European Journal of Cardiovascular Medicine

Traumatic axillary artery injuries account for 15–20% of upper limb arterial injuries. 94% of the injuries are due to penetrating trauma and 6% from blunt trauma. Due to the complex anatomy of the axilla, associated injuries like brachial plexus injury, fracture of humerus and soft tissue injury are common. Incidence of concomitant brachial plexus injuries ranges from 27% to 44%[1]. Such injuries are critical and necessitate prompt surgical repair to prevent loss of affected limb. A multidisciplinary strategy enhances successful postoperative results. Management and outcomes of a case series of three patients with axillary artery injury have been discussed here.

This study presents three patients with traumatic axillary artery injury at a tertiary care centre between June 2024 and June 2025. After clinical evaluation, X-ray of the affected limb, colour Doppler, and computed tomography angiography (CTA) was performed on an emergency basis. This was followed by emergency vascular repair. The vascular, plastic surgery and orthopedic specialties were involved in the management of cases.

DESCRIPTION OF CASES

Patient 1

A 34-year-old male presented with history of 12 hour old, penetrating trauma to Left shoulder & axilla. Examination revealed exposed nerves and vessels, cold upper limb, delayed Capillary Refill Time and absent brachial, radial, and ulnar artery pulsations. Sensations were diminished but there was no evidence of any bony injury. Ultrasound Doppler evaluation showed monophasic waveform in brachial, radial & ulnar arteries. CT Angiography showed occlusion of second part of axillary artery.

On emergency exploration, there was exposed brachial plexus and 3cm long contused segment of second part of axillary artery. Contused segment was excised. Multiple swipes proximally & distally were taken with Fogarty’s embolectomy catheter. Both proximal and distal ends of artery had good antegrade and retrograde flow. Revascularization was performed with an interposed reverse saphenous vein graft in an end-to-end fashion. Brachial plexus injury was dealt by team of Plastic surgeons. Post anastomosis distal pulses were present.

Postoperative recovery was uneventful. The affected limb was warm and  distal pulses were well felt. Patient was discharged on 7^th postoperative day.

Fig. 1- Intra-operative image showing reverse saphenous interposition vein grafting.

Patient 2

A 44-year-old man presented to our institute 24 hours after a road traffic accident with penetrating injury to the right axilla. Right upper limb was cold with absent peripheral pulsations, restricted limb movements and diminished sensations. CT Angiography was suggestive of abrupt cutoff at 2nd part of right axillary artery.

About 4cm length of the second part of axillary artery was found to be contused. Involved segment was excised,  multiple swipes taken proximally & distally with Fogarty’s embolectomy catheter and good antegrade and retrograde flow was established. Revascularization was performed with an interposed reverse saphenous vein graft in end-to-end manner. Concomitant brachial plexus injury repair was performed. Radial pulse was well palpable post procedure. Patient was discharged on 10^th postoperative day.

Patient 3

A 28-year-old man presented to the emergency department with a reported penetrating injury to the left shoulder and axilla, sustained 12 hours prior. On examination, limb was cold with delayed capillary refill time & absent pulsations. Proximal humerus fracture was present. Color Doppler of left upper limb revealed the monophasic flow in brachial, radial & ulnar artery. Occlusion at the third part of axillary artery was confirmed by CT angiography.

On emergency exploration, third part of axillary artery had a thrombus. Also, rent in axillary vein, brachial plexus injury and proximal humerus fracture were present. Primary repair of axillary vein was performed. Arteriotomy was done over the involved segment of axillary artery. Thrombus evacuated with multiple swipes of Fogarty’s embolectomy catheter. Brisk backflow and antegrade flow were present. Primary closure of axillary artery was performed. The orthopedic team performed surgical intervention for humerus fracture. Distal pulses were palpable postoperatively. Recovery was uneventful and the patient was discharged on 7^th postoperative day.

Fig. 2- Intraoperative image showing repaired axillary artery and vein.

All patients in the study were young males with traumatic injuries to axilla. Penetrating trauma was the cause of injury in all of them. Brachial plexus injury was the associated finding in all patients. One patient presented with fracture of humerus. Clinical features of all the patients were as follows-

1. Contused, lacerated wound over the axilla
2. Absent brachial, radial and ulnar pulsations
3. Cold affected limb
4. Delayed capillary refill time
5. Reduced sensations

Color Doppler and CT angiography was performed on an emergency basis. Axillary artery injury was confirmed. Two patients sustained injuries to the left axillary artery, while one patient had an injury to the right axillary artery. Emergency exploration was performed under expert guidance through the same wound with extension of incision.

