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.

Axillary Artery Injuries Associated With Proximal Humerus Fractures: A Literature Review and a Proposal of a Novel Multidisciplinary Surgical Approach.

INTRODUCTION: Proximal humerus fractures (PHF) are common injuries that can lead to axillary artery injury, which carries the risk of not being identified during initial assessment. The aim of this study was to describe the management of suspected axillary artery injury associated with PHF according to our experience and to describe a new multidisciplinary surgical approach. METHODS: This was a single-center retrospective study. A database was created for patients admitted for PHF to the emergency department of the Hospital of Cannes between October 2017 and October 2019. Patients admitted with PHF associated with suspected ipsilateral upper limb ischemia, and/or massive diaphysis displacement, and/or upper limb ipsilateral neurological deficits were included in this study. RESULTS: In total, 301 patients diagnosed with PHF were admitted within these periods. Among these patients, 12 presented with suspected axillary artery lesions, of whom, 6 were included in the present study and treated according to our new approach. A description of these 6 cases, along with an extensive literature review is presented. CONCLUSION: Based on our experience, the endovascular approach proposed for the management of axillary artery injury associated with proximal humerus fractures is effective, feasible and reproducible.

Axillary Artery Transection and Brachial Plexus Injury After Open Inferior Glenohumeral Dislocation: A Case Report.

CASE: A judo athlete presented with an open inferior shoulder dislocation that occurred during competition. Examination revealed a transection of the axillary artery and neuropraxia of the posterior cord. Neuropraxia was resolved within 2 weeks. The axillary artery was repaired with a femoral vein graft. He regained full strength, range of motion, and function at 8 months. CONCLUSION: Inferior glenohumeral dislocations are rare, and their management can be complicated by vascular and neurological injuries. We emphasize the importance of examination, diagnosis, and treatment of neurovascular pathologies to avoid catastrophic outcomes.

The spectrum of computed tomography findings in blunt trauma of the subclavian/axillary artery: a pictorial essay.

Traumatic injuries of the subclavian and axillary arteries are uncommon but have high morbidity and mortality. In contrast to penetrating injuries, which are often lethal, blunt injuries present a wide and heterogeneous spectrum of imaging findings. If a vessel tear or transsection is a life-threatening circumstance, minor injuries might be overlooked in an emergency setting but could cause or aggravate the functional loss of a limb. The aim of this pictorial essay is to acquaint radiologists with the spectrum of imaging findings that could be encountered during the radiological evaluation of the subclavian/axillary artery (SAA) in trauma patients and offer tips and tricks to improve the diagnostic workup of patients with suspected blunt SAA injuries.

Endovascular Repair of Transected Axillary Artery via Snare Assisted Through and Through Femoral to Brachial Artery Access.

Axillary artery injury is a rare but complex surgical problem that often requires challenging exposures, lengthy operations, and morbid outcomes for repair. For these reasons, endovascular repair is an attractive alternative as it obviates many of the challenges present with open repair. While pseudoaneurysms, dissections, and short segment injuries with limited arterial disruption are regularly treated endovascularly, complete arterial transections are almost exclusively treated with open repair as obtaining wire access across the site of injury is often not possible. Here we report a case of successful endovascular repair of a completely transected axillary artery with the use of snare assistance to obtain through and through femoral to brachial artery access. This ultimately allowed for covered stent deployment across the axillary transection restoring distal blood flow. Snare assistance in obtaining through and through access across areas of complete transection can allow for increased use of endovascular repair.

Analysis of Traumatic Axillo-Subclavian Vessel Injuries: Endovascular Management is a Viable Option to Open Surgical Reconstruction.

