[Trauma of the brachial plexus and associated vascular injury--a case report]

Acute vascular trauma in the axillary region is usually associated with brachial plexus injury and presents a great challenge to surgeon and formidable obstacle to restore a useful limb function. Interdisciplinary operative and postoperative approach is mandatory providing an optimal care of these severe patients. Here we present a case of neurovascular trauma that affected axillary artery and vein, complete transection associated with complete transection of the brachial plexus. Immediately after admission emergency surgery was performed and in postoperative follow up, after several operations and rehabilitation that continued for 24 months, entire functional recovery was achieved without any disabling consequences.

Endovascular treatment of penetrating injury of axillary vein with Viabahn endoprosthesis

Penetrating injuries of the axillary or subclavian venous system are associated with extensive blood loss and are fatal in more than 50% of cases. Patients are usually unstable and are treated with surgical exploration. We present a case of axillary venous injury that was treated in the operating room with intravenous placement of a self-expanding Viabahn endoprosthesis (W.L. Gore). The device was delivered to the injured site percutaneously via a basilica vein, with immediate control of hemorrhage.

Feasibility of endovascular repair in penetrating axillosubclavian injuries: A retrospective review

BACKGROUND

Penetrating injuries to the axillary and subclavian vessels are a source of significant morbidity and mortality. Although the endovascular repair of such injuries has been increasingly described, an algorithm for endovascular versus conventional surgical repair has yet to be clearly defined. On the basis of institutional endovascular experience treating vascular injuries in other anatomic locations, we defined an algorithm for the management of axillosubclavian vascular injuries. Subsequently, a near decade long experience with the management of axillosubclavian vascular injuries was retrospectively analyzed, so as to more accurately assess the true feasibility of endovascular treatment in these patients.

METHODS

We defined a management algorithm that included (1) indications, (2) relative contraindications, and (3) strict contraindications for the endovascular repair of axillosubclavian vascular injuries. Anatomic indications for endovascular repair were restricted to relatively limited axillosubclavian injuries (pseudoaneurysms, arteriovenous fistulas, first-order branch vessel injuries, intimal flaps, and focal lacerations). Relative contraindications for endovascular repair included injury to the axillary artery's third portion, substantial venous injury (eg, transection), refractory hypotension, and upper extremity compartment syndrome with neurovascular compression. Strict contraindications to endovascular repair included long segmental injuries, injuries without sufficient proximal or distal vascular fixation points, and subtotal/total arterial transection. Within the context of these definitions, we retrospectively reviewed 46 noniatrogenic subclavian and axillary vascular injuries in 45 patients identified by a prospectively maintained computer registry during a 9-year period. Presentations were reviewed concurrently by two endovascular surgeons, and potential candidates for endovascular management were defined.

RESULTS

Among 46 total case presentations and among the 40 patients who maintained vital signs on presentation, 17 were potentially treatable with endovascular therapy. Among the cohort of 40 presentations, the most common contraindications to endovascular therapy were hemodynamic instability (n = 10), vessel transection (n = 7), and no proximal vascular fixation site (n = 3).

CONCLUSIONS

Despite growing enthusiasm for endovascular repair of injuries to the axillary and subclavian vessels, realistic clinical presentation and anatomic locations restrict the broad application of this technique at present. In our experience, less than but approaching 50% of all injuries encountered could be addressed with an endovascular approach. This percentage will increase during the upcoming decades if the endovascular technologies available in hybrid endovascular operating rooms uniformly improve.

Endoluminal repair of axillary artery and vein rupture after reduction of shoulder dislocation. A case report

A case of endoluminal repair of vein and artery axillary rupture after reduction of shoulder dislocation in an 83-year-old woman is reported. The lesions were repaired successfully with two cover stents (JOSTENT and Passager). Endovascular treatment of such vascular injuries seems to be feasible and safe, though further investigation is warranted.

Subclavian and axillary vascular injuries

Injuries to the subclavian or axillary vessels are associated with a high mortality rate and only patients with short prehospital periods or contained bleeding survive long enough to be treated. The surgical exposure of these vessels can be difficult and excellent knowledge of the local anatomy is critical. This article describes the anatomy, epidemiology, diagnosis, and surgical exposure of these injuries. Newer diagnostic and therapeutic modalities are discussed also.

Penetrating injuries to the subclavian and axillary vessels

BACKGROUND

Subclavian and axillary vascular injuries are notorious for their mortality and their difficult surgical exposure. In the present study we analyze our experience with 79 patients and describe the techniques used for surgical access to these vessels.

