UPPER  EXTREMITY

SUBCLAVIAN  ARTERY

Pearls

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

Pearls

BRACHIAL  ARTERY

Pearls

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.