Procedures for penetrating trauma of the axillary artery
(Portuguese PDF version)

Charles Angotti Furtado de Medeiros1, Rodrigo Machado Landim2, André Nóbrega Castro2, Marcus Ageu Ribeiro Batista2, Patrícia Diana Kluge3, Walmir Cândido Oliveira4, Eduardo Faccini Rocha5, George Carchedi Luccas6

1. Graduate Program in Peripheral Vascular Surgery
2. Resident, Peripheral Vascular Surgery Residency Program
3. Resident, Radiology Department
4. Contracted Doctor, Radiology Department
5. Contracted Doctor, Peripheral Vascular Surgery
6. Professor of Peripheral Vascular Surgery

Universidade Estadual de Campinas (UNICAMP)

Correspondence:
Charles Angotti Furtado de Medeiros
Rua Izabel Negrão Bertoti, 101/52
CEP 13087-671 - Campinas - SP
Tel.: +55 (19) 3256.9771
E-mail: drcharlesangotti@hotmail.com

ABSTRACT

This article aims at analyzing penetrating trauma of the axillary artery and discussing the different procedures to be performed in the acute phase, with emphasis on diagnosis and treatment, based on the report of three cases of penetrating trauma of the axillary artery caused by gunshot treated at the emergency room at Hospital de Clínicas of Universidade Estadual de Campinas in the first semester of 2002. In the first case, false aneurysm was diagnosed and handled with endovascular therapy. In the second case, there was axillary artery thrombosis and brachial plexus injury but with a brachial-brachial index equal to 0.6, for which case only conservative measures were adopted. In the third case, acute ischemia of right arm was diagnosed and an emergency surgical procedure was carried out. Arterial reconstruction was performed with saphenous graft. All patients showed satisfactory development during follow-up. The authors concluded that the treatment of traumatic vascular injuries of the axillary artery must be individualized, with regard to the possibilities suitable for each individual patient.

Key-words: gunshot wounds, axillary artery, therapy.
Palavras-chave: trauma, artéria axilar, tratamento.

J Vasc Br 2003;2(3):223-226

Trauma of subclavian and axillary arteries is uncommon but potentially catastrophic.1 However, in arterial injuries of the upper limbs, the ischemia can be compensated due to the presence of ample collateral circulation.2 Firearms (FA) and cutting and thrusting weapons are the habitual mechanisms causing this type of injury in most urban centers both in Brazil and in the world, but iatrogenic trauma1,3-6 is also frequent. The anatomical complexity presents a challenge to the treatment of traumatic injuries in this area. The objective of the present study is to discuss penetrating trauma of the axillary artery and the different procedures to be performed in the acute phase, with emphasis on diagnosis and treatment.

CASE REPORTS

The reports are of three cases of penetrating trauma of the axillary artery treated at the Emergency Room at Hospital de Clínicas, Universidade Estadual de Campinas (UNICAMP). The wounds had been caused by a FA up to 24 hours earlier. The three cases were followed in the Peripheral Vascular Surgery course in the first semester of 2002.

Case 1

Case 1 is a 31 year-old male patient who arrived at the ER with a FA wound. The entrance orifice of the bullet (EO) was in the right subscapular region and the exit orifice (EXO) in the right infraclavicular region. On physical examination, the patient's clinical status was as follows: hemodynamically stable, pulse (+) and symmetric, normal peripheral perfusion, intact sensitivity and motivity, audible systolic murmur in the right infraclavicular region. Duplex mapping was carried out, confirming the diagnostic hypothesis of false aneurysm of the axillary artery (Figure 1). The patient was submitted to digital angiography and correction of the axillary artery wound, with placement of an endoprosthesis (JOMEDR) through retrograde brachial access in a one step procedure (Figures 2 and 3).

click hereFigure 1 - Duplex mapping showing false aneurysm immediately after the end of the right subclavian artery.

click hereFigure 2 - Digital subtraction angiography through the right brachial artery confirms the diagnosis of false aneurysm of the axillary artery and enables one-step retrograde fixation of endoprosthesis.

click hereFigure 3 - Duplex mapping with flow through an endoprosthesis.

Case 2

The second case is a 19-year old female with multiple FA wounds. Upon initial examination, the patient presented paraplegia affecting the lower limbs with sensitivity level corresponding to T1/T2. Vascular examination showed the absence of palpable pulse in the upper right arm and brachial plexus injury, however with a left and right ankle brachial pressure index of 0.6. Exploratory laparotomy showed a non expanding hematoma in the retroperitoneum. A pericardium examination was also carried out, with negative results. A digital angiography revealed segmental thrombosis of the right axillary artery that prompted the adoption of a conservative procedure (Figure 4).

click hereFigure 4 - Femoral digital subtraction angiography shows segment thrombosis in the right axillary artery.

