Management of traumatic brachial artery injuries: A report on 49 patients

BACKGROUND AND OBJECTIVE: The brachial artery is the most frequently injured artery in the upper extremity due to its vulnerability. The purpose of our study was to review our experience with brachial artery injuries over a 9-year period, describing the type of injury, surgical procedures, complications, and associated injuries. PATIENTS AND METHODS: Forty-nine patients with brachial artery injury underwent surgical repair procedures at our hospital, from the beginning of May 1999 to the end of June 2008. The brachial artery injuries were diagnosed by physical examination and Doppler ultrasonography. Depending on the mode of presentation, patients were either taken immediately to the operating room for bleeding control and vascular repair or were assessed by preoperative duplex ultrasonography. RESULTS: This study group consisted of 43 males and 6 females, ranging in age from 6 to 65 years with a mean (SD) age of 27.9 (6.7) years. The mechanism of trauma was penetrating in 45 patients and blunt in the remaining 4 patients. Stab injury was the most frequent form of penetrating trauma (24 of 45). Treatment included primary arterial repair in 5 cases, end-to-end anastomosis in 28 cases, interposition vein graft in 15 cases, and interposition-ringed polytetrafluoroethylene graft in 1 case. Associated injuries were common and included venous injury (14), bone fracture (5), and peripheral nerve injury (11). Fifteen patients developed postoperative complications. One patient underwent an above-elbow amputation. CONCLUSIONS: Prompt and appropriate management of the brachial artery injuries, attention to associated injuries, and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage.

U pper extremity arterial trauma may signific c cantly impact the outcome of the trauma pac c tient, but the literature regarding this topic is scarce. Although relatively uncommon, injuries to the arteries of the upper extremity are serious and have the potential to significantly impact the outcome of the trauma patient. 1 The brachial artery is the most frec c quently injured artery in the upper extremity. Its injury accounts for approximately 28% of all vascular injuries. 2 The degree of ischemia after brachial artery injuries dec c pends on whether the injury is proximal or distal to the profunda brachii. 3 All brachial artery injuries can be managed successc c fully unless associated with severe concomitant damage to nerves. The median nerve courses with the brachial artery throughout its length. The radial and ulnar nerves parallel portions of the brachial artery. Therefore, as in all upper extremity vascular injuries, there is a high inc c

Management of traumatic brachial artery injuries: A report on 49 patients
cidence of associated nerve injuries with brachial artery injuries. 3 The purpose of our study was to review our experience with brachial artery injuries over a 9cyear pec c riod. The type of injury, surgical procedures, complicac c tions, and associated injuries were reviewed.

PATIENTS AND METHODS
Fortycnine patients with brachial artery injury underc c went surgical repair procedures at our hospital from the beginning of May 1999 to the end of June 2008. The brachial artery injuries were diagnosed by physical exc c amination and Doppler ultrasonography. The following findings were considered to be signs of arterial injury: brisk bleeding, expanding pulsatile hematoma, pale and cold upper extremities, absent or weak radial and ulnar pulses and associated profound neurological deficits. In this series, an average brachialcbrachial Doppler index less than 0.5 was considered diagnostic for brachial arc c tery injury. The initial management of the patients was conducted according to the principles of the advanced trauma and life support (ATLS) guidelines for trauma management. 4 For patients presenting with hard signs of penetrating vascular injury, prompt surgical interc c vention without further diagnostic evaluation was used. Patients with blunt arterial injury or with penetrating injuries with clinical soft signs (cod extremity, color change, nonexpanding hematoma) underwent plain upc c per extremity radiography and Doppler ultrasonograc c phy ( Figure 1).
The indications for fasciotomy were clinically evident or impending compartment syndrome, massive swelling in the upper limb, ischemia lasting more than 6 hours and any motor or sensory deficits. In all patients with associated bone fracture, vascular repair always prec c ceded orthopedic reconstruction. Endoluminal shunts were not required in any of the patients. Successful repair was assessed by the return of radial and ulnar pulses at the end of the operation.
