Management of traumatic brachial artery injuries: a report on 49 patients

Compartment Syndrome Due to Reperfusion Injury from an Axillary Artery Occlusion: A Case Report and Review of the Literature

Introduction

While commonly caused by traumatic injury and fracture, compartment syndrome can also result from reperfusion injury. Very few cases of prophylactic fasciotomy are mentioned when considering time to revascularization after prolonged vascular ischemia. We present a case of a patient who underwent multiple compartment prophylactic fasciotomies following reperfusion injury in the upper extremity.

Case Report

We report a 72-year-old male that suffered from an anterior shoulder dislocation after a ground-level fall. After reduction, pulses were not measurable, and angiography indicated an axillary artery occlusion. Immediately after operative reperfusion, compartments became tense. Orthopedic surgeons subsequently performed arm anterior, posterior, and forearm volar and mobile wad compartment fasciotomies, after 13 h of ischemia. The patient tolerated the procedure, and at the latest follow-up, was working to improve strength in the extremity.

Conclusion

Even when the circumstances of injury seem to be less traumatic as in this case of a ground-level fall, we document the importance of prompt recognition and intervention of suspected compartment syndrome following prolonged ischemia and revascularization of the upper extremity.

Pseudoaneurysm of the brachial artery in an infant due to vaccination: a case report

BACKGROUND

Pseudoaneurysm is a known complication of penetrating arterial injuries such as catheterization, gunshot wounds, and open fractures. Vaccination is an effective method for preventing multiple, serious, infectious diseases in children. Common adverse reactions related to vaccination include fever, swelling, redness, and pain. Brachial pseudoaneurysm after vaccination has not been previously reported.

CASE PRESENTATION

Herein we describe a novel case of brachial pseudoaneurysm after vaccination in a child aged 1 year and 3 months. A pulsatile mass was formed in the medial left arm of the infant 10 days after vaccination at a community hospital and gradually grew larger. Preoperative images depicted an eccentric aneurysm in the brachial artery and a swirling flow pattern in the mass. The pseudoaneurysm was excised, and vein graft interpositioning was successfully performed. There were no short-term or long-term complications during the follow-up period.

CONCLUSIONS

Brachial pseudoaneurysm is a rare complication of vaccination via intramuscular injection. Medical staff should avoid puncture wounds to the brachial artery during vaccination, especially in infants.

Brachial artery trauma as a complication of bicep muscle injury

We describe a rare case of injury to a branch of the brachial artery in a 48-year-old man with a bicep musculotendinous injury. His presenting symptoms included severe pain, swelling, and paresthesias in the right upper extremity. Examination revealed significant soft tissue swelling with ecchymoses in the right upper arm with diminished palpable pulses. Imaging revealed a biceps muscle injury along with active arterial extravasation of a branch of the deep brachial artery. Interventional radiology successfully performed coil embolization. Bicep musculotendinous injury is typically characterized by pain, swelling, and decreased strength. Rarely, complications such as compartment syndrome have been reported. Brachial arterial injury has not been implicated in the setting of this entity, especially in the absence of blunt or penetrating trauma, until our current patient's presentation.

[Compressive false aneurysm of the brachial artery in a hemodialysis patient: Always superficialize the basilic vein of the arm!]

The creation and preservation of vascular accesses, in patients with end-stage renal failure, remains a challenge for nephrologists and vascular surgeons. Native fistula is the best vascular access, humeral-basilic fistula is a precious access in patients who have exhausted their venous capital in the forearm and in whom the cephalic vein of the arm is small or damaged. Given its deep location, any puncture of this vein is prohibited before its superficialization, even if it is of good caliber, because it can have dramatic consequences, in particular the loss of the limb or even death. We report the case of a patient undergoing hemodialysis for seven years with a non-superficialized humeral-basilic fistula, admitted for an iatrogenic false aneurysm of the brachial artery following a puncture for dialysis, with compression of the median nerve, treated surgically.

Primary amputation versus limb salvage in upper limb major trauma: a systematic review

PURPOSE

Severe upper limb injuries can result in devastating consequences to functional and psychological well-being. Primary objectives of this review were to evaluate indications for amputation versus limb salvage in upper limb major trauma and whether any existing scoring systems can aid in decision-making. Secondary objectives were to assess the functional and psychological outcomes from amputation versus limb salvage.

