European Journal of Cardiovascular Medicine

Traumatic vascular injury is a significant cause of morbidity and sometimes mortality, depending on the associated mode and level of injury; hence should be dealt with on an emergency basis considering hemodynamic status of the patient and the level of expertise available at the center. 

Most common forms of vascular injury include penetrating trauma and blunt trauma. Nowadays iatrogenic arterial injury is another emerging cause of vascular trauma. Vascular injuries, such as vasospasm, contusion, intimal flaps, intimal disruption or hematoma, external compression, laceration, transection and focal wall defects with pseudoaneurysm etc are different types of vascular injuries. Penetrating trauma usually results in laceration or transection of the vessel without contusion. A completely transected artery often retracts and spasm with subsequent thrombosis. An incompletely transected artery may be more prone to bleeding. 

Blunt trauma can lead to damage of the vascular wall, from small intimal flaps to severe transmural damage with thrombosis and extravasation. In patients with blunt trauma, the shearing or compressive forces can lead to contusion, tearing and dissection of blood vessels. 

In adults incidence of vascular trauma is estimated between 1.6% and 2%.[1]

80% of all cases of vascular trauma includes peripheral injuries in which penetrating trauma accounts for 70-90% of vascular injuries.

Vascular and neurological injuries have been seen with fractures. Among these axillary and subclavian artery injuries, brachial plexus nerve injuries have been reported to be secondary to proximal humeral fractures. Vascular injury can lead to acute limb ischemia, necessitating early diagnosis and timely revascularization. 

Hence carotid to axillary/brachial artery bypass can be time saving emergency intervention for traumatic upper limb ischemia to save the limb. There is very minimal data available in medical literature about bypass grafting in emergencies.

A 23 year old male was referred to EMD 8 hours after a motorcycle collision. On arrival, the patient's vitals were stable, and he complained of right shoulder pain and an absence of motor and sensory functions below the right shoulder. On examination, his right upper limb was cold, pale, pulseless with saturation < 80% and no withdrawal reflex upon painful stimulation. The injury was associated with swelling, tenderness, crepitus, abnormal mobility and deformity in the right mid arm with a subcutaneous hematoma of 10x4cm in the same region. The patient’s right radial, ulnar and brachial pulses were not recordable by Doppler. A diagnosis of right upper limb ischemia secondary to proximal humeral fracture with the possibility of brachial plexus injury was made. Due to high suspicion of vascular injury, the patient was shifted for CT angiography of the right upper limb which revealed traumatic laceration of the right distal subclavian and proximal axillary artery with absence of blood flow distally. Comminuted displaced fracture of the proximal shaft of humerus with a superolateral displacement of distal fracture fragment(fig.1).

The patient was taken to the operating room for right humerus fracture reduction under general anaesthesia followed by revascularization  with autologous reverse saphenous vein graft from the right common carotid to the proximal brachial artery(fig.2).

The intraoperative findings showed contusion involving the distal part of the right axillary artery extending to the proximal part of brachial artery(mid-arm region) with intramuscular hematoma in the right bicep brachialis. Distal to the contused part, the entire brachial artery was under severe spasm.

The brachial artery was exposed proximally from the contused part of the distal axillary artery and distally till its bifurcation into the radial and ulnar arteries. Fogarty balloon catheter of size 4 and 5Fr passed distally from the brachial to the radial and ulnar artery to look for showers of emboli/ thrombi and to relieve spasms.

After exploring the right common carotid artery near the clavicular head of the SCM, a jump graft from the right common carotid (T-anastomosis) to the right proximal brachial artery (Yanastomosis ) was done with prolene 7-0 using left RGSV harvested by the no-touch technique from the left lower limb, by making a tunnel through the right axilla over the clavicle and from the deltopectoral groove. Keeping the contused part of the axillary artery as it is, a bypass to the brachial artery was made. Just proximal to the Y-anastomotic end and distal to the contused part, the axillary artery was ligated to prevent the progression of dissection.

Intraoperative and postoperative unfractionated heparin was given 6 hourly to prevent the risk of graft thrombosis. At the end of grafting, limb perfusion was restored, with a palpable radial and ulnar pulse. Due to prolonged ischaemic time before revascularisation, the risk of upper limb compartment syndrome was considered and tackled with arm and forearm fasciotomy. Clinical improvement of the right upper limb seen with normalisation of temperature, palpable pulses and spo2 >98% in all the fingers.

After reduction of upper arm edema, STSG was performed for fasciotomy wounds. He was discharged with dual anti platelets and advised for physiotherapy. No signs or symptoms of ischemia with the improvement of motor and sensory functions till the elbow region was noted on regular consecutive follow-ups but the paralysis remained due to associated brachial plexus injury.

Fig .1: Comminuted displaced fracture of the proximal shaft of humerus with superolateral displacement of distal fracture fragment. Traumatic laceration of the right distal subclavian and proximal axillary artery with short segment reformation of the distal axillary artery via collateral filling.

Fig.2. Postoperative CT angiogram showing RSVG from right common carotid to right proximal brachial artery.

The incidence of a combined axillary artery and brachial plexus injury in the literature is reported as 27–44%[1]. The warm ischaemia time after arterial occlusion has been reported in the literature as 4 hours for proximal lesions (ie: proximal to the profunda brachii branch), but up to 12 hours distal to this[2,3].Thus, timely diagnosis and management with clinical exam (ie: the presence or absence of hard signs of vascular injury) with or without CT angiography (where appropriate)[4]. Although the upper limb is more resistant to warm ischaemia compared with the lower limb, a missed opportunity to reperfuse the upper limb can lead to a greater disability, especially when the dominant arm is involved (eg: chronic ischaemic neuropathy, chronic ischaemic neuritis, ischaemic contracture, etc).

As mentioned above, an arteriogram should be performed promptly if arterial injury is suspected. If arterial blood flow is disrupted, surgical options for vascular repair include thrombectomy[8], saphenous vein grafting[9] or prosthetic vein grafting and excision with primary repair with end-to-end anastomosis, lateral arteriorrhaphy, ligation and vein patch angioplasty[12]. It has been reported that performing arteriotomy and thrombectomy without addressing the intimal lesion will almost certainly lead to recurrent occlusion[10]. Early surgical management is critical, as devastating complications, including limb loss, have been described with prolonged ischemia[11].

The causes of brachial plexus injury associated with proximal humeral fracture are compression by hematoma and fracture fragments and ischemia of the brachial plexus[7]. Blunt brachial plexus trauma may result in neuropraxia or axonotmesis but rarely requires any operative management, often improving within 3–6 months[4,5]. In a report of 15 cases of brachial plexus paralysis secondary to proximal humeral fracture, six cases were associated with axillary artery injury[6].

For selective cases in emergency conditions ,especially where ischemic time is already prolonged, in a case of subclavian artery trauma or occlusion, carotid to axillary/brachial bypass is less time-consuming and less risky by avoiding time and efforts necessary for exposure of the proximal part of the subclavian artery, which is required for subclavian to brachial artery anastomosis. Hence in this case jump graft is a comparatively preferred choice than interposition graft for earliest reperfusion of the limb.

Conflict of interest: Nil

Acknowledgement:

We would like to express gratitude to all the people who have helped with the successful completion of the paper.Firstly we would like to thank Dr. Ajit K.Joshi [Medical superintendent, BV(DU)MCH , Sangli] for his valuable feedback and support in completing this paper. We would also like to appreciate the work of the anaesthesia team and residents Dr. Anil Kumar Ch and Dr. Dhruv Oza (Junior resident, department of Anaesthesia, BVDU,MCH)  in the successful completion of the surgery.

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