Brachial artery injury Supparerk Prichayudh, M.D.

Anatomy Course Branches Teres major m. Medial bicipital sulcus Cubital fossa Bifurcation (opposite to radial head) Branches Deep brachial a. Ulnar collateral a. (superior and inferior)

Ligation of brachial a. proximal to Deep brachial a. should not be performed due to poor collateral circulations in this area.

the anastomosis around the elbow-joint.

Medial bicipital sulcus Coracobrachialis m., Biceps m. Triceps m. Cubital fossa Artery lies medial to biceps tendon, coverd by bicipital aponeurosis. Median n. Ulnar n.

Venous system Deep Superficial All drain into the axillary v. Accompanied by a pair of venae comitantes Superficial Basilic v. Cephalic v. Median cubital v. All drain into the axillary v.

Basilic v. Cephalic v Medial Arm level Lateral Runs superficially Accompanied by 2 medial antebrachial cutaneous n. Upper 2/3  underneath the fascia, medial to Brachial a. Cephalic v Lateral Runs superficially Deltopectoral groove  underneath the fascia

Incidence and Mechanism Vascular Trauma 50% neck, torso 50% extremities Brachial artery  most common in UEVI (30-50%) Penetrating  most common (70-80%), Urban Blunt  Rural

Feleciano, Trauma 5th ed 9 9

42.5% 43.5% 7% 1% 3% 3%

Incidence in Thailand (2002-2007) 52 patients with UEVIs, Blunt 25 (48%), Penetrating 27 (52%) The mean ischemia time was 10.07 h. The mean ISS was 17.52. subclavian artery 12 (23%), axillary artery 3 (5.76%) , brachial artery 18 (34.61%), radial artery and/or ulnar artery 19 (36.54%) Management of upper extremity vascular injury: outcome related to the Mangled Extremity Severity Score. Prichayudh S, Verananvattna A, Sriussadaporn S, Sriussadaporn S, Kritayakirana K, Pak-art R, Capin A, Pereira B, Tsunoyama T, Pena D. World J Surg. 2009 Apr;33(4):857-63.

Diagnosis PE Arterial Pressure Index Doppler US – sensitivity 50% CTA Injured limb SBP/ Uninjured limb SBP < 0.9  specificity 97%, sensitivity 95% > 0.9  NPV 99% Doppler US – sensitivity 50% CTA Angiography  gold standard

Hard vs. Soft signs of Vascular injury Hard signs Soft signs Active arterial (pulsatile) bleeding Minor bleeding Pulseless/ ischemia Injury in proximity to major vessel Expanding pulsatile hematoma Small to moderate size hematoma Bruit or thrill Associated nerve injury API < 0.9 Operation Mandatory Further W/U

Doppler signal normal (“triphasic”) Doppler velocity waveform rapid antegrade flow reaching a peak during systole transient reversal of flow during early diastole slow antegrade flow during late diastole.

Indication for angiography Hemodynamic stability Uncertain diagnosis Soft signs PVD Unclear location (location determine operative approach) Multiple wounds, fractures GSW parallel to an artery Thoracic outlet wound

CTA

General Principle of management ABCs Temporary bleeding control  digital pressure, Tourniquet Active bleeding, limb threatening ischemia  OR Stable, good limb viability  may investigate Non-operative management  non-occlusive lesion in asymptomatic patient Pre-operative management Prophylactic antibiotic Single dose heparin iv if no C/I

Surgical treatment Prepare for Incision & exposure leg (SVG) Tourniquet Intraoperative angiogram Incision & exposure Proximal & distal control Identify injury and resect the injured segment Thrombectomy with a Fogarty catheter  obtain good inflow and back-bleeding before the repair.

Extensile exposure

Arm  incision along bicipital sulcus

Cubital fossa  S shape incision - Cut bicipital aponeurosis Retract brachioradialis m. (lateral) and Pronator teres m. (medial) Preserve elbow collateral.

