UPPER EXTREMITY

SUBCLAVIAN ARTERY

- Recommendations: Repair
- Utility of temporary shunt: Low (excellent distal collateral flow)
- Method/Conduit: Interposition graft /6-8mm ePTFE or Dacron (rifampin soaked if possible)

Pearls

- Proximal right and left subclavian arteries can be approached by median sternotomy with extension to the neck and resection of the clavicular head for exposure in a patient in extremis, a clamshell thoracotomy can also expose both vessels.
- The supraclavicular approach is through the clavicular head of sternocleidomastoid muscle and scalene fat pad with retraction of phrenic nerve and division of the anterior scalene muscle
- Place small roll under the shoulders and gently extend head away from side of injury.

Avoid injury to phrenic nerve, brachial plexus, and vertebral arteries. The proximal left subclavian artery is approached using a high (3rd intercostal space) anterolateral thoracotomy and the innominate and proximal right subclavian artery through a median sternotomy and supraclavicular incision. The innominate vein can be ligated and divided to facilitate exposure to the innominate artery. Alternatively, the mid and distal subclavian arteries on both sides can be exposed through a supraclavicular incision or combined supraclavicular/infraclavicular incisions. There is no requirement to obtain proximal vascular control within the surgical field of injury; using separate incisions through non-traumatized tissues can expedite rapid vascular control. When approaching this injury, the operator should err on the side of ample proximal exposure and if necessary, can resect the clavicular head. In an unstable patient it is recommended that initial proximal control be obtained via thoracotomy as this will allow for more rapid control than use of the supraclavicular approach. Because of the technical challenges with exposure, the utility of temporary vascular shunts in this injury pattern is limited. Most often interposition graft using 6-8 mm ePTFE or Dacron is required for subclavian artery repair, being mindful of the vertebral artery and the phrenic nerve. If endovascular capability is available, balloon occlusion of the proximal subclavian artery can be a useful adjunct, and repair with a covered stent can be considered.1,2 (see Appendix E)

AXILLARY ARTERY

- Recommendations: Repair
- Utility of temporary shunt: High (low probability of shunt thrombosis based on author’s experience)
- Method/Conduit: Interposition graft with reversed saphenous vein (favored) or ringed PTFE

Pearls

- Supra- and infraclavicular incisions allows proximal control and distal exposure.
- Prep axilla, arm, and hand of upper extremity into operative field.
- Avoid brachial plexus which will be deep or lateral to axillary artery.
- Control of the proximal axillary artery is best accomplished through a supraclavicular incision, although the artery itself is exposed through an infraclavicular incision extending into the axilla. The infraclavicular exposure includes division of the clavipectoral fascia, and the blunt separation or selective division of the fibers of the pectoralis major muscle for the entire length of the wound. The axillary vein is the first structure to be encountered in the axillary sheath, inferior to the artery. The axillary artery lies superior and deep to the vein, mobilization and caudal retraction of the axillary vein will expose the first segment of the axillary artery. The first segment of the axillary artery is then visible coursing under the pectoralis minor muscle which can be retracted laterally or commonly divided. It is important when exposing the artery to have the arm and hand prepped in the operative field and extended out onto an arm board. Repair of the axillary artery most commonly involves an interposition graft using reversed saphenous vein.

BRACHIAL ARTERY

- Recommendations: Repair
- Utility of temporary shunt: High (low probability of shunt thrombosis based on authors experience)
- Method/Conduit: Interposition graft with reversed saphenous vein

Pearls

- Medial approach; adjacent to the median nerve in brachial sheath in bicep/triceps groove.
- Elastic artery with redundancy; flex arm slightly for interposition grafts to avoid kinking.
- Depending upon damage to collaterals, distal ligation (below profunda brachial or deep brachial artery) may be tolerated.

Brachial Artery Exposure

The brachial artery with the median nerve rests in the brachial sheath and is exposed through a medial incision in the upper arm in the groove between the bicep and triceps (see below). The median nerve is the most superficial structure encountered upon entering the brachial sheath. The ulnar nerve runs posterior to the artery which is surrounded by paired deep brachial veins. A common anatomic variant is for there to be a high bifurcation of the brachial artery in the upper third of the arm. Repair is most commonly accomplished using a reversed saphenous vein interposition graft. Although it may be possible to ligate the brachial artery below the origin of the deep (profunda) brachial artery and maintain a viable arm and hand, this proposition is based on intact collateral circulation. Unfortunately, collaterals from the shoulder and deep brachial artery are often damaged in the setting of penetrating or blast wounds and therefore maintenance of flow through the brachial artery with a temporary shunt or vascular repair is advised. Ligation or primary amputation is an acceptable damage control maneuver if there is not time for shunting or the patient is in extremis.