Patients with more severe soft tissue and muscle injuries were treated with thorough debridement of all grossly nonviable tissue, with removal of foreign bodc c ies and copious irrigation with isotonic saline solution, and then injured vessels were exposed. Heparin was adc c ministered intravenously for systemic anticoagulation before the vessels were clamped proximally and distally with nontraumatic vascular clamps. Fogarty catheters were used for thrombectomy of the distal and proxic c mal arterial segments. All patients received intravenous heparin for a period of 5c7 days postoperatively and were discharged home on oral aspirin 100 mg/day for a period of 3 months.
Exposure of the brachial artery in the arm was alc c ways approached with a median incision in the line of the sulcus separating the biceps muscle from the triceps muscle. The median nerve was always identified and separated from the brachial artery. Exposure of the arc c tery at the elbow was performed with a skin crease inc c cision made at the elbow, with longitudinal extensions along the line of the brachial artery medially and down the brachioradialis laterally. Primary arterial repair or endctocend anastomosis was preferred whenever posc c sible; otherwise, the interposition saphenous vein graft was used ( Figure 2).
All associated brachial venous injuries except one were repaired, in an attempt to prevent postoperative venous hypertension and to minimize development of compartment syndrome. Associated nerve injuries were repaired whenever possible. Repaired vessels, especially at the anastomotic suture lines and graft location, were compulsorily covered with muscles and soft tissue to prevent desiccation and disruption. All patients rec c ceived intravenous prophylactic antibiotics, which were continued postoperatively for 3 to 5 days, unless proc c longed use was dictated by the presence of contaminac c tion or infection.
One month after hospital discharge, patients were routinely examined in the outpatient department where segmental pressures were measured and functional stac c tus of the upper extremity assessed. Thereafter, they were followed at 3cmonth periods.
Statistical analysis was performed using the paired samples t test to determine whether there was any stac c tistically significant difference between preoperative and postoperative Doppler pressure indices. A P value of less than .05 was taken to indicate significance.

RESULTS
This study group consisted of 43 males and 6 females, ranging in age from 6 to 65 years with a mean (SD) age of 27.9 (6.7) years. The right upper limb was the more frequently affected side as it was involved in 28 patients and the left side in 21 patients. The mechanism of trauma was penetrating in 45 patients and blunt in the remaining 4 patients (from road traffic accidents). Stab injury was the most frequent form of penetrating trauma (24 of 45). Other forms of penetrating trauma in a descending order of frequency were window glass injuries in 11 patients, gunshot injuries in 9 patients, and industrial accident in 1 patient. Thirtycfour patients presented with hemorrhage, 28 with ischemia, 8 with hematoma and 1 with a pseudoaneurysm (Table 1).
In 42 patients the diagnosis of arterial injury was based on clinical and handcheld Doppler examination. Preoperative duplex scan was used in only 7 patients. Physical examination and Doppler ultrasonography rec c vealed the absence of arterial pulses in 43 patients and weak arterial pulses in 6. For brachial artery injuries the average brachialcbrachial Doppler pressure index was 0.434 (0.046), (range, 0.23 to 0.48) preoperatively, and 0.894 (0.031) (range, 0.83 to 0.93) postoperatively (P<.05). Treatment included primary arterial repair in 5 cases, endctocend anastomosis in 28 cases, interposition vein graft in 15 cases and interposition ringed PTFE graft in 1 case. There were 14 patients with associated brachial vein injury, of which 4 cases had primary repair, 8 had endctocend anastomosis and 1 had saphenous vein graft interposition. One severely injured brachial vein was compulsory ligated. Five of the 49 patients had injuries to bony structures. Fractures occurred most frec c quently among patients with blunt trauma (3 patients); fracture was also detected in 2 patients with gunshot wound. All fractures were treated with external fixation.
Eight patients had tendinous injuries that were repaired perioperatively by orthopedic surgeons. Additionally, fasciotomy was performed in 6 patients.
