Case Report

Axillary artery transection after recurrent anterior Shoulder dislocation

Abstract

Axillary artery transection after recurrent Anterior shoulder dislocation is extremely rare. We present 2 such patients. The first, a 62-year-old man, presented with acute ischemia and a large hematoma in the axilla and chest wall. The second, a 63-year-old man, had a pseudoaneur- ysm and palpable peripheral pulses. Both underwent urgent computed tomography, which confirmed the clinical diagnosis, and the patients were taken to the operating room. In the first patient, intraoperative angiogram through both the brachial and the femoral route showed complete disruption of the axillary artery rendering an endovascular approach not possible. Proximal balloon occlusion was then undertaken through the femoral artery, controlling the bleeding and allowing easier dissection of the ruptured segment. Revasculariza- tion was performed with an interposition polytetrafluoro- ethylene (PTFE) bypass restoring normal Blood supply to the upper extremity. The second patient had a Viabhan (W.L. Gore, Flagstaff, Ariz) stent-graft implanted through the Brachial artery with an excellent clinical and angio- graphic result. As expected, both patients had significant neurologic morbidity due to associated brachial plexus palsy. Ruptured axillary artery after shoulder dislocation is very uncommon. EndoVascular repair and hybrid proce- dures combining open and endovascular techniques can offer reliable solutions to these challenging problems.

Injury to the axillary artery after shoulder dislocation is extremely rare. We present 2 such cases and discuss the immediate management of these challenging clinical problems. A 62-year-old man presented as an emergency to the Orthopedic surgeons of a peripheral hospital. After heavy alcohol consumption, he sustained a fall onto a tree injuring his left shoulder. His medical history included Recurrent episodes of anterior dislocation of the left shoulder, coronary artery disease requiring angioplasty, depression, and excessive alcohol abuse. He was on dual antiplatelet treatment with aspirin and clopidogrel. On arrival to the emergency department (ED), he was diagnosed to have an anterior shoulder dislocation, which was easily reduced. It

was also noted that a large hematoma was forming in the deltopectoral and axillary region and there were signs of acute upper Limb ischemia. The patient was too drunk and agitated to allow satisfactory assessment, but he was not able to move his arm. An arterial injury was suspected as a result of his shoulder dislocation and he was transferred to our unit for further management. On arrival, he was tachycardic; hypotensive; had an expanding hematoma occupying the whole anterior and lateral left chest wall and axilla; and his upper limb was cold, pulseless, and swollen. There were no audible signals with the hand-held Doppler in the left forearm and wrist. Resuscitation was initiated and an urgent computed tomography (CT) confirmed the clinical findings. He was immediately taken to the operating room, and angiography via a brachial artery cut-down confirmed axillary artery injury with contrast extravasation (Fig. 1). Further angiography via a right femoral puncture and selective catheterization of the left subclavian artery showed complete disruption of the proximal axillary artery. Because of the nature of the in- jury, it was not possible to advance the wire through the lesion and bridge the gap by endovascular means. However, a 7 mm x 6-cm angioplasty balloon (Opti-Plast XT, Bard Peripheral Vascular, Crawley, UK) was intro- duced over the wire and was used for proximal control in the subclavian artery while the axillary artery was dissected through a infraclavicular incision, therefore, obviating the need for proximal dissection and clamping and minimizing blood loss (Fig. 1). The large hematoma was evacuated and the axillary artery was found transected and so was the axillary vein. The cords of the brachial plexus were found macroscopically intact. A 7-mm polytetrafluoroethylene (PTFE) interposition bypass graft was used to reconstitute the artery, and this restored the circulation to the upper arm with palpable distal pulses. The severed axillary vein was ligated. Because of forearm compartment syndrome, he required decompression via a volar fasciotomy incision. His postoperative course was uneventful, and delayed primary suturing of his fasciotomy wound was undertaken on the 10th day once the limb edema had settled. From the neurologic stand point, he appeared to have severe brachial plexus palsy, and this was confirmed by an electromyogram 2 weeks after the injury. He was discharged to the care of the orthopedic surgeons, neurologists, and rehabilitation physicians having a well-perfused but useless arm.

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Fig. 1 Intraoperative arteriogram through the brachial approach showing transection of the axillary artery (A) and proximal balloon occlusion through the femoral route (B).

