What is the management for a third part axillary artery injury?

Management of Third Part Axillary Artery Injury

Immediate surgical repair via primary end-to-end anastomosis or interposition grafting is the definitive treatment for third part axillary artery injuries, with endovascular stenting reserved as an alternative when the vessel is not completely transected and surgical access poses significant risk. 1, 2, 3

Initial Assessment and Hemorrhage Control

• Apply direct manual compression to control active bleeding while preparing for definitive repair—avoid blind clamping or deep suturing around the neurovascular bundle as this causes iatrogenic brachial plexus injury 4
• Assess for hard signs of vascular injury: absent distal pulses, expanding hematoma, pulsatile bleeding, bruit/thrill, or signs of acute limb ischemia 1
• Evaluate for associated injuries including brachial plexus damage (present in majority of cases and represents the primary source of long-term morbidity), venous injury, and fractures 1
• Obtain immediate vascular surgery consultation—do not delay for imaging if hard signs are present 4, 1

Diagnostic Imaging

• Digital subtraction angiography is indicated when clinical examination is equivocal or to define the exact injury pattern (false aneurysm, occlusion, dissection, or partial transection) before operative planning 1, 5
• Angiography identifies false aneurysms (most common finding) and total occlusions as the two predominant injury patterns 1
• In delayed presentations with progressive ischemia despite initial collateral compensation, angiography is essential to document occlusion and plan revascularization 5

Surgical Management Algorithm

Open Surgical Repair (First-Line for Complete Transection)

• Primary end-to-end repair is achievable in approximately 60% of penetrating axillary artery injuries and should be attempted when vessel ends can be approximated without tension 1
• Interposition grafting using autogenous saphenous vein is required when primary repair is not feasible due to segmental loss or excessive tension 5
• Surgical exposure requires careful technique: infraclavicular incision with potential extension via supraclavicular approach, median sternotomy, or thoracotomy depending on injury location—avoid extensive dissection that increases morbidity 2
• Proximal control may require axillary artery cannulation via prosthetic side-graft if needed for cardiopulmonary bypass in hemodynamically unstable patients 6

Endovascular Management (Alternative for Partial Injuries)

• Self-expanding stent placement is the preferred option when the artery is not completely transected, particularly for dissections or partial avulsions where open repair poses high risk of iatrogenic neurovascular injury 2, 3
• Endovascular approach avoids extensive surgical dissection and associated morbidity/mortality from complex anatomical exposure 2
• This technique is especially valuable in elderly patients or those with significant comorbidities 3

Damage Control in Extremis

• Axillary artery ligation is life-saving in critically ill, hemodynamically unstable patients when repair is not immediately feasible 1
• Ligation is tolerated due to extensive collateral circulation around the shoulder, though this should only be performed when survival takes precedence over limb salvage 1
• The limb salvage rate approaches 100% even with temporary ligation if collateral flow is adequate 1

Critical Pitfalls to Avoid

• Never place deep blind sutures around the axillary neurovascular bundle for hemorrhage control—this causes permanent median nerve palsy and brachial plexus injury 4
• Do not dismiss absent distal pulses in the early post-trauma period as benign—progressive ischemia may develop after initial collateral compensation, requiring delayed angiography and revascularization 5
• Avoid delaying anticoagulation after graft placement—maintain oral anticoagulation for at least 6 months to prevent graft thrombosis in chronic cases 5
• Do not underestimate associated brachial plexus injuries, which represent the major source of long-term functional disability rather than the vascular repair itself 1

Post-Operative Management

• Monitor distal perfusion with serial pulse checks and Doppler assessment 1
• Initiate anticoagulation therapy (minimum 6 months) following interposition grafting to prevent thrombosis 5
• Arrange early physical therapy and occupational therapy for associated brachial plexus injuries, which determine ultimate functional outcome 1
• Obtain neurosurgical consultation for nerve injuries requiring potential reconstruction 1