METHODS

A systematic review was carried out in accordance with PRISMA guidelines. A search strategy was conducted on the MEDLINE, EMBASE, and Cochrane databases. Quality was assessed using the ROBINS-I tool. The review protocol was registered in PROSPERO.

RESULTS

A total of 15 studies met inclusion criteria, encompassing 6113 patients. 141 underwent primary amputation and 5972 limb salvage. General indications for amputation included at least two of the following: uncontrollable haemodynamic instability; extensive and concurrent soft tissue, bone, vascular and/or nerve injuries; prolonged limb ischaemia; and blunt arterial trauma or crush injury. The Mangled Extremity Severity Score alone does not accurately predict need for amputation, however, the Mangled Extremity Syndrome Index may be a more precise tool. Comparable patient-reported functional and psychological outcomes are seen between the two treatment modalities.

CONCLUSIONS

Decision regarding amputation versus limb salvage of the upper limb is multifactorial. Current scoring systems are predominantly based on lower limb trauma, with lack of robust evidence to guide management of the upper extremity. Further high-quality studies are required to validate scoring systems which may aid in decision-making and provide further information on the outcomes from the two treatment options.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries

The peripheral arteries and veins of the extremities are among the most commonly injured vessels in both civilian and military vascular trauma. Blunt causes are more frequent than penetrating except during military conflicts and in certain geographic areas. Physical examination and simple bedside investigations of pulse pressures are key in early identification of these injuries. In stable patients with equivocal physical examinations, computed tomography angiograms have become the mainstay of screening and diagnosis. Immediate open surgical repair remains the first-line therapy in most patients. However, advances in endovascular therapies and more widespread availability of this technology have resulted in an increase in the range of injuries and frequency of utilization of minimally invasive treatments for vascular injuries in stable patients. Prevention of and early detection and treatment of compartment syndrome remain essential in the recovery of patients with significant peripheral vascular injuries. The decision to perform amputation in patients with mangled extremities remains difficult with few clear indicators. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seeks to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

Injury of the brachial artery accompanying simple closed elbow dislocation: a case report

Background:

Elbow dislocation is the second common dislocation in adults, after the shoulder. The anatomical proximity to the joint of the brachial artery could lead to concomitant vascular injuries, even if their occurrence remains very rare.

Method:

It is reported the case of a right-hand-dominant 42-year-old man who sustained a simple closed posterior elbow dislocation of his left elbow, associated to a complete brachial artery rupture. He urgently underwent the reduction of the joint dislocation and an artery-repairing surgical procedure using a graft from ipsilateral saphenous vein.

Results:

The full functional capacity of the elbow was obtained.

Conclusions:

The abundance of the brachial artery collateral network may hide the presence of a vascular injury, potentially associated to a closed elbow dislocation. Therefore, a high index of suspicious should be maintained. The Emergency Team plays a crucial role in its early diagnosis, which is essential to avoid irreversible ischemia related damages. A prompt reduction of the joint dislocation and the vascular injury surgical repair are required. Regarding the treatment of the concomitant collateral ligaments and capsular injuries, the indication to proceed to the simultaneous ligaments reconstruction is still controversial in literature.

Radial Recurrent Artery: Autologous Patch Graft for Acute Brachial Artery Laceration

Brachial artery injury is the most common vascular disruption in upper extremity penetrating trauma, usually treated by primary repair or saphenous vein interposition graft. We report the case of a young male who presented after assault with stab wound to the right antecubital fossa, an asymmetric vascular exam, and unknown depth contaminated wound that warranted operative exploration. We performed open exploration through a triangular flap extension of his oblique linear laceration for both exposure and flexor surface scar contracture prophylaxis. Exploration revealed brachial artery laceration with loss of approximately 30% of vessel circumference proximal to the radial and ulnar artery bifurcation. A near-complete transection of the recurrent radial artery was also present, leading to the decision to sacrifice this vessel for use as an autologous patch graft of the injured brachial artery. Distal vascular flow was re-established, and the vessel was slightly ectatic with no evidence of stenosis. Patient suffered no complications and was discharged at post-operative day four after perioperative heparin drip on anti-platelet therapy. Autologous patch grafting in the acute setting is a less-often considered surgical option that is effective for arterial bifurcation reconstruction, which may be employed through the sacrifice of injured and redundant local branch vessels. Patch grafts are commonly utilized in planned vascular surgery, such as carotid endarterectomy, but this is the first report of autologous patch graft to an acute brachial artery injury. By combining knowledge of the lateral arm flap with the plastic surgery principles of "like replaces like", this technique avoids the stenosis associated with primary repair, the multiple anastomoses necessary for interposition grafting, the need for a secondary donor site, and provides a theoretical blood-flow advantage.