BACKGROUND: In traumatic axillo-subclavian vessel injuries, endovascular repair has been increasingly described, despite ongoing questions regarding infection risk and long-term durability. We sought to compare the clinical and safety outcomes between endovascular and surgical treatment of traumatic axillo-subclavian vessel injuries. METHOD: A search query of the prospectively maintained PROOVIT registry for patients older than 18 years of age with a diagnosis of axillary or subclavian vessel injury between 2014-2019 was performed at a Level 1 Trauma Center. Patient demographics, severity of injury, Mangled Extremity Severity Score (MESS), Injury Severity Score (ISS), procedural interventions, complications, and patency outcomes were collected and analyzed. RESULTS: Twenty-three patients with traumatic axillo-subclavian vessel injuries were included. There were similar rates of penetrating and blunt injuries (48% vs. 52%, respectively). Eighteen patients (78%) underwent intervention: 11 underwent endovascular stenting or diagnostic angiography; 7 underwent open surgical repair. There was similar severity of arterial injuries between the endovascular and open surgical groups: transection (30% vs. 40%, respectively), occlusion (30% vs. 40%, respectively). The open surgical group had worse initial clinical comorbidities: higher ISS scores (17.0 vs 13.5, p = 0.034), higher median MESS scores (6 vs. 3.5, P = 0.001). The technical success for the endovascular group was 100%. The endovascular group had a lower estimated procedural blood loss (27.5 mL vs. 624 mL, P = 0.03). The endovascular arterial group trended toward a shorter length of hospital stay (5.6 days vs. 27.6 days, P = 0.09) and slightly reduced procedural time (191.0 min vs. 223.5 min, P = 0.165). Regarding imaging follow up (average of 60 days post-discharge), 7 patients (54%) underwent surveillance imaging (5 with duplex ultrasound, 2 with computed tomography angiography CTA) that demonstrated 100% patency. Regardless of ISS or MESS scores, at long term clinical follow up (average of 214 days), there were no limb losses, graft infections or vascular complications in either the endovascular or open surgical group. CONCLUSIONS: Endovascular treatment is a viable option for axillo-subclavian vessel injuries. Preliminary results demonstrate that endovascular treatment, when compared to open surgical repair, can have similar rates of technical success and long-term outcomes in patency, infection and vascular complications.

Surgical Management of Subclavian and Proximal Axillary Artery Injuries.

Subclavian and proximal axillary arterial injuries are rare and difficult to manage. Eight patients were managed from January 2008 to December 2018 at The Aga Khan University Hospital, Karachi, Pakistan with mean age of 36.13 ± 14.48 years. All patients had penetrating injuries, from gunshot in 5 (62.5%), bomb blast in 2 (25%), and stab wound in 1 (12.5%) case. Six (75%) patients presented in haemodynamically stable condition. The mean time between the injury and patient presentation was 28 ± 8.39 hours. The injuries were approached via supraclavicular incision in 3 (37.5%) patients, infraclavicular incisions in 2 (25%) patients and median sternotomy in 2 (25%) patients. Three (37.5%) patients had false aneurysm, while 5 (62.5%) had transected artery. Primary repair was performed in 2 (25%) cases, while 6 (75%) patients were treated with interposition graft with polytetrafluoroethylene (PTFE). All patients have salvaged limbs with good functional outcomes.  Key Words: Subclavian artery, Penetrating injury, Vascular trauma, Vascular repair.

Damage control of peripheral vascular trauma - Don't be afraid of axillary or popliteal fosses.

Peripheral vascular injuries are uncommon in civilian trauma but can threaten the patient's life or the viability of the limb. The definitive control of the vascular injury represents a surgical challenge, especially if the patient is hemodynamically unstable. This article proposes the management of peripheral vascular trauma following damage control surgery principles. It is essential to rapidly identify vascular injury signs and perform temporary bleeding control maneuvers. The surgical approaches according to the anatomical injured region should be selected. We propose two novel approaches to access the axillary and popliteal zones. The priority should be to reestablish limb perfusion via primary repair or damage control techniques (vascular shunt or endovascular approach). Major vascular surgeries should be managed post-operatively in the intensive care unit, which will allow correction of physiological derangement and identification of those developing compartmental syndrome. All permanent or temporary vascular procedures should be followed by a definitive repair within the first 8 hours. An early diagnosis and opportune intervention are fundamental to preserve the function and perfusion of the extremity.

El trauma vascular periférico no es común en el contexto civil, pero representa una amenaza para la vida del paciente o de la extremidad. El control definitivo de la lesión vascular representa un desafío quirúrgico, especialmente en pacientes con inestabilidad hemodinámica. Este artículo describe la propuesta de manejo del trauma vascular periférico de acuerdo con los principios de la cirugía de control de daños. Se debe identificar los signos sugestivos de lesión vascular y realizar oportunamente maniobras temporales para el control del sangrado. Se debe elegir el abordaje quirúrgico dependiendo del área anatómica lesionada. Se proponen dos nuevas incisiones para acceder a la región axilar y poplítea. La prioridad es restablecer la perfusión de la extremidad mediante el reparo primario o técnicas de control de daños (shunt vascular o abordaje endovascular). Los pacientes sometidos a cirugías vasculares mayores deben ser manejados postoperatoriamente en la unidad de cuidados intensivos para corregir las alteraciones fisiológicas e identificar aquellos que desarrollen un síndrome compartimental. Todos los procedimientos vasculares permanentes o temporales deben contar con un reparo definitivo en las primeras 8 horas. El diagnóstico temprano e intervención oportuna son fundamentales para salvaguardar la perfusión y funcionalidad de la extremidad.