Eleven of 49 patients had peripheral nerve injury: 2 had injuries to the median and ulnar nerves, 6 had injuries to the median nerve alone and 3 had injuries to the ulnar nerve alone. Eight of the 11 nerve injury cases were primarily repaired perioperatively by neuroc c surgeons. Postoperatively, all patients with nerve injury underwent electromyelography for evaluation of nerve deficit. During the followcup period, functional recovc c ery was achieved in 6 of these patients. In the remaining patients, functional disability was evident throughout followcup period. They were followed up neurosurgery and rehabilitation clinics.
Fifteen patients developed postoperative complicac c tions consisting of wound infection (2 patients), permac c nent nerve damage (4 patients), ischemic symptoms due to graft thrombosis (4 patients) and thrombosis of the venous repair (5 patients). Amputation was required in one patient who was involved in a traffic accident and suffered from a proximal brachial artery laceration with injuries to the brachial vein, and the median and ulnar nerves above the elbow in association with a fracture of the humerus. He was operated on 10 hours after inc c jury. Arterial flow was reestablished successfully with a saphenous vein bypass graft and the brachial vein was ligated, but subsequent abovecelbow amputation was required due the severity of concomitant nerve and bony injuries with a nonfunctional right upper limb and infection. Two patients with blunt trauma experienced wound infections, but these infections were resolved within 15 days by antibiotic therapy. Four patients exc c perienced early postoperative graft thrombosis. In these patients, thrombectomy was performed. It was successc c ful in three patients. Although thrombectomy was unc c successful in the remaining one patient with prosthetic graft interposition, amputation of the limb was not rec c quired due to adequate collateral circulation.
Postoperatively, all patients who had brachial vein injury experienced various degrees of edema in the upc c per extremity. This edema decreased with elevation in all patients during the followcup period (approximately 15 to 45 days). Postoperative venous Doppler studies showed thrombosed repair in five cases without any complication. No patients expired and 48 patients were discharged home with good functional vascular status and limitations based on the degree of associated nerve injury.
The average followcup period was 20 months (range 3c32 months); followcup visits were usually necessary for neurological examination.

DISCUSSION
Penetrating trauma is generally considered to be the most common cause of a vascular injury in the upper extremity. 5 In addition to the usual types of blunt and penetrating injuries, supracondylar fractures or dislocac c tion of the humerus may injure the brachial artery. 3 The role of angiography in patients with brachial arc c tery injury appears to be controversial. 9 Upper extremc c ity arterial injury often can be managed without arteric c ography, particularly in cases with penetrating trauma 6 as seen in this series. Bynoe et al 7 has reported 99% senc c sitivity and 98% accuracy of duplex ultrasonography. Furthermore, duplex ultrasonography has no intervenc c tional risks and is more costceffective for screening such injuries than angiography. Doppler ultrasonography was found to be more sensitive than angiography in an exc c perimental trial, thereby supporting its use in the trauma setting. 8 Doppler ultrasonography of the upper extremc c ity has been shown to be as specific and sensitive as artec c riography in detecting brachial artery injuries. 9 If uncerc c tainty remains regarding vascular injuries after physical examination and Doppler ultrasonography, angiography may be performed to confirm vascular injury. 9 The mainstay of diagnosis of brachial artery injury in our study was based on clinical assessment and handc held Doppler examination. Doppler ultrasonography was carried out in stable patients with associated soft signs of injury, to make a conclusive decision. We believe that angiography remains an effective method for diagc c nosing the vascular lesions, but it is also a timecconsumc c ing procedure, especially in traumatic vascular injuries requiring prompt surgery. Additionally, preoperative angiography did not offer any benefits in patients with obvious arterial injury. Angiography may be useful, esc c pecially in patients with multiple sites of potential vascuc c lar injury. 10 We have used angiography in patients with stable axillary artery injury associated with chest trauma causing subcutaneous emphysema, which prevented ulc c trasonographic examination. Additionally, angiography  must be used during endovascular surgery. Normally the average brachialcbrachial Doppler pressure index between the 2 upper extremities is apc c proximately 0.95; it is rarely less than 0.85. 11 In our sec c rious, preoperative values were significantly lower than normal, but postoperative values were similar to norc c mal. Duplex ultrasonography is fairly reliable, except with minor injuries, depending on the experience of the sonographers. 2 However, in addition to assessing the upper extremity for pulse pressures by physical examic c nation and continuouscwave Doppler, neuromuscular function, soft tissue involvement, and skeletal integrity should be evaluated. 1 The timing of vascular repair in relation to fracture management has long been a source of controversy. Because prevention of prolonged tissue ischemia is the objective, the standard recommendation is for vascular repair to precede fracture management. 12 In contrast, Hunt et al 13 suggested that arterial revascularization should be followed by skeletal stabilization and nerve and tendon repair. In the rare instance when external fixation is immediately required to stabilize the limb following massive musculoskeletal trauma, temporary selective use of shunts to restore circulation may be used to allow rapid fixator placement, with later vascular and orthopedic repair. 1 Unstable fractures jeopardize arterial repairs more in the upper extremities than in the lower extremities because of less adjacent muscle. 14 Therefore, we have routinely controlled the repaired vessels after bone fixation for patency.
