Operative exposure and management of axillary vessel injuries

Historical perspective

In 1920 Makins described the World War I British experience with penetrating vascular injuries. He reviewed a total of 1191 arterial injuries, of which 108 were axillary artery injuries, and calculated a 9.0% incidence; however, none underwent repair. In 1946, DeBakey and Simeone published the World War II American experience. In this series they reported a total of 2471 vascular injuries, of which 74 were axillary artery injuries, for an incidence of 2.9% and a high rate of limb loss of 43.2%. During the Korean Conflict, Hughes reported a total of 304 arterial injuries, of which 20 were axillary artery injuries, for an incidence of 6.5%. Rich, in 1970, reported 1000 cases from the Vietnam War sustaining vascular injuries, of which there were 59 axillary injuries for an incidence of 2.6% ( Table 1 ).

Incidence and mechanism of injury

Reports of the military experience from the major conflicts reveals an incidence of axillary injuries ranging from 2.9% to 9% of all arterial injuries sustained in combat. This incidence is remarkably similar to that reported from the civilian experience, which ranges from 1.5% to 8.6%. A review of recent civilian series reveals that axillary arterial injuries account from 4.7% to 42.9% of all upper extremity vascular injuries ( Table 2 ).

Penetrating mechanisms account for the majority of all axillary vascular injuries. Graham recently reported 65 patients with axillary vascular injuries; 95% were due to penetrating trauma but only 5% were due to blunt trauma. Similarly, the experience from the Vietnam War revealed that 98% of all axillary arterial injuries resulted from gunshots and fragment injuries (i.e., grenades or shrapnel) and only 2% were caused by blunt trauma.

Anatomy

The axillary artery measures approximately 15 cm in length. It is the natural continuation of the subclavian artery. It begins at the lateral border of the first rib and ends at the inferior border of the teres major muscle, where it transitions to become the brachial artery.

The pectoralis minor muscle divides the axillary artery into three parts. The first part is proximal to the muscle and gives rise to one branch, the superior thoracic artery, which courses medially to supply the muscles of the first two intercostal spaces. The second part courses under the muscle and gives rise to two branches, the thoracoacromial and lateral thoracic arteries. The thoracoacromial artery is an important branch contributing to a very rich collateral circulation. It arises as a short trunk and divides into four branches to supply the deltoid and pectoral muscles as well as the acromioclavicular region. The lateral thoracic artery travels along the lower border of the pectoralis minor muscle to supply the chest wall.

The third part lies lateral to the muscle and gives rise to three branches: the subscapular artery and the anterior and posterior circumflex humeral arteries. The subscapular artery is the largest branch. It originates from the axillary artery at the level of glenoid fossa and descends along the lower border of the scapula to the muscles of the posterior axillary wall. It anastomoses with the descending branch of the profunda brachii artery beneath the triceps and contributes to the collateral blood supply of this area. The anterior and posterior circumflex arteries form a ring around the neck of the humerus. Anastomosis of the posterior circumflex humeral artery with the ascending branch of the profunda brachii artery provide another important contribution to the collateral circulation.

The axillary vein is formed by the joining of the two venae comitantes of the brachial artery, the brachial veins, and the basilic vein. It courses into the axilla and becomes the subclavian vein once it travels underneath the clavicle, entering the thoracic cavity by the ligament of Halsted. The axillary vein covers the axillary artery when the arm is abducted. This relationship may contribute to arteriovenous fistula formation following penetrating injuries.

The brachial plexus also lies in close proximity to the axillary artery; as a matter of fact they are invested in a common fascial sheath. The three major cords of the plexus (medial, lateral, and posterior) surround the axillary artery in its proximal portion. The major peripheral nerves of the upper extremity derive directly from these cords. The median nerve lies anteriorly, the ulnar nerve lies medially, and the radial nerve lies posteriorly to the axillary artery.