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Acute arterial injuries of the upper extremity
Acute Arterial
Injuries of the Upper Extremity*
LOUIS L. SMITH, M.D., ROBERT FORAN,
M.D. AND
From tbe Department of Surgey, School of Medicine, Loma Linda University and tbe Los Angeles County Hospital, Los Angeles, California.
This study constitutes a report of fifty-four acute arteria1 injuries involving the upper extremity, which occurred during a tweIve year period beginning in rggo. The object of this paper is to cIarify indications for surgical expIoration, provide information regarding the best methods for surgical management and to determine find1 resuIts of therapy.
ESPITE the fact that the first arteria1 injury was successfuIIy repaired by Mr. HaIIoweII at NewcastIe on Tyne, EngIand in 1759 [I] and considering that precise technics for the anastomosis of bIood vesseIs were perfected fifty-six years ago by CarreI [2] and Guthrie [3], present day management of acute arteria1 injuries has evoIved sIowIy. During the past two decades, conservatism in the management of this type of injury has given way to an aggressive approach stressing earIy diagnosis and immediate surgical repair. This change in management was initiated during WorId War II and was put to test during the Korean War. Previous reports of acute arteria1 trauma have incIuded both upper and Iower extremity injuries. Difference in circuIation and functionaI demand suggests that arteria1 injuries of the upper extremity should be considered separateIy from those occurring in the Iegs.
D
TABLE LOCATION
OF
FImY-FOUR OF
THE
UPPER
Fiftylfour acute arteria1 injuries to the upper extremity constitute the basis for this study. Forty-eight were in patients treated on the Loma Linda University VascuIar SurgicaI Service at the Los Angeles County HospitaI, and six were in private patients of ours. TabIe I shows the Iocation of these acute arteria1 injuriks. The vesse1 most frequentIy TABLE CAUSE
ARTERIAL
I
: 30 6 6
.
3
* Presented at the AnnuaI Meeting of the Pacific Coast Surgical Association, 1963. American Journal
of Surgery,
Volume
106, August
1963
THE
II
ACUTE UPPER
Laceration................................. Gunshot.. Fracture.................................. DisIocation shouIder.. . . . . (avulsion axiIIary artery) “Crutch thrombosis”. . . . (axillary artery) Crush injury forearm.. . Retrograde aortogram.. (brachial artery) Cardiac catheterization.. . (brachial artery) Cut-down injury.. . (radial artery)
No.
... .... .
FIFTY-FOUR
ARTERIAL
INJURIES
EXTREMITY
No.
Cause
INJURIES
.
OF
OF
EXTREMITY
Location
Innominate................................ SubcIavian................................ AxiIIary................................... BrachiaI................................... Radial.. . UInar..................................... Combined radia1 and uInar..
CLINICAL MATERIAL
I
ACUTE
MAX R. GASPAR, M.D., Los Angeles, California
I44
36
.
.
.
.
7 3
.
.
I
.
I
...
I I
... .
.
.. .
I I
PaIm Springs, California, February 3-6,
ArteriaI TABLE ASSOCIATED ARTERIAL
INJURIES
Injuries
III IN
INJURIES
FIFTY-FOUR OF
THE
ACUTE
UPPER
EXTREMITY
Data
Adjacent structures Nerves.................................. Tendons................................. Bone or joint.. Vein.......................,............ Arteriovenous fistula (acute). Gunshot wound of chest.. . SpinaI cord transection.. ... Gunshot wound of head.. .
No.
~8
i 5
4 I I I
injured was the brachia1 artery; there were thirty such injuries. The average age for the entire group of patients was thirty years; the oIdest was sixty-three and the youngest one year. There were thirty-six maIe and eighteen femaIe patients. The cause of these vascular injuries is shown in TabIe II. Sixteen of the thirty-six Iacerations were caused by either broken gIass windows or bottIes! Associated injuries were frequentIy encountered and are Iisted on TabIe III. It wiI1 be noted that twenty-eight patients had injury to adjacent nerves, making this the most frequent associated injury. Seven patients had injury to adjacent tendons and in four acute arteriovenous fistuIae deveIoped.
Frc. I. Emergency chest roentgenogram of a patient with an innominate artery stab wound. Note the widening of the right superior media&mm due to hematoma formation.
presence of a huge hematoma of the neck and shouIders and a mediastina1 hematoma on chest roentgenogram were heIpfu1 in the diagnosis of a subcIavian and innominate arteria1 injury respectiveIy. (Fig. I.) One patient with a crutch thrombosis of the axiIIary artery compIained of forearm and hand cIaudication with exercise. Arteriography was not routineIy used to estabIish the diagnosis of arteriai injury in this study aIthough its vaIue is we11 estabIished.