A 63-year-old man was transferred from an outlying hospital as a vascular emergency. He presented to the local orthopedic surgeons having suffered an injury to the left shoulder 3 days earlier. He felt an excruciating pain in shoulder and upper arm while trying to lift a heavy bucket. He also mentioned that 2 months earlier had suffered a similar injury. At that time he felt his shoulder “dislocat- ing,” but “managed to put it back in” without seeking medical advice. During this presentation, he attended the local accident and ED and was diagnosed as having anterior shoulder dislocation that was easily reduced. This was presumed to be the second episode. He was discharged home on a broad arm sling and pain killers and was given a follow-up appointment for the orthopedic clinic. Because of severe pain, he returned back to the ED 2 days later. He had severe pain and swelling around the shoulder and was noted not to be able move his arm indicating a possible Brachial plexus injury. A pulsatile swelling was palpable in the axillary region. Plain x-rays revealed no bony or joint abnormality, but CT angiography demonstrated a disrupted axillary artery (Figs. 2A and B). On arrival to our unit, he was also noted to have a warm arm with palpable peripheral pulses and no pressure gradient compared to the normal right upper limb. There was an enlarging

pulsatile hematoma in the axilla. He was taken to the operating room and via a brachial artery cut-down, angiography was performed, which confirmed injury to the axillary artery (Fig. 2C-E). A 7 mm x 5-cm stent-graft (Viabhan, W.L. Gore, Flagstaff, Ariz) was implanted and postdilated with a 7-mm angioplasty balloon. Completion angiogram showed a patent axillary artery and successful exclusion of the pseudoaneurysm. Postoperatively, his recovery was uneventful from the vascular point of view but was overshadowed by the associated brachial plexus palsy. This was confirmed by an electromyogram 2 weeks after the injury. He was discharged to the care of the orthopedic surgeons and rehabilitation physicians.

Axillary artery rupture after dislocation of the Shoulder joint is indeed very unusual [1-5]. This is more likely to occur in elderly patients because of the loss of arterial elasticity secondary to atherosclerosis [5]. The injury usually involves the third segment of the axillary artery because of its relative fixation by the branches of the circumflex humeral and subscapular arteries. Recurrent dislocation may be a common feature. It is likely that the initial injury may cause the artery to be fixed by inflammatory tissue in the torn shoulder joint capsule, and this renders it more susceptible to injury with subsequent dislocations [5]. The pathognomonic triad of anterior shoulder dislocation, expanding axillary hema- toma, and diminished peripheral pulse should alert emergency physicians to the possibility of such an injury. The latter is not always present, as seen in our second patient who had normal pulses and blood pressure. Association with a severe brachial plexus lesion is also very common in such injuries, but proper preoperative clinical Neurologic assessment is made difficult by the presence of an ischemic limb [5]. Involvement of the brachial plexus represents the most important determinant of Long-term disability. As a result, both these patients had a well-perfused but significantly impaired upper extremity. Severe brachial plexus injury results in devastating functional disability and persistent causalgia, which may lead to repeated hospitalization and even subsequent elective amputation regardless of patent arterial repair [5,6]. Once the diagnosis is clinically suspected, CT or magnetic resonance angiography may be of value depending on the local resources. Conventional angiography is the gold standard, and we prefer to perform this in a dedicated vascular operating room with endovascular facilities. Depending on the nature of the arterial injury, we may then proceed to immediate open surgery or endovascular intervention. The latter is increasingly used in trauma cases, is less invasive, and can be performed under local anesthesia [7]. It does not preclude immediate or late formal exploration of the brachial plexus and indeed may make such surgery easier. One unresolved issue is the durability of endovascular repair in a region exposed to extreme arm movements. If an endovascular option is not feasible, as seen in our first

Case Report 119.e7

Fig. 2 computed tomographic angiography (A, B) and intraoperative arteriography (C) revealed disruption of the axillary artery, which was repaired using a covered stent. This was postdilated with an appropriate-sized angioplasty balloon (D) producing an excellent angiographic result (E).

patient, a hybrid approach using proximal balloon occlusion may also be beneficial [5,7]. This would allow stabilization of the patient by minimizing blood loss and facilitate Open repair without the need of more proximal dissection.

Christos D. Karkos MD, FRCS, PhD Dimitrios G. Karamanos MD, PhD Konstantinos O. Papazoglou MD, PhD Dimitrios N. Papadimitriou MD Neophytos Zambas MD

Ioannis N. Gerogiannis MD Thomas S. Gerassimidis MD, PhD 5th Department of Surgery

Medical School Aristotle University of Thessaloniki

Hippocrateio Hospital 546 42 Thessaloniki, Greece

E-mail address: [email protected] doi:10.1016/j.ajem.2009.04.033

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