STUDY DESIGN

Retrospective review of the medical records of all patients with penetrating injuries to the subclavian or axillary vessels who had been admitted to 2 Los Angeles trauma centers during a 4-year, 3-month period.

RESULTS

Seventy-nine patients were admitted during the study period January 1993 to March 1997 (58 gunshot injuries, 21 other penetrating injuries). The artery was injured in 59 patients and the vein in 40 (20 patients had both arterial and venous injuries). Eighteen patients (23%) were admitted with no signs of life or were in extremis and underwent an emergency room thoracotomy without any survivors. Fifty-eight patients underwent exploration in the operating room, 1 patient with an arteriovenous subclavian fistula was successfully managed with a radiologically placed endovascular stent, and 2 patients with minimal subclavian artery injuries were managed nonoperatively. Overall mortality was 34.2%. Excluding the ER thoracotomies the overall mortality was 14.8%. The mortality for isolated arterial injuries was 20.5%, for isolated venous injuries 50%, and for both vessels 45.0%. The mortality in venous injuries was significantly higher than in arterial injuries (p < 0.05). The standard clavicular incision provided adequate exposure in 32 (50.0%) of the operating room cases. In the other 50% of operating room cases a combination of a clavicular incision with a median sternotomy or thoracotomy was necessary. Proximal subclavian injuries may be accessed through a clavicular incision combined with a median sternotomy irrespective of left or right site location.

CONCLUSIONS

Subclavian and axillary vascular injuries remain lethal. A clavicular incision provides satisfactory surgical exposure in about half the patients. In patients with proximal injuries addition of a median sternotomy provides adequate surgical access in both right and left subclavian vessels.

Injury potential to venous valves from the Amplatz thrombectomy device

PURPOSE

To evaluate the acute effects of the Amplatz thrombectomy device (ATD) on peripheral venous valves in a canine model.

MATERIALS AND METHODS

ATD thrombectomy was performed in 17 veins, and control experiments with use of an 8-F sheath-dilator were performed in four veins. Prethrombectomy ascending venography was performed, followed by device passage across the vein segment. Post-thrombectomy ascending venography was then performed, followed by heparinization and euthanasia. The treated veins were carefully explanted and stored in formaldehyde for histopathologic examination. Severity of valve injury was graded on a scale of 0 to 4.

RESULTS

In ATD-treated veins: 10 veins sustained no injury [grade 0] (diameter, 6.7 mm +/- 1.7; antegrade/retrograde approach, 5/5), five veins sustained mild injury [grade 1-2] (diameter, 5.2 mm +/- 0.8; antegrade/retrograde, 3/2), while the remaining two veins sustained moderate-to-severe injury [grade 3-4] (diameter, 5 and 6 mm; antegrade/retrograde, 1/1). In sheath-dilator treated veins: no injury [grade 0] in any of the four treated veins (mean diameter, 5.5 mm +/- 0.6; all retrograde). In ATD-treated veins, valve injury (of any grade) was significantly more frequent in veins 6 mm or less in diameter than in veins at least 7 mm in diameter (seven of 12 vs zero of five; P < .03). There was no significant association between thrombectomy approach and injury grade.

CONCLUSION

Veins 7 mm or greater in diameter were associated with no significant valve injury during ATD thrombectomy. However, long-term and short-term effects on valvular function will need to be assessed.

[An anatomic study of the superficial radial nerve and its clinical implications]

In hand surgery, the k-wires are used frequently and effectively. Several texts mention complications following surgery of the wrist and hand. A safe zone has been described by Steinberg et al., where 40 K-wires were placed in the anatomic snuffbox of 10 cadaveric forearms. The placement of the k-wires were evaluated radiologically and by dissection to examine the underlying structures. A branch of the superficial radial nerve (NRS) was injured in 22% (2/9) of the specimens and the cephalic vein in 33% (3/9). The radial artery was never injured but had a K-wires at least 1 mm away in 22% of the specimens. The anatomy and pattern of distribution of the NRS was studied and compared with the data found in the literature. The NRS emerged between the tendons the muscles of brachioradialis and extensor carpi radialis longus in 9 of 10 specimens, and at a mean distance of 7.8 cm from the radial styloid. The first and second division were at a mean distance proximal to the radial styloid of 4.5 and 3.0 cm, respectively. The mean number of branches of the NRS at the radial styloid was 5.1. Despite a relatively consistent anatomy of the NRS, the anatomic snuffbox remains a complex and dangerous area due to the variability of the nerve's anatomy. An open surgical approach is thus preferred to avoid traumatizing the nerves and vascular structures.