Repair options Primary repair  defect < 1-2 cm (33-67%) Graft Reverse SVG (31-59%) PTFE (6-12%) Combined vascular- orthopedic injury Bone alignment 1st Limb threatening ischemia  shunt Damage control Ligation (0-1%) Shunt (0-2%) Risk factors for compartment syndrome in traumatic brachial artery injuries: an institutional experience in 139 patients. Kim JY, Buck DW 2nd, Forte AJ,et al. J Trauma. 2009 Dec;67(6):1339-44. Management of traumatic brachial artery injuries: a report on 49 patients. Ekim H, Tuncer M. Ann Saudi Med. 2009 Mar-Apr;29(2):105-9.

Temporary shunts In complex extremity vascular injury, Damage control Heparin-bonded shunts Argyle - Inahara Sundt Self-constructed shunt The TIVSs were assembled from simple intravenous and extension tubes available in the operating room. Rigid stabilization of the injured bones and/or joints, debridement of the devitalized soft tissues, saphenous vein harvest for interposition grafts, and repair of any associated venous injuries were performed while the shunts were in place. Then, the shunts were removed and the injured arteries were repaired. J Trauma. 2002 Jun;52(6):1129-33. Temporary intravascular shunt in complex extremity vascular injuries. Sriussadaporn S, Pak-art R. 25

Indications for Fasciotomy S & S of compartment syndrome compartment pressure > 30 - 35 mmHg ∆P (DBP-CP) < 30 mmHg Prophylactic any combined arterial and venous injury prolonged extremity ischemia > 4-6 h vascular injury associated with shock; crush injuries; combined skeletal and vascular extremity trauma; and the ligation of a major extremity vein or artery.

Risk Factors for Compartment Syndrome in Traumatic Brachial Artery Injuries 139 patients 29 (20.9%) CS 110 (79.1%) No CS GSW 67, Sharp LW 64, Blunt 7 1 Amputation in CS group Risk factors for compartment syndrome in traumatic brachial artery injuries: an institutional experience in 139 patients. Kim JY, Buck DW 2nd, Forte AJ,et al. J Trauma. 2009 Dec;67(6):1339-44.

Arm Compartments Anterior Posterior

Fasciotomy of the Anterior and Posterior Compartments of the Arm Using 1 Skin Incision. A 15-cm skin incision is made over the medial intermuscular septum, carefully avoiding the underlying neurovascular bundle. Using rake retractors and the electrocautery device, skin and subcutaneous tissue flaps are raised anteriorly and posteriorly. The fascia over the anterior compartment is then opened midway between the anterior border of the biceps muscle and the medial intermuscular septum for the length of the skin incision. The fascia over the posterior compartment is then opened midway between the posterior border of the triceps muscle and the medial intermuscular septum for the length of the skin incision. Using 2 Skin Incisions. A 15-cm skin incision starting medial to the bicipital sulcus is extended up the anteromedial arm to the acromion and through the fascia to decompress the anterior compartment. A 15-cm skin incision starting at the tip of the olecranon is extended up the posterolateral arm and through the fascia to decompress the posterior compartment. 29

Forearm compartments Volar Lateral (Mobile WAD) Dorsal This figure shows a cross section through of a left forearm.  The compartments are labeled anterior (volar), posterior (dorsal) and the mobile WAD*.  If you horizontally split the figure above; the top half would be the anterior (volar) compartment, and the lower half the posterior (dorsal) compartment.  The posterior compartment contains those muscles which extend the wrist and fingers, and is innervated by the Radial nerve.  The anterior compartment contains the muscles which flex the wrist and fingers,and is innervated mainly by the median nerve.  *(Mobile WAD is a collective term for the lateral muscles brachioradialis, extensor carpi radialis brevis & extensor carpi radialis longus).  These three muscles act as flexors at the elbow joint.[ Dorsal 30

