Novel Endovascular Techniques for Repair of Traumatic Bilateral Axillary Artery Disruption with Long-Term Follow-Up
Article Outline
We describe a case of innovative endovascular techniques to repair traumatic bilateral axillary artery disruption. A 36-year-old male construction worker fell eight stories from a scaffold and sustained bilateral axillary artery injuries. The injuries between the brachial and axillary arteries were bridged using long bare self-expanding stents (Zilver). To the best of our knowledge, this is a novel case report from a level-one trauma center where endovascular techniques were employed to repair bilateral axillary arteries with long-term follow-up.
Traumatic axillary artery injuries are rare but can threaten the viability and use of the arm and hand. Early recognition of these injuries is critically important because of the need for hemostasis and prompt revascularization. The majority of these injuries result from penetrating wounds rather than blunt trauma. We report the novel successful repair of bilateral simultaneous axillary artery disruption injuries using endovascular techniques.
Case Report
A 36-year-old male construction worker fell eight stories from a scaffold. Fortunately, he became partially entangled in the scaffolding during the descent, thereby enabling his survival. Upon arrival in our emergency room the patient was in obvious pain. He had multiple soft tissue injuries of the head, trunk, and extremities. He was hemodynamically stable but had expanding left shoulder and left axillary hematomas, to which pressure was applied. He had bilateral shoulder dislocations, which were reduced in the emergency room. There were no palpable pulses in either arm before or after each shoulder reduction procedure, and sensation and motor function in the arms and hands were reduced bilaterally but more on the left. No arterial flow could be detected using a Doppler probe over the left brachial or radial arteries, and only monophasic arterial signals were obtained on the right. A contrast computed tomographic (CT) scan of the chest showed injuries of both axillary arteries with surrounding hematoma (Fig. 1). Upper extremity angiography revealed bilateral axillary artery occlusion (Fig. 2, Fig. 3). He was taken to the operating room for revascularization of his arms. Bilateral brachial artery cutdowns were performed. Brachial artery sheaths were placed and retrograde contrast studies were performed sequentially on the left and right vessels. This demonstrated contrast extravasation into the surrounding tissues and loss of continuity with the proximal axillary artery bilaterally (Fig. 4, Fig. 5). The left side was addressed first because of the associated hematoma and more severe ischemia. Using fluoroscopic imaging, directional catheters (Cook, Bloomington, IN), and guidewires, the injured axillary artery was eventually crossed with a 0.035-inch nimble guidewire (Cook). The injuries between the brachial and axillary arteries were bridged using 40-mm-long bare self-expanding stents (Zilver, Cook). Gentle balloon angioplasty was performed following stent placement because of mild residual stenosis revealed angiographically. Angiography following dilation showed restoration of axillary artery flow and no significant residual stenosis and no extravasation at the site of injury. The right arm was then addressed in similar fashion. The area of injury was at the level of the distal axillary and proximal brachial arteries. Retrograde angiography showed mirror image disruption of the artery at the level of the distal axillary extravasation of contrast and no visualization of the proximal artery (Fig. 5). This injury was repaired using a similar technique as that used for the left arm. A 10-mm-diameter
×30-mm-long Zilver self-expanding stent was advanced to straddle the injury. Repeat angiography showed a widely patent vessel with no evidence of stenosis or extravasation (Fig. 6). Doppler assessment of the arms and hands revealed restoration of pulsatile flow bilaterally. The patient's postoperative course was remarkable for persistent sensory and motor dysfunction of the left shoulder and arm, resulting from injuries to the rotator cuff of the shoulder, and stretch injury of the brachial plexus bilaterally. This patient has now been followed clinically for more than 3 years.
Fig. 1
Bilateral axillary (arrows) hematoma.
Fig. 2
Occlusion (arrow), left axillary artery.
Fig. 3
Occlusion (arrow), right axillary artery.
Fig. 4
Extravasation (arrows) of contrast on right intraoperative fluoroscopy.
Fig. 5
Extravasation (arrows) of contrast on left intraoperative fluoroscopy.
Fig. 6
Completion fluoroscopy right side, no stenosis (arrows).