Venous rupture complicating hemodialysis access angioplasty: percutaneous treatment and outcomes in seven patients

OBJECTIVE

To evaluate percutaneous treatment options for preserving hemodialysis access after angioplasty-related venous rupture, we retrospectively reviewed the charts for all dialysis access angioplasties performed over a 33-month period. Seven cases of venous rupture after venous angioplasty were identified (four men and three women; mean age, 63.5 years). Treatment included observation only (n = 1), a second prolonged balloon inflation at the rupture site (n = 2), stent insertion (n = 5), and manual graft occlusion (n = 1). Treatment was successful in eliminating contrast extravasation in all patients while maintaining immediate graft function in six out of seven patients. None of the patients required emergent surgical intervention. The mean primary and secondary patency rates of the salvaged grafts after intervention were 2.3 and 9.3 months, respectively. Five of seven access sites were still patent at the most recent follow-up.

CONCLUSION

Prolonged balloon inflation or placement of a stent may salvage hemodialysis access in most patients after angioplasty-related venous rupture. Primary and secondary patency have proven to be satisfactory.

Aggressive management of vascular injuries of the thoracic outlet

PURPOSE

We present a review of 35 patients who underwent an operation for subclavian (n = 18) or axillary (n = 17) vessel injury. In some patients, both an artery and a vein were damaged, resulting in a total of 30 arterial and 16 venous injuries.

METHODS

The wounding source included a gunshot (n = 19), a stab wound (n = 9,) and blunt trauma (n = 7). Seven patients had hypotension and were taken immediately to the operating room. Seventeen patients had diminished or absent pulses, whereas 13 patients had normal pulses despite an arterial injury. Associated injuries included nerve injury (n = 15), pneumohemothorax (n = 5), and fractures (n = 7). Angiography in 21 patients demonstrated an intimal flap (n = 8), extravasation (n = 5), a pseudoaneurysm (n = 3), an arteriovenous fistula (n = 2), and occlusion (n = 1). Two angiograms were normal. Arterial repair was accomplished by interposition graft (n = 17), primary repair (n = 9), patch angioplasty (n = 3,) and ligation (n = 1).

RESULTS

No functional deficits occurred in patients with an isolated vascular injury. Seven patients with associated brachial plexus injuries experienced severe disability. One arm of a patient was amputated. Two patients died.

CONCLUSIONS

The use of angiography helps to confirm and localize injuries. Prompt correction of the vascular injury avoids disability resulting from ischemia. Although the amputation rate is low with vascular repair, the functional disability resulting from associated nerve injuries can be devastating.

Reductions in tissue plasminogen activator and thrombomodulin in blood draining veins damaged by venous access devices

A frequent complication of venous access devices (VADs) is axillary-subclavian venous thrombosis. To study this problem we have compared blood drawn through VADs with peripheral blood samples in a group of oncology patients with venographically demonstrated venous damage (N = 14) and a group with normal venograms (N = 21). The samples were assayed for a battery of proteins believed to be involved in thrombogenesis. After approximately six weeks of catheterization the venographically abnormal patients had significantly less thrombomodulin (P = 0.0055) and significantly higher PAI:tPA (P = 0.022) in catheter-drawn samples as compared with the venographically normal group. Although the data are inconclusive, it is hypothesized that these changes resulted from local endothelial injury.

Extravascular axillary vein compression in a competitive swimmer: a case report

An unusual case of acute axillary vein compression secondary to hypertrophy and intramuscular edema of the subscapularis muscle is described in a competitive swimmer. The signs and symptoms of this condition are similar to those of axillary vein thrombosis, including nonedematous swelling, discoloration, pain, and prominent cutaneous veins of the involved upper limb. Early recognition and diagnosis by means of venography are important to distinguish the condition from axillary vein thrombosis and to alert the practitioner to the potential of future axillary vein thrombosis in such a case. The treatment is primarily conservative.

The risk of injury to the axillary nerve, artery, and vein from proximal locking screws of humeral intramedullary nails

An elderly female cadaver fore-quarter amputation was dissected, and a custom straight intramedullary nail with a 55 degrees oblique downward lateral to medial proximal screw was inserted with a trocar protruding beyond the medial cortex of the humeral surgical neck. The main trunk of the axillary nerve was found to be at risk with any penetration from anterior to posterior and any screw penetration beyond the medial cortex with internal rotation. The axillary artery and vein were at risk with penetration of over 3 cm by a drill point or screw tip whether a transverse or oblique downward screw was used. Transverse screws inserted through the humeral neck from lateral to medial have the potential for damaging a small branch of the axillary nerve laterally, and care must be taken of the lateral humerus while inserting these screws. Screws inserted in a downward direction near the greater tuberosity, if originating above the equator of the humeral head, may cause impingement.