[Arterial trauma of the upper limbs: Particularities of the population in Tunisia and risk factors for amputation]. / Traumatismes artériels des membres supérieurs : particularités de la population en Tunisie et facteurs de risque d'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.

Brachial Plexus Injury Significantly Increases Risk of Axillosubclavian Vessel Injury in Blunt Trauma Patients With Clavicle Fractures.

BACKGROUND: A national analysis of clavicle fractures is lacking and the risk of concomitant axillosubclavian vessel injury (ASVI) in patients with clavicle fractures is unknown. A minority of patients may have a combined brachial plexus injury (BPI). We sought to describe risk factors for concomitant ASVI in patients with a clavicle fracture; hypothesizing patients with combined clavicle fracture and BPI has a higher risk of ASVI. METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for blunt trauma patients with a clavicle fracture. A multivariable logistic regression model was used to determine risk factors for ASVI. A subset analysis on patients with isolated clavicle fractures was additionally performed. RESULTS: From 59 198 patients with clavicle fractures, 341 (.6%) had concomitant ASVI. Compared to patients without ASVI, patients with ASVI had a higher median injury severity score (24 vs. 17, P < .001) and rates of pulmonary contusions (43.4% vs. 37.7%, P = .029) and BPI (18.2% vs. .4%, P < .001). After controlling for associated chest wall injuries and humerus fracture, the BPI odds ratio (OR 49.17, 35.59-67.92, P < .001) was independently associated with risk for ASVI. In a subset analysis of isolated clavicle fractures, BPI remained associated with risk of ASVI (OR 60.01, confidence intervals 25.29-142.39, P < .001). CONCLUSION: The rate of concomitant ASVI in patients with a clavicle fracture is <1%. Patients presenting with a clavicle fracture had a high rate of injuries including pulmonary contusion. Patients with findings suggestive of underlying BPI had a nearly 50 times increased associated risk of ASVI. Thus, a detailed physical exam in this setting including brachial-brachial index appears warranted.

Tratamento endovascular com endoprótese aórtica para aneurisma de artéria subclávia secundário à fístula arteriovenosa axilo-axilar traumática tardia / Endovascular treatment with aortic endoprostheses for subclavian artery aneurysm secondary to late traumatic axillary-axillary arteriovenous fistula

Resumo As fístulas arteriovenosas (FAVs) traumáticas envolvendo os vasos axilares e subclávios são incomuns e correspondem de 5 a 10% de todos os traumas arteriais. A anatomia complexa dessa região torna desafiador o tratamento desse segmento. Neste desafio terapêutico, descrevemos o caso de um homem de 73 anos, encaminhado por edema progressivo e úlcera no membro superior direito, com história pregressa de ferimento por arma de fogo na região infraclavicular direita há cerca de 50 anos. Foi realizada angiotomografia e identificou-se FAV axilo-axilar associada à tortuosidade e dilatação aneurismática de artéria subclávia a jusante. O paciente foi submetido à intervenção endovascular com endoprótese cônica (monoilíaca) 26 × 14 × 90 mm Braile® na artéria subclávia aneurismática, posterior à saída da artéria vertebral direita, e endoprótese monoilíaca 16 × 16 × 95 mm Excluder® com sobreposição na primeira prótese, apresentando resultado satisfatório. Portanto, descreve-se a possibilidade de utilização de endoprótese aórtica em situação incomum e de exceção, com sucesso.

Abstract Traumatic arteriovenous fistulas (AVFs) involving the axillary and subclavian vessels are uncommon and account for 5 to 10% of all arterial traumas. The complex anatomy of this region makes treatment of this segment challenging. In this therapeutic challenge, we describe the case of a 73-year-old man, referred for progressive edema and ulceration involving the right upper limb and with a history of gunshot wound to the right infraclavicular region about 50 years previously. Angiotomography was performed and an axillary-axillary AVF was found, associated with tortuosity and aneurysmatic dilation of the subclavian artery downstream. He underwent endovascular intervention and a conical (monoiliac) 26 × 14 × 90 mm Braile® endoprosthesis was used in the aneurysmatic subclavian artery, posterior to the exit of the right vertebral artery and a 16 × 16 × 95mm Excluder® monoiliac endoprosthesis was placed overlapping the first prosthesis, showing a satisfactory result. Therefore, the possibility of successfully using aortic endoprostheses in an unusual and exceptional situation is described.

