Management of Axillary Artery Dissection
Endovascular stenting is the preferred initial management approach for traumatic axillary artery dissection, as it avoids the significant morbidity and mortality associated with extensive open surgical exposure requiring combinations of supraclavicular, infraclavicular, median sternotomy, or thoracotomy incisions. 1
Immediate Assessment and Diagnosis
When axillary artery dissection is suspected, look specifically for:
- Cool, pale upper extremity with diminished or absent distal pulses 2
- Numbness or paresthesias in the affected limb 2
- History of trauma, particularly anterior shoulder dislocation 1
Obtain immediate angiography (conventional or CT angiography) to confirm the diagnosis, define the extent of dissection, and assess distal perfusion 2
Treatment Algorithm
First-Line: Endovascular Management
For hemodynamically stable patients with isolated axillary artery dissection, proceed directly with endovascular stent placement 1, 2:
- Self-expanding stents (typically 10mm x 40mm) are placed across the intimal flap to restore flow 2
- This approach eliminates the need for extensive surgical dissection through anatomically challenging territory 1
- Immediate postoperative duplex scanning confirms restoration of normal flow 2
Surgical Management: Reserved for Specific Scenarios
Open surgical repair should be considered when:
- Endovascular access is not feasible
- Concomitant injuries require open exploration 1
- Hemodynamic instability requires immediate proximal control 3
If open repair is necessary, obtain proximal control first - in hemodynamically unstable patients, this may require axillary artery cannulation via prosthetic side-graft for cardiopulmonary bypass 3
Critical Pitfalls to Avoid
- Do not delay treatment - the axillary artery's anatomical position makes open surgical exposure technically demanding with high morbidity 1
- Avoid routine open exploration when endovascular options are available, as standard surgical exposure causes significant morbidity and mortality 1
- Be aware of anatomical variations - the axillary artery may have abnormal courses relative to brachial plexus divisions and variable branching patterns that complicate surgical approaches 4
Post-Intervention Monitoring
- Perform early duplex ultrasound to confirm patency and normal flow patterns 2
- Monitor for distal perfusion, pulse examination, and neurological function
- Watch for compartment syndrome development in the forearm/hand