Brachial plexus injury: association with subclavian and axillary vascular trauma

Proximal upper extremity (subclavian and axillary) vascular injury (SAVI) and brachial plexus injury (BPI) occur uncommonly. However, BPI may be associated with SAVI and frequently is an important determinant of long-term disability. The medical records of patients with traumatic SAVI, BPI, or both over a 5-year period were reviewed. A total of 31 patients were identified. The group was predominantly male (28 men/3 women) with a mean age of 30.5 +/- 1.8 years (range, 15-63 years). Blunt trauma accounted for 43.5% of SAVI cases and 77.8% of BPI cases. Thirteen patients (41.9%) sustained SAVI alone (group I), 10 patients (32.2%) had combined SAVI and BPI (group II), and 8 patients (25.9%) had BPI alone (group III). Subclavian and axilliary vascular injury occurred in 10 of 18 patients (55.6%) with a BPI. Brachial plexus injury occurred in 10 of 23 patients (43.5%) with a SAVI. Patients with SAVI from blunt trauma were significantly more likely to have an associated complete BPI than patients with penetrating trauma. All patients with a complete BPI (6 patients) had an associated SAVI regardless of mechanism of injury. Only one patient with a partial BPI from blunt trauma had an associated SAVI. The Injury Severity Score was significantly higher for patients in group II. An average of 2.8 and 3.3 associated injuries were observed in patients with SAVI (groups I and II) versus patients without SAVI (group III), respectively. No patient who had a complete BPI showed an improvement in neurologic status during a mean follow-up of 7.2 months. No late vascular sequelae occurred in group-III patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Effort thrombosis

Venous thrombosis of the upper extremity can be very minor (superficial phlebitis from IV's) or quite dramatic (effort thrombosis of the axillary or subclavian veins). Rarely is it life threatening. Long-term sequelae are not seen.

Non traumatic dislocation of shoulder with rupture of axillary vessel branch in a paraplegic patient: a case report

Spinal cord injured (SCI) patients utilize the shoulder joints for wheelchair propulsion, for transfers in and out of wheelchairs and for wheelchair "push-ups" for pressure relief, to prevent pressure sores. Accurate incidence of shoulder dislocation in SCI patients is not known. A majority of the dislocations seen are secondary to trauma. A 66-year-old, T10 paraplegic since 1942, developed severe osteoarthritic changes in both shoulders and experienced nontraumatic, recurrent dislocation of his right shoulder with a rupture of the axillary vessel branch. This case is reported here because of its rarity.

Axillary vein thrombosis in a female backpacker: Paget-Schroetter syndrome

In 1875 Sir James Paget reported the first case of primary axillary vein thrombosis. Since then numerous reports of axillary vein thrombosis have appeared citing various initiating events and possible causes. We report here a patient with axillary vein thrombosis. The thrombosis appears to have been provoked by carrying a backpack.

Upper-extremity vascular injuries

Although upper-extremity injuries alone are usually not life-threatening, they can produce significant immediate or long-term morbidity, especially if there is an associated nerve injury. The diagnosis of an arterial injury may be readily apparent, but the excellent upper-extremity collateral circulation may create palpable distal pulses despite a significant proximal arterial injury. Therefore, a high index of suspicion and the liberal use of arteriography are necessary to avoid missing these injuries. Compression of the brachial plexus by a hematoma can produce a serious neurologic deficit. Prompt evacuation of the hematoma may significantly reduce the deficit, another fact that supports an aggressive surgical approach in these patients. The long-term results of upper-extremity vascular injuries are usually determined by the extent of any associated nerve injuries.

Neurovascular injuries of the thoracic outlet and axilla

In this retrospective series of 46 patients with neurovascular injury of the thoracic outlet or axilla, our management strategy emphasized prompt recognition of trauma that may be superficially innocuous. Whenever possible, the precise site of vascular injury was identified arteriographically to help plan an incision that would provide proximal vascular control as well as expedient injury exposure. Vascular reconstruction was accomplished with either end-to-end primary anastomosis (n = 17) or autogenous saphenous vein graft interposition (n = 26). No case of ischemic limb loss occurred, although two repairs failed. Primary neural repair (n = 4) was possible only with simple laceration, but decompression of a tense hematoma led to prompt resolution of neuropraxia in nine patients. Secondary neural reconstruction was largely unsuccessful, and approximately 25 percent of our patients had serious chronic disability related to neural injury. In addition, two patients died as a consequence of numerous associated injuries.