[Arterial trauma of the upper limbs: Particularities of the population in Tunisia and risk factors for amputation]

AIM OF THE STUDY

The purpose of our study was to review the population at risk of upper limb arterial injury, to determinate the rate of upper limb salvage and the predictive factors of limb loss.

METHODS

This was a retrospective study, involving 128 patients with upper extremity arterial trauma operated between January first, 2006 and June 30, 2017. Exclusion criteria were arterial ligation, primary limb amputation and arterial iatrogenic injuries. End points were immediate technical success, primary patency and limb salvage rate.

RESULTS

The average age was 27.7 years with a sex ratio M/F=41, causes of trauma were self-inflicted wounds (51%), assaults (23%), road traffic accidents (10%), work accidents (9%) and domestic accidents (7%). Injured arteries were brachial (66.5%) usually because of self-inflicted injuries; arteries of the forearm (31%) and axillery arteries (2.5%). The techniques of arterial repair were vein graft interposition in 52% of cases, end-to-end anastomosis in 23%, primary arterial repair in 21% and venous patch in 4%. Eight reconstructions occluded during the first week (6.25%). Four patients required secondary amputation and limb salvage rate was 96.8%. After a median follow-up time of 62 days, only 21% were followed at 3 months. Mechanism of injury, soft tissue loss and arterial reconstruction thromboses were selected as factors influencing the rate of limb salvage. One death occurred at day 14 secondary to multi-component poly-trauma.

CONCLUSION

Prompt diagnosis, appropriate multidisciplinary management of the upper extremity arterial trauma and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage. Associated soft tissue injury is a poor limb salvage factor.

Acute Presentation of a Pseudoaneurysm After a Proximal Humerus Shaft Fracture: A Case Report

CASE

A 69-year-old woman presented with a brachial artery pseudoaneurysm causing median, ulnar, and radial nerve compressive neuropathies 8 weeks after a proximal humerus shaft fracture treated with intramedullary nailing. She underwent a brachial artery bypass with a reverse cephalic vein interposition graft and neurolysis after decompression of a large pseudoaneurysm. Postoperatively, the patient had a normal vascular examination with recovering neurological function.

CONCLUSIONS

A high index of suspicion for a brachial artery pseudoaneurysm should be maintained in patients with a displaced proximal humerus shaft fracture, particularly when an abnormal neurovascular examination is present.

Operative management of non-iatrogenic pediatric and adolescence peripheral arterial trauma: An experience from a resource challenged setting

OBJECTIVES

To evaluates the management and outcome of non-iatrogenic pediatric and adolescence extremity arterial injuries in a resource-challenged setting.

METHODS

A retrospective study of the surgical management for non-iatrogenic extremity arterial trauma in pediatric and adolescence during the period from January 2008 to December 2015. This study was performed in two different countries at tertiary referral university and teaching hospitals having a specialized emergency and trauma centers. A thorough study of each patient record was collected from these centers including, the original demographic data and their clinical presentations. Operative data of each patient was also reported.

RESULTS

During the 8-year period of the study, 149 pediatric and adolescent extremity arterial trauma patients were treated. They were 93.3% male, and 6.7% female, respectively. The age ranged from 2 to 18 years with a mean of 10.25 ± 4.05 years. Lower extremity arterial trauma was recorded in 51%, while 49% were having upper extremity injuries. Primary repair with end-to-end vascular anastomosis was performed in 51.7%, while an interposition reversed saphenous vein graft was performed in 48.3%. The operative procedures were performed by an experienced vascular surgeon and well-trained pediatric surgeons and general surgeons. Pseudoaneurysms was recorded in 9% of cases. Fasciotomy was performed in 15% of cases.

CONCLUSION

Treatment of pediatric and adolescent extremity arterial injuries with primary end-to-end vascular anastomoses or with the use of an interposition reversed saphenous vein graft is a reliable, feasible, and more cost-effectiveness technique with good results. Moreover, it should be adopted for all vascular trauma patients, whenever possible.

Early Outcomes of Vein Grafting for Reconstruction of Brachial Arterial Injuries in Children

PURPOSE

We postulated that, with microsurgical technique, vascular reconstruction with interpositional vein grafts in the pediatric population is safe and results in sustained vascular patency and excellent midterm outcomes.

