Brachial vessel injuries: High morbidity and low mortality injuries

Historical perspective

Hallowell, in 1759, was first to repair a brachial artery injury using the “veterinarian’s or Farrier’s stitch,” supplanting the original technique of ligation and thus providing the founding step for the management of vascular trauma. Torrance, in 1903, performed a successful suture repair of a brachial artery injury following a blunt trauma, and Jones, in 1919, reported two cases of brachial artery ligation following gunshot wounds with a 1-year follow-up, reporting that both patients had extensive residual disability of the affected arm. Since that time there have been many evolutionary and revolutionary advances. Even with these early reported cases, ligation remained the primary treatment during both World War I and World War II, especially in combat situations. Long transport times to definitive care, lack of antibiotics, and inadequate fluid resuscitation necessitated amputation for other than technical reasons. The results were far from desirable, with amputation rates of nearly 50% for these patients ( Table 1 ).

Incidence and mechanism of injury

Brachial artery injuries are the most commonly reported arterial injury of the upper extremity. In large military and civilian series, brachial artery injury accounts for 15% to 30% of all peripheral arterial injuries. The reason for this relatively high frequency is that the brachial artery is relatively long, superficial, and exposed when compared to other peripheral arteries. Furthermore, the upper extremity is often used as a lever, hammer, and weapon, as well as a protective or restraining device for the torso, all of which place the brachial artery at risk for injury.

Overall vascular injuries of the extremities are infrequently reported. A recent review of the National Trauma Database (NTDB) medical records of 1,861,779 patients revealed that 1.6% of all patients sustained vascular injuries, 0.3% of all patients had upper extremity vascular injuries, and 0.1% of all patients sustained brachial arterial injuries. Brachial artery injury composed 28% of all upper extremity injury and 15.5% of all peripheral vascular injures. Ninety-seven percent of brachial artery injuries were due to penetrating trauma. Some reports showed great differences in the rate of reported brachial injuries ranging from 14% to 50%.

Data from the military setting revealed that between 3.8% and 6.6% injuries were vascular related. Brachial artery injuries accounted for 23% of all extremity vascular injures and as much as 58% of all upper extremity vascular injuries. The mean age of injury has been reported to be from 27 to 31 years of age in both civilian and military populations; males represent about 90% of the injuries in civilian series and nearly 100% in all military series.

There was a preponderance of males versus females in the civilian population, almost 90% being male and nearly 100% of military brachial artery injuries were male. Of these injuries the vast majority were penetrating (94%) versus blunt (6%).

Penetrating trauma remains the most common cause of brachial artery injury. Most injuries are caused by gunshot wounds, stab wounds, or lacerations from broken glass or other jagged objects, especially in civilian trauma. Rich in 1970 reported a large series from the Vietnam conflict consisting of 283 patients with brachial artery injuries; 250 of these patients sustained injuries from either fragments or shrapnel. Over 50% of the brachial artery injuries occurred secondary to fragments from various exploding devices and, approximately 40% of the patients sustained gunshot wounds.

Recently, the increase in the number of diagnostic cardiac catheterizations has resulted in a concomitant increase in the number of brachial artery injuries, often followed by thrombosis, which are seen at most tertiary medical centers. In contrast to the civilian experience, in the military setting, thrombosis of either the axillary or brachial arteries occurs infrequently, occurring in less than 1%. With penetrating trauma being the most common mechanism of injury, the majority of brachial artery injuries found at the time of surgery are transections (60%–84%) followed by lacerations (13%), thrombosis (5%–16%), intimal flaps (3%), and pseudoaneurysms (15.3%), yet arteriovenous (AV) fistulas are uncommon (3%). Interestingly enough isolated brachial arterial injuries occur, with a frequency of 22%.

Blunt injury of the brachial artery occurs with a lesser frequency but deserves emphasis, as its diagnosis may be easily overlooked. Supracondylar fracture of the humerus, particularly with anterior displacement or elbow dislocation, should alert the trauma surgeon to the possibility of an underlying brachial artery injury. This has resulted in the ischemic syndrome of Volkmann’s contracture. Fortunately, this is now a rare occurrence due to awareness and monitoring of high-risk injuries and immediate vascular repair and decompression if symptoms of a compartment syndrome are present ( Table 2 ).

Anatomy

The brachial artery is a continuation of the axillary artery and begins at the lower border of the teres major muscle. Exiting the axilla, the brachial artery is a relatively superficial structure covered only by skin, subcutaneous tissue, and deep fascia. Proximally, it lies medial to the humerus and is accompanied by the median nerve (superiorly and laterally) and the ulnar and radial nerves (medially). Distally, it lies anterior to the elbow and is crossed by the median nerve, which then lies medial to the artery. Just proximal to the elbow, the ulnar nerve is posterior to the artery as it goes behind the medial epicondyle of the ulna. The brachial artery terminates approximately 3 to 5 cm below the elbow skin crease, where it divides into the radial and ulnar arteries.

The brachial artery has three main branches. The first (most proximal) is the profunda brachii, which is accompanied by the radial nerve and passes posteriorly between the medial and long head of the triceps muscle. The profunda brachii provides an important collateral anastomosis with the axillary artery through its posterior circumflex humeral branch. The profunda also has a collateral anastomosis with the radial recurrent artery. The profunda brachii artery has two branches: the anterior branch, which anastomoses with the radial recurrent artery, and the posterior interosseus recurrent artery. Both branches form additional important collateral pathways. The second main branch of the brachial artery is the superior ulnar collateral, which accompanied by the ulnar nerve passes behind the medial epicondyle to provide a collateral anastomosis with the posterior ulnar recurrent. The third (most distal) main branch is the inferior ulnar collateral, which provides a rich anastomotic collateral network around the elbow with the ulnar artery through its anterior recurrent branch.