Intraoperatively, second part of the axillary artery was injured in two patients, while one patient had an injury to the third part.

Reverse saphenous vein graft repair was performed for injuries to the second part of the axillary artery while the third case required only embolectomy. Palpable radial pulse was demonstrated immediately after vascular repair indicating successful procedure. After vascular intervention, plastic surgery and orthopedic were involved in management of other associated injuries.

Unfractionated heparin was given for 5 days after the repair. Post-operative recovery was uneventful. All patients were discharged by7-10 days after management of other traumatic injuries.

30%–50% of all vascular trauma to the extremities is the injury to the upper limb. Penetrating trauma is more common than blunt trauma[2]. Subclavian and axillary artery injuries have high incidence of mortality, limb loss, or limb disabilities while accounting  for less than 5% of all vascular injuries[3].

The axillary artery is shielded by the bones (e.g., clavicle, scapula, and humerus) and muscles (e.g., pectoralis major, pectoralis minor, and subscapularis) of the shoulder region, which act as a barrier against external trauma. This robust anatomical enclosure reduces the likelihood of direct injury compared to more exposed vessels in the extremities. Additionally, the axillary artery’s deep location within the axilla further minimizes its vulnerability to trauma[4].

The axillary artery is anatomically divided into three segments by the pectoralis minor muscle[5]. Injuries to the first and second segments often result from hyperabduction and traction of the shoulder. Literature indicates that 89% of axillary artery injuries occur at the third segment, but in this study, 66.6% of patients had trauma to the second segment, with one patient sustaining injury to the third segment.

The extensive collateral network around the shoulder can mask classic signs of ischemia in axillary artery injuries. Injury to the axillary artery presents with loss of pulse, pulsatile haemorrhage, expanding haematoma,  cold upper extremities and poor capillary refill[6]. All three patients in our study presented with similar findings.

Complications such as hemorrhage, ischemia, pseudoaneurysm formation and loss of limb viability are common if unattended. For upper limb injuries, the first 4 hours are vital for proximal lesions, while up to 12 hours are crucial for distal lesions.[7]

Doppler ultrasound, being cost-effective and convenient, is frequently used to identify the site of arterial injury. Computed tomography angiography (CTA) and digital subtraction angiography are also used for the diagnosis of the site and extent of axillary injuries. Conventional arteriography is time consuming, hence, not routinely required.[8]

After diagnosis and localization of the injury, prompt arterial repair is essential, even in patients with adequate distal perfusion[9]. Conservative management is not recommended for open axillary artery damage.

Before definitive surgical repair, use of endovascular balloon for temporary proximal occlusion ensures hemostatic stability and reduces morbidity. This is known as the ‘hybrid approach’ [10]. However, it was not employed in our cases.

Vascular repair can be performed by direct anastomosis or the use of an interposition graft. Direct repair is suitable when the damaged segment is 2 cm or less, while an interposition graft is employed for longer segment loss [11]. In the first and second cases presented, for 3–4 cm segment loss, reversed saphenous vein interposition grafting was utilized.

A significant characteristic of axillary artery trauma is its association with brachial plexus injury. There is 43.5% incidence of brachial plexus injury in patients with subclavian and axillary artery vascular trauma[12]. In this series, the brachial plexus injuries were addressed concurrently with the arterial injuries with minor postoperative sensory deficits.

Trauma to the periclavicular region may result in humerus shaft fracture[13]. In this case series, only one patient had an associated humerus shaft fracture. Axillary artery repair was  prioritized before fracture fixation as an emergency

Despite the robust protection provided to the axilla, penetrative injuries to the axillary artery are fairly common. There is significant loss of function and morbidity associated with such injuries. The sinister presentation of normal capillary refill time (CRT), palpable pulses, or monophasic flow on Color Doppler due to collateral blood supply may make the diagnosis challenging. When vascular injury is suspected, early diagnosis and immediate surgical exploration are critical to prevent limb ischemia. Concurrent brachial plexus, soft-tissue and bony injuries should be handled with expertise. Prompt vascular surgery and multi-disciplinary intervention play a key role in limb recovery and overall outcomes.

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