METHODS

Twenty children with brachial artery injuries were treated with interpositional vein grafting at a tertiary pediatric hospital from 1995 to 2013. Medical records were evaluated for demographic, clinical, and radiographic data. Ten patients were available for longer-term follow-up. Pain at rest, pain with exercise, and temperature intolerance were assessed with visual analog scale (VAS) (range, 0-5). Functional outcomes were assessed using the Pediatric Outcomes Data Collection Instrument (PODCI) and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Graft patency and flow were characterized via duplex sonography. Peak flow velocity and resistive index (RI) were compared with the contralateral extremity. Median patient age at the time of injury was 7.75 years (range, 4.6-11.5 years) and median follow-up was 1.75 years (range, 0.3-6.3 years).

RESULTS

All patients had perfused hands with palpable radial pulses at follow-up. There were no clinically meaningful differences in motion, sensibility, or strength between affected and unaffected limbs. Mean VAS scores for pain at rest, pain with exercise, and temperature intolerance were 0.4, 0.4, and 0.6, respectively. Mean global PODCI and DASH scores were 98.0 and 5.1, respectively. Nine of 10 patients had patent arteries with normal flow patterns. In the patient with graft occlusion, there was collateralization around the elbow with normal reconstitution of the distal vessels. Mean peak flow velocity proximal and distal to the graft were 77.7 cm/s and 66.5 cm/s, respectively. Mean RI of the graft were 0.84 and 0.77, respectively.

CONCLUSIONS

Brachial artery reconstruction using interpositional vein graft and microsurgical technique is safe and effective and results in excellent functional outcomes in children.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Fracture-pattern-related therapy concepts in distal humeral fractures

Around one third of humeral fractures and 2–6% of all fractures occur to the distal part of the humerus. There is a bimodal distribution differentiating between young male patients with high-energy and elderly female patients with low-energy trauma related to osteoporosis. The AO classification and Dubberley subclassification are used in daily routine. Most fractures are diagnosed on radiographs. For further evaluation, three-dimensional computed tomography is recommended, especially for comminuted or complex fractures. Owing to the long immobilization and resultant poor functional outcome, conservative treatment is followed for inoperable patients. The operative approach and osteosynthesis depend on the fracture pattern. In A1 avulsion fractures, open reduction and screw fixation are recommended. In A2/A3 fractures, a triceps-sparing approach following a 90° double-plate construction (radial dorsal/ulnar lateral) with locking plates is favored. Partial articular B1/B2 fractures are exposed via a medial or lateral approach using unilateral locking plates to stabilize the medial/lateral column. Coronal shear fractures (B3) are classified after Dubberley and are treated via an extended Kocher approach and headless compression screws in anteroposterior direction. If there is a further posterior comminution or a lateral column fragment, stabilization is needed for the lateral/medial column with a precontoured locking plate. In solely articular fracture patterns, a dorsal approach with either a 90° or 180° double-plate construction is advised. If a reconstruction is not possible owing to fracture complexity or bone quality, total elbow arthroplasty is a viable option. However, lifelong limitation in weight-bearing up to 5 kg, limited longevity, and the potential for complicated revision surgery should be considered.

Delayed brachial artery reconstruction after traumatic injury: a case for sustainment of surgical intervention

The brachial artery is the commonest artery injured in the extremities. Although the patients present late, nevertheless reconstructions is advocated in other to salvage the limb and maintain function of the hand. We retrospectively examined 25 consecutive patients with vascular injuries treated at The Cardiovascular and Thoracic Surgery Unit of a tertiary health centre over a period of 4 years. We assessed the pre-tertiary methods of stopping of bleeding injured brachial arteries, mechanisms of injury, associated injuries, treatment and the outcome following vascular repair in terms of functionality of the forearm and the volume of the radial pulsation. A total of 12 patients (48.0%) had brachial artery injuries out of the 25 patients with different forms of vascular injuries during the period. There were 10 males and 2 females, aged 7.5-65 years. The aetiology of the brachial artery injuries were: Glass cut in 5 patients, knife cut in 3 patients, surgical complication of tendon release (iatrogenic) in 1 patient, injury from self injection of pentazocine in 1 patient, machete cut in 1 patient and blunt vascular injury from fan belt injury in 1 patient. Except for the young girl whose brachial artery was injured at surgery, and had lateral repair done within 3hours, the timing between injury and repair in the remaining 11 patients ranged between 6-288 hours. This was beyond the golden time in trauma cases. Two patients had the brachial artery revascularised using the Reversed Saphenous Vein Graft (RSVG). The wrist pulsation was small volume in one patient as felt by palpation before discharge though the forearm was viable. Otherwise the remaining patients’ outcome was good. Most of the patients with brachial artery injury present late following injury. Revascularisation beyond the golden hour is still desirable as it will help to prevent limb loss. Plans should be put in place to train vascular surgeon to encourage prompt and expertise care.