Endovascular Treatment of a Traumatic Axillary Artery Rupture Using the Dual Bull's-Eye Technique.

BACKGROUND: Our purpose is to report a case of an axillary artery rupture treated by endovascular means using the dual bull's-eye technique. An 83-year-old woman with multiple comorbidities was diagnosed with axillary artery rupture after the reduction of a shoulder dislocation. METHODS: An endovascular repair attempt was made, but, despite the use of a double approach (antegrade and retrograde), reconnecting both ends of the severed artery was deemed not possible. 5-mm Amplatz GooseNeck snares were advanced from each access and superposed in a perpendicular plane. A percutaneous infraclavicular puncture with a lumbar needle was made through both snares, and a V14 guidewire was subsequently introduced. The guidewire was recovered through femoral and brachial accesses, and a 7 × 100 mm covered self-expandable stent was deployed. RESULTS: The final angiographic control did not show further hemorrhage, and the patient recovered radial pulse. Follow-up showed complete patency and no complications at 9 months after the procedure. CONCLUSIONS: The dual bull's-eye technique can be used as a resource tool in cases of arterial rupture, when the arterial continuity cannot be re-established by conventional approaches.

Management and Outcomes of Isolated Axillary Artery Injury: A Five-Year National Trauma Data Bank Analysis.

BACKGROUND: The aim of this study is to evaluate recent national trends in the clinical characteristics, management, and outcomes of patients with isolated axillary artery injuries. METHODS: The National Trauma Data Bank was queried to identify records submitted from 2011 to 2015 that contained an ICD-9-CM diagnosis code for an injury to axillary artery (903.01) and an external cause of injury code indicating blunt or penetrating trauma. Records that contained a diagnosis code for an injury to an additional blood vessel (900.00-903.00, 903.2-904.9), an injury to a nonupper extremity or unclassifiable body region, or whose operative management could not be discerned were excluded. The final study sample included 221 patients with isolated axillary artery injury. The patient's clinical management was the primary outcome of interest. The study sample was stratified by trauma type, and descriptive statistics were performed on all variables. RESULTS: Seventy-one percent of patients received operative management. Patients with penetrating injury were 24% more likely to be managed operatively than bluntly injured patients (76.9% vs. 62.1%, P = 0.0178). In operatively managed patients, the open repair rate was 82.8% and endovascular repair rate was 10.2%. Graft repair was performed most often (28.0%), followed by placement of a temporary intravenous shunt (17.8%) and surgical occlusion (10.2%). Surgical vessel occlusion was significantly more likely to be performed on patients with penetrating injury than with blunt injury (14.6% vs. 1.9%, P = 0.0124). Patients with penetrating injury had significantly shorter median emergency department length of stay (87.0 min vs. 152.0 min, P < 0.0001), intensive care unit length of stay (2.0 days vs. 3.0 days, P < 0.0388), hospital length of stay (4.0 days vs. 5.0 days, P = 0.0026), and time-to-operative management (1.6 hr vs. 3.9 hr, P < 0.001) compared to bluntly injured patients. Patients with blunt injury had a higher reportable in-hospital complication rate (13.8% vs. 6.0%, P = 0.0477). The overall mortality rate was 3.1% for isolated axillary artery injuries and did not significantly differ by trauma type. CONCLUSIONS: Axillary artery injury is more often caused by penetrating trauma. Despite introduction of novel endovascular techniques, the majority of patients with isolated axillary artery injury are managed using open repair. Penetrating axillary artery injury is significantly more likely to be managed using open repair and by surgical occlusion. Patients with blunt injury have higher complication rates and longer hospital length of stays. The mortality rate is lower than previously published.

Subclavian-axillary arterial thrombosis and distal embolisation after traumatic anterior glenohumeral dislocation. / Trombosis arterial subclavioaxilar y embolización distal tras luxación glenohumeral anterior traumática.

Arterial vascular injury associated with anterior dislocation of the shoulder is a rare but potentially devastating complication, often seen in the context of high-energy trauma or penetrating injury. It is a medical emergency that can compromise both the viability and functionality of the limb, as well as the patient's life if it is not identified early and treated properly. However, its diagnosis can be difficult, since it requires a high index of suspicion. The presence of an axillary artery thrombosis after shoulder dislocation resulting from low-energy trauma is extremely rare, even more so with subacute clinical presentation associated with embolism to the radial artery.

