1. Brachial artery injury
Supparerk Prichayudh, M.D.

2. 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)

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

4. the anastomosis around the elbow-joint.

5. 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.

6. 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.

7. 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

8. 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

9. Feleciano, Trauma 5th ed 9 9

10. 42.5%
43.5% 7% 1% 3% 3%

11. Incidence in Thailand (2002-2007)
52 patients with UEVIs, Blunt 25 (48%), Penetrating 27 (52%)
The mean ischemia time was h.
The mean ISS was
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 Apr;33(4):

12. 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

13. 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

14. 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.

15. 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

16. CTA

19. 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

20. 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.

21. Extensile exposure

22. Arm  incision along bicipital sulcus

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

24. 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 Dec;67(6):
Management of traumatic brachial artery injuries: a report on 49 patients.
Ekim H, Tuncer M.
Ann Saudi Med Mar-Apr;29(2):105-9.

25. 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 Jun;52(6):
Temporary intravascular shunt in complex extremity vascular injuries.
Sriussadaporn S, Pak-art R. 25

26. Indications for Fasciotomy
S & S of compartment syndrome
compartment pressure > 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.

27. 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 Dec;67(6):

28. Arm Compartments
Anterior
Posterior

29. 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

30. 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

31. 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

33. 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

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

35. 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

36. 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.

37. 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.

38. 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?

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

40. 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.

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

42. 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

43. Preparations?, incision?

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

45. Repair options?

46. 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

47. Thank you