Surgical repair of brachial artery injuries can be acc c complished by a variety of techniques, including lateral repair, resection with endctocend anastomosis, or interc c position grafting, usually with a saphenous vein. 3 Endc tocend anastomosis is preferable if it can be performed without tension or damage to major collateral vessels. Otherwise, the saphenous vein interposition graft is the next best choice, because it has better patency rates and better resistance to infection compared with synthetic grafts. 15 However, we had to use a ringed polytetrac c fluoroethylene (PTFE) graft in one patient with inadc c equate saphenous vein. Endovascular techniques have increasingly been used in the management of penetratc c ing injuries and may have some advantages even in blunt trauma. 16 They are especially ideal for managing blunt axillary artery injuries that are anatomically difficult to repair. 1 It is important to limit the period of ischemia, and so minimize the degree of ischemiacreperfusion injury and the systemic consequences after the arterial repair. The extent of ischemiacreperfusion injury is directly proportional to the severity and duration of striated muscle ischemia. Beyond a golden period of 6 to 8 hours of ischemia, ischemiacreperfusion injury will endanger the viability of the limb and sometimes even the patient' s life. 2 In this series, while 9 patients experienced a durac c tion of ischemia longer than this period, there was only one amputation. The infrequent need for amputation was probably related to the rich collateral circulation in the upper limb of most patients. 2,17 Therefore, we sugc c gest that all patients without obvious necrotic changes should be operated on irrespective of time interval bec c tween the beginning of trauma and arrival to the operatc c ing room, as was done in this series.
Neurological injury continues to destroy the funcc c tion of the upper extremity even after a successful artec c rial repair. 9 The rate of functional disability ranges from 27% to 44% when injury to the upper extremity includes nerve injuries. 18 Nichols and Lillehei 19 recommend pric c mary nerve repair for penetrating trauma (lacerations and stab wounds), while with gunshot wounds, because of the degree of contusion, acute nerve repair is rarely inc c dicated. 20 Additionally, major venous injuries, fractures and widespread tissue destruction may also influence the long term function of the extremity. 21 Venous injuries generally remain unrecognized until surgical exposure. The indication for venous repair in the upper limb is not clear. Injuries of the brachial or arm veins can be treated by ligation, as edema is rare. However, in the case of a severe softctissue injury where maximal venous return is necessary, venous repair is probably warranted. 5 We would add that brachial vec c nous continuity, when possible, is maintained.
In conclusion, the elbow, like the shoulder, is known to have extensive collateral circulation that may mask the signs of acute arterial injury, 22 but whether this circ c culation is adequate is debatable. 23 Therefore, all brac c chial artery injuries should be repaired. Careful clinical examination, Doppler ultrasonography and pressure measurements are as important as angiography in the diagnosis of vascular injuries. 9 Also, the superficial loc c cation of brachial artery makes the diagnosis relatively simple. Therefore, brachial artery injuries may be dic c agnosed without angiography. We believe that angiogc c raphy should be performed when the vascular injuries would be impossible to diagnose with other diagnostic modalities or when endovascular procedures are rec c quired. Prompt and appropriate management of the brachial artery injuries, attention to associated injuries and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage.