially or dividedfor additional exposure (Fig. 6). By definition, the ax-illary artery is extrathoracic in location and not exposedvia median sternotomy or thoracotomy. Supraclavicular,exposure and control of the subclavian artery may berequired in some patients when proximal control of theaxillary artery cannot be attained via the infraclavicularincision. Division or resection of the clavicle was infre-quently performed in this experience and, in general,found to add little to axillary exposure. Regardless offthe choice of incision, the extensive collateral networkabout the shoulder and the intertwining proximity ofthe brachial plexus demand careful but rapid dissection.All efforts should be extended to preserve collateralbranches and avoid additional nerve injury. The site ofarterial injury may usually be digitally compressed tobmaintain hemostasis as the dissection proceeds. Thefrequent association of concomitant subclavian (14%)or brachial artery (20%) injury demands that the sur-geon be familiar with the limits of the various incisionsused for exposure of the axillary vessels. Extended ap-proaches to exposure of the right and left subclavianarteries are available and have been previously de-scribed.7

Repair of the axillary vascular wound is dependentupon the nature of the injury and size of the defect. Inmost instances of venous injury, lateral repair may beperformed (65%). Larger defects may be ligated withimpunity, as no morbidity was observed in this expe-rience from such treatment. Although venous end-to-~end anastomosis may be accomplished and short-termpatency may be demonstrated (Fig. 7), little if any ad-ditional benefit may be recognized. Although no patientin this series underwent axillary artery ligation, thisalternative could be used in the profoundly hypotensivepatient with multiple associated injuries.8"4 The lowrate of limb amputation in this (1.6%) and other seriesreflects improved techniques of arterial repair andavoidance of arterial ligation.8" 4 In the past, ligationof the acutely injured axillary artery has been associatedwith an amputation rate of 9.0 to 43.2%.' 3 Lateral ar-teriorrhaphy is reserved for cutting wounds that pro.'duce simple, incomplete arterial disruption. Most com-

Ann. Surg. - February 1982

Vol. 195 . No. 2 VASCULAR INJURIES OF THE AXILLA 237

plex arterial wounds, such as those produced by gunshotwounds, have extensive intimal disruption and requirecomplete transection at the site of injury and debride-ment of each open end. The choice of reconstructionin these injuries may then be end-to-end anastomosisor interposition of a substitute vascular conduit. Col-lateral branches should not be sacrificed to allow ade-quate mobilization of arterial ends to perform an end-to-end anastomosis. With such an approach, the use ofsubstitute vascular conduits (81%) will be greater thanin repair of other peripheral arteries, but the collateralnetwork about the shoulder will be maintained. Autog-,enous saphenous vein grafts were preferentially used asa substitute vascular conduit early in this experience.The necessity of performing an additional incision ata remote or separate site from the original injury andthe time required for harvesting and preparation havealways been problems in an acutely traumatized pa-lient. In addition, clinical observations and laboratoryinvestigations at this institution have revealed an in-creased propensity toward disruption and hemorrhageof an infected saphenous vein graft as compared to syn-thetic grafts when infected.2'9 During the past four tofive years, prosthetic grafts have been routinely used forjill peripheral vascular wounds requiring relatively short(2-6 cm) segmental replacement. At present, the choice'of synthetic graft is expanded polytetrafluoroethylene(Gore-Tex).20 This preference is based upon its avail-ability in smaller sizes (4-6 mm), and a high degreeof resistance to infection following placement intogrossly contaminated wounds at this institution. Theshort-term patency rates for both saphenous vein and'Prosthetic interposition grafts in this study have beenequal. Although peripheral pulses were palpable at thetime of hospital discharge, patients having late occlu-sion of vascular grafts may well remain asymptomatic.'4Although previous long-term studies of patency forsmall 4-6 mm prosthetic grafts have been discouraging,their use in the patient with severe traumatic woundsmay be justified. In patients sustaining symptomaticlate graft occlusion or in the event of prosthetic graftinfection, the saphenous veins have been preserved andmay be utilized for elective vascular reconstruction.The incidence of concomitant brachial plexus and

axillary artery injury in the Vietnam experience was92%.'4 The 39% incidence seen in this series may reflectthe more limited nature of civilian wounds. Residualneuropathy in Vietnam also accounted for most post-operative morbidity, including late amputation of oneupper extremity that was without motor or sensoryfunction.'4 Although the results for repair of brachialplexus injuries have been discouraging in the past, cur-

Xu}.~~~~~~~~~~~~~~~~~A

4

N-- ~~~~~~~fik

FIG. 7. Postoperative venogram two weeks following segmental re-section and end-to-end anastomosis of the axillary vein.

rent techniques of microvascular funicular repair mayprove rewarding.

Conclusion

Injuries of the shoulder may not be as innocuous ascommonly thought. Axillary vascular wounds are ac-companied by associated injury of the subclavian and/or brachial vessels in 34% of patients. Preservation ofcollateral vessels is essential in operative exposure andrepair. Associated brachial plexus injury accounts forthe majority of long-term morbidity.

References

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238 GRAHAM AND OTHERS Ann. Surg. * February

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