Special problems after iatrogenic vascular injuries

Iatrogenic vascular injuries occurring at our institution were reviewed and several special problems not previously well described were found. These include carotid and femoral pseudoaneurysms, occult hemorrhage and knotting of the angiographic catheter. These problems are exemplified in four patient reports to illustrate how appropriate planning of operative approach and adherence to vascular surgical principles can optimize results.

Civilian vascular trauma of the upper extremity

One hundred forty-three patients with 163 upper extremity vascular injuries were reviewed. Penetrating trauma accounted for 94% of the injuries and blunt trauma for 6%. Absent pulses are not a completely reliable sign of upper extremity arterial injury. The most frequently injured upper extremity vessel is the brachial artery, followed in decreasing frequency by ulnar, radial, and axillary arterial injuries and axillary venous injuries. The most common technique of vascular repair was end-to-end anastomosis, followed by vein graft interposition. No amputations were required. Despite excellent results of vascular reconstruction, functional impairment due to associated nerve injuries was a distressingly predominant finding.

Subclavian-axillary vascular trauma

Traumatic vascular injuries to the subclavian and axillary vessels are often associated with permanent neurologic impairment either by direct injury to the brachial plexus or by compression from an expanding hematoma. Prompt decompression of the plexus by evacuation of the hematoma may avoid permanent neurologic damage and decrease the morbidity of these injuries. We reviewed our experience with these injuries with particular reference to the effect of early decompression of the brachial plexus. From 1963 to 1984 we treated 40 patients. The causes of the injuries were penetrating trauma in 85% and blunt trauma in 15%. The results of arterial repair were excellent with only two failed repairs; neither resulted in severe ischemia. Two patients were suspected of having thrombosed venous repairs. Among the 12 patients with direct injury to the brachial plexus (partial or complete transection), only six had subsequent improvement of their neurologic dysfunction. In contrast, six of seven patients in whom there was only compression of the plexus by hematoma but no direct injury, had neurologic improvement following evacuation of the hematoma. This finding suggests that prompt decompression of the brachial plexus following these injuries may reduce the amount of neurologic impairment and reduce the morbidity of these injuries.

Management of traumatic peripheral vein injuries. Primary repair or vein ligation

The management and outcome of 83 patients who had 86 venous injuries were retrospectively reviewed to identify optimal management techniques in patients with peripheral vein injuries. Venous injuries of the arms were associated with no long-term sequelae, and management with vein ligation appears safe. In patients with venous injuries of the legs, primary repair by lateral suture or primary end-to-end reanastomosis is recommended when technically easy. In patients who are unstable or in whom primary repair cannot be performed, vein ligation is recommended. Autogenous vein interposition grafting appears indicated only in the popliteal area when vein reconstitution should be aggressively sought. Vein ligation in peripheral vein injuries should be followed with aggressive postoperative management to prevent the development of distal edema. Limb elevation is effective in minimizing the development of adverse sequelae.

Vascular injuries of the axilla

Between January 1970 and December 1980, 65 patients sustaining 85 vascular injuries of the axillary artery and/or vein were managed at the Ben Taub General Hospital in Houston, Texas. Concomitant injuries of the subclavian and/or brachial vessels were noted in 34 per cent of patients. A variety of exposure techniques was used in approaching the axillary vessels. Emphasis upon preservation of collateral vessels led to an increased use of substitute vascular conduits over end-to-end anastomosis. The ready availability of prosthetic conduits, absence of graft infection, and excellent short-term patency have made them a primary choice for axillary arterial reconstruction in 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 required upper extremity amputation following failure of repeated revascularization attempts.

Venous revascularization of the arm: report of three cases

Three patients with disabling sequelae of venous obstruction in the upper extremity were treated surgically. In one, direct venous repair was used, whereas in the other two, the internal jugular vein was used to bypass the area of obstruction. Restoration of adequate venous return was associated with permanent symptomatic relief.

Major venous injuries and bullet wounds

A review of the reported incidence, management and results of treatment of major vein injuries is presented and a brief account given of the mechanism of vascular damage by high-velocity bullet wounds. This paper reports 3 cases of isolated major venous injury caused by high-velocity bullets. Repair was performed in each case. Two patients survived with a good short-term clinical result. The third patient died during operation. The advantages of repairing injured veins are discussed.