Evaluation and Management of Vascular Injuries (Upper and Lower Extremities)

A continuation of the subclavian artery

Extends from the lateral margin of the first rib to the lateral margin of the teres major muscle

Externally origin of the axillary artery corresponds with mid clavicle, courses deep in the deltopectoral groove, and ends at the lateral border of the axilla

Divided by the pectoralis minor into three parts

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  First part

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    Proximal to the muscle

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    One branch

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      Superior thoracic artery

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  Second part

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    Posterior to the muscle

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    Surrounded by the cords of the brachial plexus

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    Two branches

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      Acromiothoracic artery

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      Lateral thoracic artery

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  Third part

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    Distal to the muscle

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    Surrounded by the nerves of the brachial plexus

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    Three branches

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      Subscapular artery

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      Anterior circumflex humeral artery

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      Posterior circumflex humeral artery

Injury to axillary artery has a high incidence of associated arteriovenous fistula and nerve injury due to its proximity to the axillary vein and brachial plexus.

Begins at the lateral margin of the teres major muscle as a continuation of the axillary artery.

Terminates 2–3 cm below the elbow crease at its bifurcation.

Course

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  Lies in the groove between the biceps and triceps muscles

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  The proximal part of the artery lies on the medial side of the humerus. It gradually travels to the lateral side of the humerus, and the distal part of the artery is situated anterior to the humerus.

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  In the antecubital fossa, the artery is located deep to the bicipital aponeurosis and bifurcates into the radial and ulnar arteries.

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  Two brachial veins (venae comitantes) run on either side of the artery.

Branches

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  Profunda brachii artery: Large branch of brachial artery from posterior surface of proximal part of the artery

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  Superior ulnar collateral artery

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  Inferior ulnar collateral artery

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  Terminal branches

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    Radial artery

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    Ulnar artery

Important relations

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  Median nerve

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    Anterolateral to the artery in the upper arm

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    Crosses the artery anteriorly in the mid upper arm

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    Posteromedial to the artery in the distal upper arm

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  Ulnar nerve

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    Posterior to the artery in the upper half of the arm

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    Pierces the intermuscular septum in the mid arm and courses away from the artery posterior to the medial epicondyle

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  Radial nerve

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    Closely related to the profunda brachii artery

Divided into:

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  deep veins, including the:

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    axillary vein.

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    brachial vein.

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  Superficial veins, including the:

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    basilic vein.

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    cephalic vein.

Axillary vein

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  Continuation of the brachial vein

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  The cephalic vein joins the terminal portion of the axillary vein just distal to the pectoralis minor muscle and continues as the subclavian vein.

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  The middle segment of the axillary vein lies inferior to the axillary artery under the pectoralis minor muscle.

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  The subclavian vein begins at the lateral border of the first rib.

Brachial veins

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  Two brachial veins (venae comitantes) start in the elbow and run on either side of the brachial artery.

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  The lateral brachial vein is the continuation of the radial venae comitantes, and the medial brachial vein is the continuation of the ulnar venae comitantes.

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  The brachial veins join and continue as the axillary vein at the inferior border of the teres major muscle.

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  The basilic vein joins the terminal part of the brachial vein.

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  Brachial veins drain muscles of the anterior and posterior compartments of the arm by multiple venous perforators.

Basilic vein

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  Superficial vein that runs in the subcutaneous tissue in the medial aspect of the arm

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  Drains the veins from the dorsal surface of the hand

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  Joins the terminal part of one of the brachial veins

Cephalic vein

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  Superficial vein that runs in the subcutaneous tissue that extends from the hand to the deltopectoral groove and joins the terminal portion of the axillary vein

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  Drains veins from the lateral aspect of the forearm and arm

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  Joins the terminal portion of the axillary vein just distal to the pectoralis minor muscle and continues as the subclavian vein

Boundaries

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  Superior border: Formed by a line between the lateral and medial epicondyles

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  Lateral border: Brachioradialis muscle

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  Medial: Pronator teres muscle

Contents from medial to lateral

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  Median nerve

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  Brachial vein and its terminal branches (ulnar and radial veins)

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  Brachial artery and its terminal branches (ulnar and radial veins)

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  Biceps tendon

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  Radial nerve and its branches (superficial and deep radial nerves)

One of the two terminal branches of the brachial artery

Courses through the forearm and terminates as the deep palmar arch

Runs under the brachioradialis muscle

Distal part of the radial artery is subcutaneous and lies on the surface of the radius.

Main branches

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  Radial recurrent artery

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  Palmar carpal branch

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  Dorsal carpal branch

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  Muscular branch

One of the two terminal branches of the brachial artery

Courses through the forearm and terminates as the superficial palmar arch

Larger than the radial artery

Major source of blood supply to the digits

The superficial palmar arch is incomplete in 20% of patients.

When both the radial and ulnar arteries are injured, ulnar artery repair should be the priority because it is the dominant arterial supply to the hand.

Radial veins are the deep venae comitantes of the radial artery.

The deep palmar venous arch drains into the radial vein.

The radial venae comitantes continue as one of the brachial veins at the elbow.

The radial veins are smaller than the ulnar veins.

The dorsal metacarpal veins drain in the radial vein.

Ulnar veins are the deep venae comitantes of the ulnar artery.

The superficial palmar venous arch drains into the ulnar vein.

The ulnar veins receive the tributaries of the deep palmar venous arch.

Superficial veins at the wrist also drain in the ulnar vein.

The ulnar venae comitantes continue as one of the brachial veins at the elbow.

Triangular space in the anterior thigh below the inguinal ligament

Borders

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  Lateral: Medial border of the sartorius muscle

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  Medial: Medial border of the adductor longus muscle

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  Base formed by the inguinal ligament

The floor is formed by the iliacus, psoas major, pectineus, and adductor longus muscles.

The roof is formed by the skin, superficial fascia, and deep fascia.

From lateral to medial side, the femoral triangle contains:

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  the femoral nerve and its branches.

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  the femoral artery.

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  the femoral vein.

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  the deep inguinal lymph nodes.

Femoral sheath

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  A fascial sheath formed anteriorly by the extension of the transversalis fascia and posteriorly by the iliac fascia

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  Divided into lateral, intermediate, and medial compartments

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  Contents of the femoral sheath

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    Lateral compartment

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      Femoral artery

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    Intermediate compartment

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      Femoral vein

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    Medial compartment

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      Referred to as the femoral canal; contains the lymphatic tissue

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      Base of the femoral canal; called the femoral ring

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      Femoral hernia occurs due to weakness in the femoral ring.