Discussion
Due to the protective effect of overlying muscles and bones, blunt injuries of the axillary arteries are uncommon. As in this case, when the axillary artery is damaged during blunt trauma, it is usually associated with damage to the brachial plexus, venous injury, and/or musculoskeletal injury. In 2007 Mehmet et al.1 reported that there were only three cases in the literature (including their own) of an isolated axillary artery injury from blunt trauma. It is hypothesized that the presence of advanced arteriosclerosis and decreased elasticity of the artery may contribute to the few cases in which a blunt injury results in damage to the artery. These features are not likely to have influenced our case as this patient was young and had normal vessels.
The clinical diagnosis of axillary artery injury in the trauma patient is usually obvious because of local signs of trauma, distal pulse deficits, and associated sensory and motor deficits. Urgent repair is almost always necessary because of active bleeding or ischemia of the forearm and hand. Clinical suspicion of this injury should prompt immediate distal pulse assessment including both manual pulse palpation and arterial waveform assessment with a handheld Doppler probe.
Diagnostic studies performed consisted of duplex ultrasound for assessment of arterial flow and CT angiography to define the exact location and character of the arterial injury. Repair should be performed immediately following identification of the injury. Surgical exposure of the axillary and subclavian arteries is difficult because of the surrounding structures and occasionally requires median sternotomy for proximal control and partial excision of the clavicle for direct exposure.
The axillary artery, which begins at the clavicle and ends at the anterior axillary line, is divided into three parts by the pectoralis minor muscle.2 Surgical exposure of the artery can be achieved by dividing the pectoralis minor at its insertion on the coracoid process and by retracting the overlying pectoralis major muscle. Except for simple laceration, primary repair of these vessels is not usually possible because of the extent of the injury and inability to create length by mobilization. Arterial reconstruction in this setting has traditionally required graft interposition and vein or prosthetic conduit.
Isolated instances of endovascular repair of axillary arterial injuries have been reported using covered stents. Xenos et al.3 compared open versus endovascular repair with covered stents of axillary and subclavian artery injuries, describing the feasibility of endovascular repair and demonstrating shorter procedure time and less blood loss. Such an approach is a good alternative in the trauma patient since surgical dissection in the area of injury is avoided and postoperative morbidity is minimized. A 2007 review by Reuben et al.4 indicates that the use of endovascular repair for traumatic vascular injuries is increasing. The number of endovascular procedures registered in the National Trauma Database increased from four in 1997 to 107 in 2003 (a 27-fold increase in cases, with nearly equal numbers of blunt and penetrating injuries being treated). While controlling for differences in injury severity and associated injuries, the mortality was lower for patients who had endovascular procedures versus those with an open repair and the total length of hospital stay was shorter.
Although most cases reported have utilized covered stents for repair of unilateral arterial injuries, we report the first case using bare stents to restore arterial continuity. Avoidance of prosthetic graft material in addition to a stent may be advantageous because of lower bulk, decreased thrombogenicity, and possible increased long-term patency of repaired vessel. The extent of the arterial disruption is likely to limit the utility of bare stent devices in these circumstances. Major disruptions are more likely to require use of covered stents or open surgical repair.
Conclusion
This is a novel reported case with follow-up of over a year of successful bare stent deployment for treatment of traumatic bilateral axillary artery disruptions using an endovascular technique. This patient is now more than 40 months out from his bilateral repair and has had an excellent recovery and nearly full use of the arms despite the need for additional shoulder surgery. Serial Doppler ultrasound assessment of the vessels has revealed normal pulsatile arterial flow bilaterally and no evidence of stenosis or pseudoaneurysm formation. Minimally invasive techniques continue to expand their applications in the vascular trauma patient. The benefits of these less invasive procedures include less dissection, faster time to revascularization, and decreased hospitalization compared to standard open surgical procedures. With further improvement in endovascular devices and techniques these procedure are likely to significantly reduce the need for traditional open surgical repair.
References
- . Isolated axillary artery injury due to blunt trauma. Turk. J. Trauma Emerg. Surg. 2007;13:145–148
- . Mastery of Vascular and Endovascular Surgery. Philadelphia: Lippincott Williams & Wilkins; 2006;
- . Covered stents for injuries of subclavian and axillary arteries. J. Vasc. Surg. 2003;38:451–454
- . Increasing use of endovascular therapy in acute arterial injuries: analysis of the National Trauma Data Bank. J. Vasc. Surg. 2007;46:1222–1226
PII: S0890-5096(09)00329-X
doi:10.1016/j.avsg.2009.08.017
© 2010 Annals of Vascular Surgery Inc. All rights reserved.