Fasciotomy of the Forearm Fasciotomy of the Volar and Lateral Compartments of the Forearm (Volar-Ulnar Approach). A transverse incision starting distal to the antecubital crease on the radial side of the forearm is extended to the ulnar side of the forearm and then turned 90°. The longitudinal component of the incision is extended down the ulnar side of the forearm until it reaches the wrist, where it curves medially to the mid-aspect of the volar wrist. The incision is now extended and curved into the thenar crease of the palm. By dividing the underlying fascia at the transverse origin of the incision distal to the antecubital crease, the muscles of the lateral (mobile wad) compartment are decompressed. The fascia underlying the longitudinal and wrist components of the skin incision is opened, thereby decompressing the superficial flexor muscles of the forearm and the carpal tunnel.151 The space between the FCU and FDS muscles (flexing the fingers will help differentiate these muscles) is separated with retractors, and the ulnar nerve and artery are visualized lying on the deep flexor compartment (Fig 16). The deep flexor compartment is opened longitudinally after retracting the ulnar artery and nerve laterally and ligating any small arterial branches in the area where the fasciotomy is to be performed. Ideally, the fascia over each deep volar muscle should be incised.149 If there is continued tightness at the level of the wrist, the tunnels of the median and ulnar nerves should be divided. Fasciotomy of the Dorsal Compartment of the Forearm. Pressures in the dorsal compartment of the forearm often return to the normal range following decompression of the volar and lateral compartments. Therefore, the pressure in the dorsal compartment is reassessed at this time toavoid an unnecessary skin incision and fasciotomy. After the forearm is pronated, a longitudinal skin incision from 2 cm lateral to and 2 cm distal to the lateral epicondyle of the humerus to the mid-aspect of the posterior wrist is made. A longitudinal fasciotomy to decompress the superficial muscles of the dorsal compartment is made between the extensor carpi radialis brevis and extensor digitorum communis muscles (extending the fingers will help differentiate these muscles). 31

Amputation: when? Non-viable or non-salvable limb Irreversible limb ischemia Extremely mangled limbs Severe necrotizing infection Safe life before limbs!!! Amputation can be life saving in life threatening extremity bleeding or infection. Functional outcome consideration

Clinical signs of irreversible limb ischemia mottled, nonblanching skin dark, tense, noncontracting muscles Do not reperfuse the dead limb  Reperfusion injury!!!!

Mangled Extremity Severity Score (MESS)  1-14 Skeletal / soft-tissue injury      Low energy (stab; simple fracture; pistol gunshot wound): 1      Medium energy (open or multiple fractures, dislocation): 2      High energy (high speed MVA or rifle GSW): 3      Very high energy (high speed trauma + gross contamination): 4 Limb ischemia      No ischemia: 0* Pulse reduced or absent but perfusion normal: 1*      Pulseless; paresthesias, diminished capillary refill: 2 *      Cool, paralyzed, insensate, numb: 3* Shock      Systolic BP always > 90 mm Hg: 0      Hypotensive transiently: 1      Persistent hypotension: 2 Age (years)      < 30: 0      30-50: 1      > 50: 2 * Score doubled for ischemia > 6 hours from Johansen et.al. 1990

MESS as a predictor for amputation Johansen et al (1990): Lower extremity trauma Slauterbeck et al (1994): Upper extremity trauma MESS of > 7 was associated with a 100% amputation rate.

52 UEVI patients (52% penetrating, 48 %blunt) Amputation: clinical signs of irreversible limb ischemia (skin & muscle changes) Amputation rate 13%, all suffered from blunt injuries and had MESS > 7, 0% mortality rate. - We could avoid amputation in 12 of 19 patients (63%) who had a MESS >7. - MESS of >7 does not always mandate amputation.

Can the revised MESS score (i.e., focusing more on the degree of skeletal/soft tissue injury) be applied to all comers to be a more sensitive predictor of limb salvage and the need for amputation?

Results Amputation rate  0-6%, Compartment syndrome 1-29%

Conclusions: Brachial a. injury The most common vascular injury in upper extremities. Early diagnosis Hard signs, API < 0.9 Angiography  Uncertain Dx or location Early treatment Hard signs+ limb threatening ischemia  OR! Outcome is good with low amputation rate.

CASE 40 y/o male 1hr PTA: Bomb  bleeding wound over Rt. Cubital fossa (arterial bleeding) GCS 15 Stable V/S Further assessments

Good sensation and motor function Rt radial pulse not palpable, not dopplerable Temporary bleeding control with digital pressure X-ray  Shrapnel, No fracture IV fluid resuscitation OR

Preparations?, incision?

Prep whole Rt arm and shoulder Prep Rt groin  SVG Heparin 5,000 unit iv x1 No tourniquet S shape incision

Repair options?

Interposition graft with reversed SVG Prolene 6-0 No fasciotomy Good radial pulse after anastomosis No completion angiography 1 close suction drain Good function, D/C 1 wk Post op

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