Case 3

The third case is an 18-year old male with FA wounds. The EO was located anteriorly at the right second intercostal space, and the EXO in the region of the side of the shoulder. The patient was suffering from hypovolemic shock and acute ischemia of the upper right arm, and underwent urgent surgery to repair a partial injury (70%) of the right axillary artery with combined upper and infrascapular access. An auto-graft with a segment of the reverse internal saphenous vein (Figure 5) was also carried out. There was furthermore a partial brachial plexus injury for which an expectant procedure was adopted.

click hereFigure 5 - Duplex mapping monitors pervious graft of reverse internal saphenous vein. Observe the proximal and distal anastomoses without stenosis.

All the patients were progressing satisfactorily at the time article was submitted to publication.

DISCUSSION

The upper limbs have a high functional capacity with exuberant nervous-vascular support.7 In this region, functional complexity is associated with anatomic complexity. The subclavian arteries have different origins. On the right hand side they begin on the brachiocephalic trunk at the sternoclavicular articulation. To the left, they originate at the aortic arch, behind the beginning of the common left carotid artery. Their course however is similar on both sides of the body. They run through the interscalene triangle right behind the scalenus anterior muscle, and cross the back of the clavicular space ending at the lower edge of the first rib. From then on, they run as axillary arteries. The main anatomical difference between the subclavian vein and the artery is its location, which is in front of the scalenus anterior muscle. Afterwards, the artery and axillary vein run on to the smaller chest muscle, and have an intimate relationship with the brachial plexus. The axillary artery ends at the lower edge of the large round muscle and continues as a brachial artery. The veins and lymphatic nodules are of extreme importance in the area since they drain not only the upper limbs but also the breasts.

The early diagnosis of arterial trauma is very important due to the morbidity associated with late treatment of hidden injuries. Clinical history is essential in order to evaluate severity and determine the probable mechanism having caused the wound. However, physical examination is not always to be trusted, and in up to 40% of patients with axillary artery trauma, there are palpable distal pulses.8

The measurement of pressure by linear Doppler ultrasound is the first non-invasive examination to be carried out. Duplex mapping is used increasingly more often due to its high sensitivity, specificity and precision.6 Arteriography is also useful, but it must be indicated with care since it is an invasive method. When used indiscriminately, arteriography results in normal diagnoses in most of the cases. It should only be used on patients who are hemodynamically stable, and must not delay any treatment.

In most cases, an upper and/or infraclavicular incision is sufficient to reach the axillary artery. However, depending on the extension of the wound, proximal control of the subclavian artery is also necessary. In this case surgical access involves a median sternotomy - for wounds on the right side - and an antero-lateral thoracotomy between the 3rd and 4th intercostal spaces - for wounds to the left side, due to the difference in anatomical origin.9

Another factor which makes the treatment still more complex is the frequent association with venous and lymphatic lesions, bone fractures, trauma to the soft tissues, and principally neurological injuries. Neurological injuries are present in half the trauma cases involving the upper limbs - this is not observed with the same frequency in trauma involving the lower limbs. In spite of the success of vascular injury treatment, the neurological injuries result in an important functional deficit in up to 40% of cases.8

Brachial plexus injuries depend upon the mechanism causing the injury, and can be caused by: 1) distension in closed injuries; 2) compression resulting from hematoma or false aneurysm; 3) laceration or 4) contusion of nerve fibers. The more severe the neurological injury, the higher the chances of a concomitant arterial injury. In specific cases related to FA wounds, surgical repair of the nerves is not indicated due to the high degree of associated contusion.8

There are vascular injuries that do not require surgical treatment. These are called minimal injuries. Several investigators have recommended observation as the best procedure in cases of isolated arterial injuries in asymptomatic patients.5,6,8,10. However this concept is new, and conservative treatment is still controversial. Patients who are not submitted to surgery must be closely followed. On the other hand, simple ligature of the subclavian or axillary artery should only be carried out in cases where hemodynamic instability or concomitant injuries threaten the patient's life, thus preventing revascularization. It is generally accepted that most complex injuries require reconstruction with grafts. Grafts should be preferentially autologous, the most frequent choice being the internal saphenous vein. Therefore, prosthesis should not be used as a first option.1,6,8 In some cases, also as an exception, resection of the injured segment and primary anastomosis of the artery can be carried out.

Many traumatic injuries can be corrected by endovascular techniques.2 However, endovascular treatment of trauma to these arteries has poor results. This is supposedly due to: 1) the strangling of the endoprosthesis by the costal-clavicular space and 2) the mobility of the shoulder girdle can function as an occlusion factor .11 Fortunately late occlusion permits the development of new collateral circulation, thus minimizing the consequences of a superjacent ischemic state. Especially in tumor syndromes, in false aneurysms (as previously discussed), and in cases of arteriovenous fistulas, endovascular treatment is of great value. Currently, it is possible to correct acute or chronic injuries by using minimally invasive techniques, thus avoiding surgery (difficult in most cases) in sites with distortion of anatomic structures and intense bleeding.

CONCLUSION

The treatment of traumatic vascular wounds resulting from a firearm bullet is essentially surgical, but it must be dealt with on an individual basis, taking into consideration the possibilities of each patient. It is necessary to acquire experience with endovascular treatment of traumatic vascular injuries in order to validate the long term efficacy of this treatment modality.

 

REFERENCES

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J Vasc Br - Official Publication of the Brazilian Society of Angiology and Vascular Surgery