Cas cliniques

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Lincoln MeMedical Colleg

CorrespondMontefiore NoE-mail: Rchan

Ann Vasc SurgDOI: 10.1016/� Annals of V�Edit�e par ELS

Nouvelle technique endovasculaire pour letraitement des ruptures traumatiquesbilat�erales des art�eres axillaires et suivi �along terme

Rajiv K. Chander, Ross T. Lyon, Andrea E. Romano, Soula Priovolos, Jayne Lieb,

Carlos Pelaez, James E. Barone, Bronx, NY, USA

Nous rapportons un cas de technique endovasculaire innovante utilis�ee pour la r�eparation d’unerupture traumatique bilat�erale de l’art�ere axillaire. Un patient de 36 ans travaillant dans leBbtiment fit une chute d’un �echafaudage d’une hauteur de huit �etages et pr�esentait des l�esionstraumatiques bilat�erales des art�eres axillaires. La continuit�e entre les art�eres brachiales etaxillaires �etait r�etablie en utilisant de longs stents nus auto expansibles (Zilver). A notre con-naissance, il s’agit d’un cas original d’utilisation des techniques endovasculaires dans un traumacenter de niveau 1 pour le traitement de l�esions traumatiques bilat�erales des art�eres axillaires,avec un suivi �a long terme.

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 dis-

ruption injuries using endovascular techniques.

CASE REPORT

A 36-year-old male construction worker fell eight stories

from a scaffold. Fortunately, he became partially entan-

gled in the scaffolding during the descent, thereby enabl-

ing his survival. Upon arrival in our emergency room the

iginal article: 10.1016/j.avsg.2009.08.017.

dical and Mental Health Center affiliate of Weill Cornelle and New York Medical College, Bronx, NY, USA.

ence : Rajiv K. Chander, MD, Department of Surgery,rth, 600 East 233rd Street, Bronx, NY 10466, USA,der08820@yahoo.com

2010; 24: 551.e5-551.e8j.acvfr.2010.12.031ascular Surgery Inc.EVIER MASSON SAS

patient was in obvious pain. He had multiple soft tissue

injuries of the head, trunk, and extremities. Hewas hemo-

dynamically stable but had expanding left shoulder and

left axillary hematomas, to which pressure was applied.

He had bilateral shoulder dislocations, which were redu-

ced in the emergency room. There were no palpable pul-

ses 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 revea-

led bilateral axillary artery occlusion (Figs. 2, 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 con-

trast 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 (Figs. 4, 5). The left

side was addressed first because of the associated hema-

toma 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

601.e1

Fig. 1. Bilateral axillary (arrows) hematoma. Fig. 2. Occlusion (arrow), left axillary artery.

Fig. 3. Occlusion (arrow), right axillary artery.

601.e2 Cas cliniques Annales de chirurgie vasculaire

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 ste-

nosis 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 showedmirror 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.

DISCUSSION

Due to the protective effect of overlyingmuscles 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 asso-

ciated 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 asso-

ciated sensory and motor deficits. Urgent repair is

almost always necessary because of active bleeding

or ischemia of the forearm and hand. Clinical suspi-

cion of this injury should prompt immediate distal

pulse assessment including both manual pulse pal-

pation 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 cha-

racter of the arterial injury. Repair should be perfor-

med immediately following identification of the

injury. Surgical exposure of the axillary and subcla-

vian arteries is difficult because of the surrounding

structures and occasionally requires median sterno-

tomy for proximal control and partial excision of the

clavicle for direct exposure.

Fig. 5. Extravasation (arrows) of contrast on left intrao-

perative fluoroscopy.

Fig. 4. Extravasation (arrows) of contrast on right

intraoperative fluoroscopy.

Fig. 6. Completion fluoroscopy right side, no stenosis

(arrows).

Vol. 24, No. 4, 2010 Cas cliniques 601.e3

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 lacera-

tion, 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 axil-

lary arterial injuries have been reported using cove-

red stents. Xenos et al.3 compared open versus

endovascular repair with covered stents of axillary

and subclavian artery injuries, describing the feasi-

bility 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 thosewith 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 inju-

ries, we report the first case using bare stents to

restore arterial continuity. Avoidance of prosthetic

graft material in addition to a stent may be advan-

tageous because of lower bulk, decreased thrombo-

genicity, and possible increased long-term patency

of repaired vessel. The extent of the arterial dis-

ruption 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 treat-

ment of traumatic bilateral axillary artery dis-

ruptions 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 ultra-

sound assessment of the vessels has revealed normal

601.e4 Cas cliniques Annales de chirurgie vasculaire

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 improve-

ment in endovascular devices and techniques these

procedure are likely to significantly reduce the need

for traditional open surgical repair.

REFERENCES

1. Mehmet OC, Murat GH, Ibrahim U, Birkan A, Mustafa Y,

Unsal E. Isolated axillary artery injury due to blunt trauma.

Turk. J. Trauma Emerg. Surg 2007;13:145-148.

2. Zelenock GB. Mastery of Vascular and Endovascular Surgery.

Philadelphia: Lippincott Williams & Wilkins, 2006.

3. Xenos ES, Freeman M, Stevens S, Cassada D, Pacanowski J,

Goldman M. Covered stents for injuries of subclavian and

axillary arteries. J. Vasc. Surg 2003;38:451-454.

4. ReubenBC,WhittenMG,SarfatiM,Kraiss LW. Increasinguseof

endovascular therapy in acute arterial injuries: analysis of the

National Trauma Data Bank. J. Vasc. Surg 2007;46:1222-1226.