Interventional treatment of arterial injury during blind central venous catheterisation in the upper thorax: experience from two centres.

AIM: To evaluate the safety and clinical efficacy of interventional treatment for arterial injury during blind, central venous catheterisation in the upper thorax at two tertiary medical centres. MATERIALS AND METHODS: Eighteen consecutive patients (37-81 years; M:F=8:10) who underwent interventional treatment for the arterial injuries that occurred during central venous catheterisation without any imaging guidance between November 2007 and December 2018 were included. Clinical data, angiographic findings, detailed interventional procedures, and technical and clinical outcomes were analysed retrospectively. RESULTS: Arterial injury sites were the subclavian artery/branches (n=12), axillary artery/branches (n=2), and common carotid artery (n=4). The target vein was not correlated with the corresponding artery/branches in eight patients (44.4%); internal jugular vein to subclavian artery branches. Angiographic findings were pseudoaneurysm (66.7%, 12/18), contrast medium extravasation (22.2%, 4/18), or both (11.1%, n=2). A stent graft was inserted for the main trunk injuries in nine patients, with (n=2) or without (n=7) prior arterial branch embolisation to prevent potential endoleak, while embolisation for the arterial branch injuries was performed in nine patients. Direct percutaneous access with thrombin injection to the pseudoaneurysm or residual arteriovenous fistula was utilised in two. The technical and clinical success rate was 94.4% (17/18) each. There were no procedure-related complications. In one patient without immediate clinical success, there was a persistent pseudoaneurysm after stent graft placement, which was treated with in-stent balloon dilation. CONCLUSION: Interventional treatment serves as a safe and effective treatment modality for inadvertent arterial injury related to blind, central venous access catheterisation in the upper thorax.

Through Thick or Thin: Disparities in Perioperative Anticoagulant Use in Trauma Patients.

Although vascular surgery guidelines recommend immediate anticoagulation for acute occlusion of a peripheral artery, it is unclear whether trauma surgeons follow this practice. A survey regarding the use of perioperative anticoagulation was sent to surgeons who perform their own peripheral arterial repairs after traumatic injury to define contemporary practice patterns. This survey demonstrated minimal consensus opinion regarding the management of extremity vascular injuries, strongly suggesting the need for a consensus conference, meta-analysis, and prospective studies to guide further care.

Late presentation of axillary arterial ischemia following a gunshot wound: Case report.

Penetrating injuries of axillary artery are uncommon and associated with high mortality and morbidity rate. Clinical presentation of these injuries may vary; therefore, a high index of suspicion is essential. We are reporting a case of late presentation of axillary arterial ischemia, 10 days after a gunshot wound, which occurred to a 20-year-old male. The patient was treated successfully with open surgical intervention.

Critical errors in infrequently performed trauma procedures after training.

BACKGROUND: Critical errors increase postoperative morbidity and mortality. A trauma readiness index was used to evaluate critical errors in 4 trauma procedures. In comparison to practicing and expert surgeon benchmarks, we hypothesized that pretraining trauma readiness index including both vascular and nonvascular trauma surgical procedures can identify residents who will make critical errors. METHODS: In a prospective study, trained evaluators used a standardized script to evaluate performance of brachial, axillary, and femoral artery exposure and proximal control and lower-extremity fasciotomy on unpreserved cadavers. Forty residents were evaluated before and immediately after Advanced Surgical Skills for Exposure in Trauma training, and 38 were re-evaluated 14 months later. Residents were compared to 34 practicing surgeons evaluated once 30 months after training, and 10 experts. RESULTS: Resident trauma readiness index increased with training (P < .001), remained unchanged 14 month later and was higher, with lower variance than practicing surgeons (P < .05). Expert trauma readiness index was higher than residents (P < .004) and practicing surgeons (P < .001). Resident training decreased critical errors when evaluated immediately and 14 months after Advanced Surgical Skills for Exposure in Trauma training. Practicing surgeons had more critical errors and performance variability than residents or experts. Experts had 5 to 7 times better error recovery than practicing surgeons or residents. Trauma readiness index area under the receiver operating curve with Youden Index <0.60 or <6 decile in their cohort, predicts a surgeon will make a critical error. CONCLUSION: Low trauma readiness index was associated with critical errors occurring in all surgeon cohorts and can identify surgeons in need of remedial intervention.