Axillary artery intimal dissection with thrombosis and brachial plexus injury after reverse total shoulder arthroplasty

Axillary Artery Injury Encountered During Chest Wall Tumor Resection

Axillary artery injuries are rare because of their anatomy but are sometimes fatal because of the difficulty of obtaining vascular integrity. We report a 50-year-old patient with an iatrogenic axillary arterial injury that occurred during the resection of a chest wall tumor. The injury occurred during an incision of the intercostal muscle along the superior margin of the second rib. Following primary hemostasis achieved by forceps and amputation of the pectoralis minor muscle, the injury site was exposed sufficiently and successfully repaired by a vascular surgeon. This successful case provided valuable insight into strategies, primary hemostasis, and subsequent revascularization for an intraoperative vascular injury.

Acute-on-Chronic Axillary Artery Thrombus After Reverse Total Shoulder Arthroplasty for Failed Proximal Humerus Open Reduction and Internal Fixation: A Case Report

CASE

A 71-year-old woman presented with post-traumatic arthritis 11 months after open reduction and internal fixation for a left proximal humerus fracture (PHF) dislocation. After revision to reverse total shoulder arthroplasty (rTSA), the patient's left upper extremity was found to be avascular. An emergent thrombectomy was performed with restoration of arterial flow after removal of an acute-on-chronic axillary artery thrombus.

CONCLUSION

Although rare, as rTSA becomes more common for management of PHF, incidence of associated vascular injuries is likely to rise. Screening methods and clinical vigilance in diagnosis are advised for patients with anterior PHF dislocations and arterial injury risk factors.

Elongation of the brachial plexus after reverse shoulder arthroplasty: an anatomical study

INTRODUCTION

The use of reverse shoulder arthroplasty (RSA) is becoming more extended and its clinical results are good or excellent according to the literature. The main biomechanical characteristic of RSA is that it lowers and medializes the centre of rotation of the shoulder causing an arm lengthening. Although the number of neurological complications is low (5%), there are more neurophysiological changes in the brachial plexus with RSA than with the anatomic shoulder arthroplasty. The main goal of this study was to quantify the lengthening of the terminal branches of the brachial plexus suffered after RSA implantation.

MATERIALS AND METHODS

20 Embalmed cadavers were analysed. Four distances using bone references were employed to measure the lengthening of the arm and subacromial space. The brachial plexus and its terminal branches (radial, axillary, ulnar, musculocutaneous and median nerves) and the axillary artery, were identified and marked. Measurements were made to determine the change of position of the neurovascular structures, the arm lengthening and the lengthening of each nerve before and after the implantation of RSA. Two models of RSA were used: SMR^®(Lima) and Delta Xtend^®(DePuy-Synthes).

RESULTS

The mean arm elongation was 10.5 mm. The subacromial space suffers an elongation of 20.5-29.8%. All the neurovascular structures suffered elongation: median nerve 23.1%, musculocutaneous nerve 22.1%, ulnar nerve 19%, radial nerve 17%, axillary nerve 12-14.5%, axillary artery 24.8%. There were no differences in the results between the types of prosthesis.

CONCLUSIONS

Due to its design, the RSA causes an arm lengthening which is reflected by the elongation of the neurovascular structures of the arm.

Surgical anatomy of the axillary artery: clinical implications for open shoulder surgery

BACKGROUND

Axillary artery injury is a devastating complication related to anterior shoulder surgery and can result in significant morbidity and/or mortality. The purpose of our study was to evaluate the course of the axillary artery in relation to bony landmarks of the shoulder and identify variations in artery position with humeral external rotation.

MATERIALS AND METHODS

Dissection of 18 shoulders (9 fresh whole-body cadavers) with simulated vessel perfusion using radiopaque dye was performed. The axillary artery position was measured from multiple points including 2 points on the coracoid base (C1 and C2), 3 points on the coracoid tip (C3-C5), 4 points on the glenoid: superior, middle, and inferior glenoid (D1-D4), and 2 points on the lesser tuberosity (L1 and L2). Fluoroscopic measurements were taken and compared at 0° and 90° of external rotation (F1 vs. F1' and F2 vs. F2'). Manual and fluoroscopic measurements were compared with one another using Kendall's τ_b correlation.

RESULTS

There were 6 male and 3 female cadavers with an average age of 67.2 ± 9.3 years (range: 49-77 years). The mean distance from the axillary artery to the coracoid base (C1 and C2) measured 21.1 ± 7.3 and 22.3 ± 7.4 mm, respectively, whereas the mean distance to the coracoid tip (C3, C4, and C5) measured 30.7 ± 9.3, 52.1 ± 20.2, and 46.5 ± 14.3 mm, respectively. Measurements relative to the glenoid face (D1, D2, and D3) showed a progressive decrease in mean distance from superior to inferior, measuring 31.6 ± 10.3, 16.5 ± 7.5, and 10.3 ± 7.3 mm, respectively, whereas D4 (inferior glenoid to axillary artery) measured 17.8 ± 10.7 mm. The minimum distance from the axillary artery to any point on the glenoid was as close as 4.1 mm (D3). There was a statistically significant difference in F1 (0° external rotation) vs. F1' (90° external rotation) (18.5 vs. 13.4 mm, P = .03). Kendall's τ_b correlation showed a strong, positive correlation between manual and fluoroscopic measurements (D4: 16.0 ± 12.5 mm vs. F1: 18.5 ± 10.7 mm) (τ_b = 0.556, P = .037).

CONCLUSION

The axillary artery travels an average of 1-1.8 cm from the inferior glenoid margin, which puts the artery at significant risk. In addition, the artery is significantly closer to the inferior glenoid with humeral external rotation. Surgeons performing anterior shoulder surgery should have a thorough understanding of the axillary artery course and understand changes in the position of the artery with external rotation of the humerus.

Externally Supported Extra-anatomical Venous Bypass to Treat Upper Limb Ischemia with Shoulder Prosthetic Infection

To report a case of acute arm ischemia and prosthetic shoulder infection treated by extra-anatomical great saphenous vein graft with external vascular scaffolding. A 65 year-old man with multiple surgical interventions for soft tissue sarcoma of the right shoulder, local radiotherapy with residual brachial plexus neuropraxia, was referred to our attention for signs of arm ischemia. Two weeks before, the patient was submitted to prosthetic shoulder replacement complicated with prosthetic infection. Considering the mechanism of vascular injury, an open surgical revascularization was planned with a deliberate avoidance of the natural anatomic pathway to reduce the risk of graft infection. Consequently, after the complete removal of infected shoulder prosthesis and placement of antibiotic spacer, an axillarbrachial artery bypass using great saphenous vein was performed using a new braided cobalt chrome kink resistant external vascular support to prevent compression, also considering the extra-anatomical position of the graft. At 12 months' follow-up, patient was in good clinical condition with complete resolution of arm ischemia; computed tomographic angiography and duplex scan revealed patency of the graft with excellent distal perfusion. The new external vascular support seems to be useful and feasible for preventing compression of extra-anatomical venous bypass.