Isolated axillary artery injury due to blunt trauma
Aksiller arterin künt travmaya ba¤l› izole hasarlanmas›
Mehmet ÖÇ, Murat GÜVENER, H. ‹brahim UÇAR, Birkan AKBULUT,
Mustafa YILMAZ, Ünsal ERSOY
C o r r e s p o n d e n c e ( ‹ l e t i fl i m ): Murat G ü v e n e r, M.D. Mutluköy sitesi, 2. Cad., 6. Sok., N o: 2 0, Ü m i t k ö y, 0 6 8 0 0Ankara, Tu r k e y.
Tel: +90 - 3 1 2 - 235 56 54 Fax ( F ak s): +90 - 312 - 311 7 3 70 e-m a i l ( e -p o s t a): g u v e n e r @ d o c t o r. c o m
Department of Thoracic and Cardiovascular Surgery, Hacettepe University,
Faculty of Medicine, Ankara, Tu r k e y.
Hacettepe Üniversitesi T›p Fakültesi, Kalp-Damar Cerrahisi Anabilim Dal›,
A n k a r a .
Kemik, brakiyal pleksus, ven ve yumuflak doku hasar› olma-
dan ani ve tek künt travmaya ba¤l› olarak aksiller arterin inti-
mal hasar› çok nadirdir. Arteriyel yaralanman›n kal›c› hasar
b›rakmamas› için erken tan› ve uygun tedavi gereklidir. Kli-
nik belirtiler genelde belli belirsizdir ve kollateral dolafl›ma
ba¤l› olmak üzere yaralanma sonras›, u z u n iskemik dönem
geçtikten sonra belirg i n l e fl m e k t e d i r. Yirmi yafl›ndak i e r k e k
hasta, kolu hiperabdüksiyon ve hiperekstansiyon pozisyonda
buzdolab› tafl›rken sol kolunu incinme ve bundan 1,5 ay son-
ra sol kolundaki a¤r› ve uyuflukluk flikayetleriyle baflvurdu.
Hastan›n hastaneye yat›fl›ndan sonra yap›lan aksiller arter di-
jital substraksiyon anjiyografisinde aksiller arterin oklüzyonu
i z l e ndi ve oklüzyonun distalinde kollaterallerle dolum göz-
l e n m ed i. Ameliyatta, aksiler ve brakiyal arter safen ven ile
baypas edild i. Üst ekstremitenin künt travmas›n›n erken dö-
neminde kollateral dolafl›m nedeniyle vasküler y e t e r s i z l i k d i s-
tal nab›zlar olsa bile tan›namayabilmekte ve üst ekstremitenin
a n j iy ografisi do¤ru tan› ve tedavi için kaç›n›lmaz olmaktad›r.
Bu olgu bizim ikinci tecrübemizdir; birinci olgudaki tecrübe-
mize dayanarak bu olguda oldu¤u gibi kronik durumlarda re-
vaskülarizasyon sonras› greft trombozu söz konusuysa oral
antikoagülasyona en az alt› ay devam edilmesi gerekti¤ini
d ü fl ü n m e k t e y i z.
Anahtar Sözcükler: Aksiller arter/yaralanma; künt travma; uzun
The intimal damage of the axillary artery due to an acute, single
blunt trauma is very rare without concomitant bone, brachial ple-
xus, venous and soft tissue injuries. Early diagnosis and approp-
riate management of the arterial injury is essential to avoid per-
manent disability. The clinical signs are usually occult and do not
become manifest until a long ischemic interval following injury,
owing to the extensive collateral network. At w e n t y - y e a r-old ma-
le patient had injured his left arm in a hyperabduction and hyper-
extension position while he was carrying a refrigerator with his
arm. An increase in the intensity of pain and numbness reappea-
red in his left arm 1.5 months after the trauma. Digital subtracti-
on angiography of the axillary artery performed after his h o s p i t a-
lization showed an occlusion of the axillary artery and no recons-
titution of distal part of the occlusion via collateral vessels.
During the operation, the axillary and brachial arteries were
bypassed with a saphenous graft. As shown in this case report, in
the early period after blunt trauma of the upper limb, progressive
signs of vascular compromise may disappear because of collate-
ral circulation even if the distal pulses are absent. Then an angi-
ography of the upper limb becomes essential for correct diagno-
sis and treatment. This is our second experience. On the basis of
our first experience that was reported, in such a chronic case, oral
anticoagulation must be carried out at least six months whenever
a graft thrombosis after revascularization is encountered.
Key Words: Axillary artery/injuries; blunt trauma; long ischemic
Turkish Journal of Trauma & Emergency SurgeryUlus Travma Acil Cerrahi Derg 2007;13(2):145-148
Traumatic lesions of the axillary artery represent
15-20% of the arterial injuries of the upper limbs.
Ninety-four percent of the traumas are resulting from
the penetrating wounds, while remaining 6% are
caused by blunt traumas that follow a shoulder-frac-
ture dislocation.[2 , 3]It is marked that axillary artery
damage often occurs together with the injury of the
current literature, isolated axillary artery injury as in
this case has been reported in two papers.[7 , 8]One of
them was reported by us.
whose incidence ranges from 27%
and venous and musculoskeletal injury.
Herein we report a case of an isolated axillary
artery injury, which occurred in a 20-year-old male
patient due to a single blunt trauma. The patient was
treated successfully with surgical intervention,
although he had been admitted to the hospital follow-
ing a long ischemic interval.
A twenty-year-old male patient was admitted to
our hospital with complaints of a chronic severe
burning type of pain, r a p i d fatigue on exertion and
numbness throughout his left upper limb. Further
questioning showed that he had injured his left arm
one month ago while he was trying to carry a refrig-
erator with his arm in a hyperabduction and hyperex-
tension position. Numbness and severe burning type
of pain appeared in his left arm however after a short
time the numbness faded out and the pain remained,
but less prominent. An increase in the intensity of
pain and numbness reappeared in his left arm 1.5
months after the trauma, so he decided to seek pro-
fessional assistance. The physical examination was
as following: Arterial pressure was 120/80 mmHg on
the right arm and the left arm was cold and cyanotic;
the pulses were absent. No limitation of the left arm
movements was detectable and the sensory-motor
function was intact. The X-ray studies of the chest
and left arm were assessed to be normal.
A n k l e -brachial ratio index was measured as 0.25.
Arterial pressure on the left arm via noninvasive
method could not be measured. Selective digital
subtraction angiography of the axillary artery sho-
wed an occlusion of the axillary artery and no re-
constitution of distal part of the occlusion via colla-
terals (Fig. 1a, b) .
During the operation, left axillary and brachial
arteries were exposed via the incision of axillary
region and the occlusion was confirmed by the
absence of pulsation just distal part of to the anteri-
or circumflex branch. Although the adventitia of the
axillary artery was intact, a dark transverse line was
evident, representing the transection of the deeper
layers of the axillary arterial wall. On palpation, the
axillary and the brachial arteries were filled with
t h r o m b u s .
There was no macroscopic evidence of associat-
ing nerve injury. Two thousand five hundred units of
heparin were administrated systemically. Axillary,
brachial, ulnar and radial arteries embolectomies
were performed and highly organized thrombus was
removed via repeated thrombectomies. However,
Ulus Travma Acil Cerrahi Derg
Nisan - April 2007146
Fig. 1. ( a ) Preoperative angiogram showing an occlusion of the axillary artery and filling of the brachial artery
beyond via collaterals. ( b ) Preoperative angiogram showing the minimal filling of radial and ulnar
arteries and no filling of distal of them.
Cilt - Vol. 13 Say› - No. 2147
Isolated axillary artery injury due to blunt trauma
there was no flow in the axillary artery; only a very
weak back-flow in the brachial artery was detected,
which was contributed by the collaterals. After an
adequate exploration, revascularization was re-estab-
lished by a saphenous interposition graft anasto-
mosed by end-to-side fashion from the axillary artery
site and end-to-end fashion to the distal part of the
brachial artery. An end-to-side fashion proximal
anastomosis was preferred to preserve main collater-
al arising in immediate proximity of dissection.
Pulses at the brachial artery reappeared and arterial
perfusion of the whole arm was maintained. But the
distal radial and ulnar pulses remained to be absent.
After the operation, TA on left arm was 120/70
mmHg and ankle-brachial ratio was measured as
0.50. Control angiography was done since radial and
ulnar pulses became palpable 12 hours after the
operation. And control angiography of the patient
confirmed the patency of the saphenous graft and
normal flow both in the graft and in the distal arter-
ies (Fig. 2a, b). A course of prophylactic antibiotics
was commenced. Coumadin and aspirin were given
together. Postoperative anticoagulation with subcu-
taneous heparin was continued until international
normalized ratio (INR) increased up to a level about
2 with coumadin. Radial and ulnar pulses became
palpable at the first postoperative day morning.
The postoperative course lacked any complica-
tion and the patient was discharged 7 days after oper-
ation with coumadin and aspirin treatment. After a
period of three months postoperatively the patient
had no complaints and distal pulses were intact.
As previously mentioned, the incidence of the
axillary artery injury due to blunt trauma is very rare.
Looking through the reported cases it w a sshown that
there w a s always an associated lesion together with
the axillary artery injury. Such as, axillary artery
injury together with the shoulder fracture-dislocation
following a blunt is not uncommon.[2 , 3 , 9]According to
some authors, presence of advanced arteriosclerosis
in the axillary artery and its diminished elastic abili-
ty to compensate for this disorganization of anatomy
may play an important role in the axillary artery
i n j u r y.
artery injury often occurs together with the injury of
the brachial plexus which may lead to severe disabil-
ity to the upper limb. Clinical evidence of nerve
lesions are encountered in 27% to 44% of cases.
Functional recovery from neurovascular damages
depends both on early revascularization and on
restoration of the nerve function.
that the ischemic interval from injury to repair and
associated nervous, venous and musculoskeletal
[3 , 5 , 9]Regarding the associated lesions, axillary
[1 0]It is well known
Fig. 2. ( a ) Postoperative angiogram showing proximal anastomoses of the saphenous graft and normal flow in the graft. ( b )
Postoperative angiogram showing distal anastomoses of the saphenous graft and normal flow in the distal arteries.
deficits are all factors in limb salvage after a blunt
t r a u m a.
around shoulder joint may obscure the physical signs
of the axillary artery injury and hinder early diagno-
sis and treatment as in this case report. The present-
ed patient did not request any medical aid until col-
lateral circulation became insufficient. Ankle-
brachial ratio was measured as 0.25. Gold standard of
the diagnosis is still angiography. Following angiog-
raphy, a surgical approach should be taken into con-
sideration as seen in our case; a good surgical result
can be obtained, regardless of the length of the
ischemic period. Usually the affected patients are
young and in the most productive period of life.
The ideal type of vascular repair depends on the
nature and extent of arterial injury and the options
available. Regarding the surgical treatment, arterial
ligation has been abandoned completely today. In
case of complete transection as seen in this case
report, the choice of reconstruction is either direct
end-to-end anastomosis or the vein or prosthetic
interposition grafts. Most vascular surgeons would
avoid using prosthetic material distal to the subcla-
vian artery since the long-term patency rate is poor.
An exploration should be made with a Fogarty
catheter to remove any intraluminal thrombus in the
distal arterial tree.Avulsion of the collateral branch
is usually treated with ligation. The important point
is that, the collateral branches should not be sacri-
ficed to allow adequate mobilization of arterial ends
to perform an end-to-end anastomosis. We per-
formed the proximal anastomosis in end-to-side
fashion to preserve the collateral arising in immedi-
ate proximity of dissection. Since the synthetic arte-
rial conduit, such as Gore-tex, carries a small but the-
oretical risk of infection,autogenous saphenous
vein grafts as employed in this case can be used pref-
erentially as a substitute to vascular conduits, espe-
cially in the mobile regions.
[5 , 1 0 , 1 1]Presence of extensive collateral network
This case report demonstrates an isolated axillary
artery injury due to blunt trauma, an example of the
natural history of an unrecognized, untreated intimal
dissection of the axillary artery and the success even in
a delayed arterial reconstruction but awarding to expe-
rience of the first case who was a 10 year-old boy with
similar history and operation,coumadin treatment
should be continued at least 6 months after the opera-
tion because of distal endothelial chronic damage in
delayed cases like this (In the first case, 6 months after
the operation saphenous vein thrombectomy was per-
formed. The reason of the saphenous graft thrombosis
might be related to bad distal run off).
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