Brachial artery pseudoaneurysm

We describe a case of an elderly man who presented with an upper arm swelling that had developed following a humeral fracture 8 months previously. The swelling was painless but associated with significantly diminished motor function of his right hand and concurrent paraesthaesia. On examination, a large pulsatile mass was identified and CT angiography confirmed the presence of an 11×7 cm brachial artery pseudoaneurysm. The patient underwent surgical repair in which a fragment of the humerus was found to have punctured the brachial artery resulting in a pseudoaneurysm. The patient had an uncomplicated postoperative period and was discharged 2 days later having regained some motor function in his right hand.

Brachial index does not reflect upper extremity functionality following surgery for vascular trauma

OBJECTIVES: Vascular injuries to the upper extremities requiring surgical repair are common after accidents. However, neither postoperative functionality nor hemodynamic status of the extremity are routinely described. We evaluated the postoperative functional and hemodynamic status of patients with vascular traumas in the upper extremities. METHODS: 26 patients who suffered penetrating vascular traumas in the upper extremities from November 2008 to December 2011 were retrospectively evaluated. Data on first approach, surgical technique employed and early postoperative outcomes were recorded. Further data on the post-discharge period, including clinical functional status of the arm, Doppler ultrasonography and brachial-brachial index were also evaluated. RESULTS: Average follow up was 33.5±10.8 months. Right (1.05±0.09) and left (1.04±0.08) brachial indexes were measured during follow up,. Doppler ultrasonography showed arterial occlusion in 4 patients (15%). Near-normal brachial-brachial indexes was observed in all four of these patients with occlusion of one of the upper extremity arteries, even though they exhibited limited arm function for daily work. CONCLUSIONS: Evaluation of the postoperative outcomes of this small series of patients with penetrating vascular traumas in the upper extremity revealed that 15% of them suffered occlusion of one artery of the upper extremity. Artery occlusion did not correlate with brachial-brachial Doppler index, probably due to rich collateral circulation, but occlusion was associated with an extremity that was dysfunctional for the purposes of daily work. The result of the brachial-brachial index does not therefore correlate with functionality.

Penetrating arterial trauma to the limbs: outcome of a modified protocol

Background

Penetrating arterial injuries to the limbs are common injuries in high volume trauma centers. Their overall surgical results reported in the literature are satisfactory - apart of those of the popliteal artery that still may lead to a significant incidence in amputations. With the present study we assessed our outcome with penetrating arterial injuries to the limb as to see if the direct involvement of vascular surgeons in the management of popliteal artery injuries leads to an improved (lowered) amputation rate. Results were benchmarked with our published results from previous years.

Methods

All patients sustaining penetrating arterial injuries to the limbs admitted to the Chris Hani Baragwanath Academic Hospital during an 18- month period ending in September 2011 were included in this study. Axillary, brachial and femoral artery injuries were operated on by the trauma surgeons as in the past. All popliteal artery injuries were operated on by the vascular surgeons (new).

Results

There were a total of 113 patients with 116 injuries, as some patients had multiple vascular injuries: 10 axillary, 47 brachial, 34 femoral and 25 popliteal artery injuries. Outcome of axillary, brachial and femoral artery injury repair were excellent and not significantly different from our previous reported experience. Injury to the popliteal artery showed a diminished re-exploration rate from 34% down to 10% (p = 0,049) and a decrease of amputation rate from 16% to 11% which was statistically not significant (p = 0,8).

Conclusion

Penetrating arterial trauma to the axillary, brachial and femoral artery is followed by excellent results when operated by trauma surgeons. In the case of popliteal artery injury operated by the vascular surgeons, the results of this study do not show any statistically significant difference related to amputation rate from our previous reported studies when operated by trauma surgeons. Taking into consideration the diminished re-exploration rate and a tendency to a lower amputation rate, we feel that there is possible tendency of better outcome if operated by vascular surgeons. Multicenter studies with large number of enrolled patients will be required to prove the validity of this suggestion.