DIAGNOSIS
CIassic signs of ischemia of the hand and forearm, such as paIIor, cooIness and sIow capiIIary fiIIing, were heIpfu1 in establishing a diagnosis of arterial injury. Absence of the periphera1 puIse was not aIways a &able diagnostic sign. Ten patients in this series presented at the hospita1 with a paIpabIe peripheral puIse despite the presence of proxima1 arteria1 injury. AImost without exception these were side-waI1 Iacerations of the vesse1 which aIIowed dista1 circulation. Two patients, having had transected radia1 arteries, had periphera1 radia1 puIses apparentIy due to exceIIent coIIatera1 circuIation. BIeeding of massive proportions was frequentIy observed and shock was present in twenty-four patients. The finding of a to and fro bruit over the site of injury established the diagnosis of an acute arteriovenous fistuIa in four patients. The
SURGICAL
MANAGEMENT
TabIe IV shows the operative procedure used, if any, in the management of these acute arteria1 injuries to the upper extremity. It wiI1 be noted that resection of the damaged segment of vessel foIIowed by end to end anastomosis was the operative procedure most frequentIy used. TweIve patients had Iigation of the injured vesse1, a procedure used with greater frequency during the earIy period of this study. Two patients were not subjected to operation. One was of interest: a twentythree year oId man presented with an absent radia1 puIse thought to be due to thrombosis of the dista1 brachia1 artery caused by an associated fracture of the humerus. No surgica1 procedure was performed; however, four months Iater he had a radia1 puIse. I45
Smith, TABLE OPERATIVE
PROCEDURES ARTERIAL
FIFTY-FOUR OF
No.
..
REPAIRS
FOR
ACUTE UPPER
IN
31 12
4 2 1 I
.
TABLE FAILURE
A periphera1 puIse was restored in twentyeight of thirty-eight patients having surgica1 repair of their injured artery. The apparent cause of faiIure to estabIish circulation in the ten patients in whom a periphera1 puIse ws not established is Iisted in TabIe v. Three patients who had repair of smai1 vesseIs in the forearm did not have a postoperative puIse recorded on the hospita1 record; and even though they had viabIe hands, they were Iisted as having had thrombosis at the site of injury. In one patient with a contaminated compound fractujre of the humerus and an associated brachia1 artery injury, a wound infection deveIoped at the site of a successfu1 arteriaI anastomosis resuIting in disruption of the suture line and secondary hemorrhage one week Iater. The brachia1 artery was Iigated, and the arm was amputated to contro1 exsanguinating hemorrhage. Twenty-one patients with viabIe extremities had Iimitation of function due to some degree of paraIysis or sensory deficit in the hand as a result of associated nerve damage at the time of origina trauma. A paIpabIe puIse was restored in fifteen of these patients. Thus, nerve deficit and not arteria1 insuffIciency became the limiting factor in rehabiIitation in this Iarge group. In three patients Aexion contractures deveIoped foIIowing associated tendon repairs which limited hand function despite successfu1 arterial reconstruction. It is of interest that in none of the tweIve patients having had Iigation of the injured artery developed postoperative arteria1 ins&iciency Iimiting norma function. AI1 were apparentIy abIe to perform their usua1 job without significant hand or arm cIaudication. IncIuded in this group were one axiIIary and three brachia1 artery injuries. Two deaths occurred in this series and are unusual. One was in a thirty-one year oId woman who sustained muItipIe gunshot wounds of head, right shouIder and chest and Ieft arm. The right axillary artery was expIored because of massive hemorrhage and the presence of an acute arteriovenous f%tuIa. A partiaIIy transected axiIIary vein was ligated together with severa branches of the axiIIary artery which were bIeeding. A Iaceration of the right puImonary vein was repaired through a thoracotomy incision at surgery. The patient bIed
EXTREMITY
End to end anastomosis. Ligation................................... LateraI suture repair.. Veingraft................................. Thrombectomy............................. Fasciotomy................................ Amputation. . ..
OF
Gaspar RESULTS
ACUTE
THE
Procedure
CAUSE
and
IV IN
INJURIES
UPPER
Foran
..
.
I
v
THIRTY-EIGHT
ARTERIAL
SURGICAL
INJURY
OF
THE
EXTREMITY
No.
Cause
Thrombosis at site of injury.. . . Postoperative death. . Arterial spasm.. Thrombosed “run off”. Infection, hemorrhage, amputation.
5 2 I
.
.
I I
A primary supracondylar amputation was performed in a nineteen year oId woman with a severeIy cornminuted compound fracture of the distaI humerus. The brachia1 artery was avulsed at the time of injury. Amputation was required due to extensive bony and soft tissue destruction. A dorsa1 and volar forearm fasciotomy was performed in a twenty-seven year oId man who had sustained an associated crush injury to the forearm during an attempted suicide by the ingestion of pheno1. CircuIation was restored to the forearm, and he survived a temporary episode of renaI faiIure as weI1. An axillary thrombectomy was performed on a fifty-six year oId man in whom thrombosis deveIoped due to trauma of a poorIy fitting homemade crutch which he used because of a previous thigh amputation. Operation discIosed thrombosis of the axiIIary as we11 as the brachia1 arteries. He was treated by thromhectomy with retrograde flushing of the artery without restoration of a periphera1 p&e. He continued to have exercise cIaudication in the arm foIIowing operation. 146
ArteriaI
Injuries
massiveIy in the postoperative period from the axihary wound and reoperation was necessary. A Iaceration of the subclavian artery was found and repaired. She continued to bIeed into the right side of the chest which required re-exploration of the chest. A cardiac arrest developed during induction of anesthesia from which she was resuscitated. She died, however, the fohowing day of cerebral anoxia and pulmonary edema. The second death occurred in a twenty-one year old man with a stab wound of the Ieft axihary artery. He was treated for severe shock in the emergency room of another hospital. The massive nature of the hemorrhage is attested by the fact that 2 units of AIbumisol,@ 2 units of pIasma and 12 units of blood were required to stabilize his bIood pressure prior to transfer to the County Hospital An emergency tracheotomy was performed during this period of emergency resuscitation because of acute respiratory obstruction. The patient presented in acute respiratory distress on admission to the Los AngeIes County Hospital due to the presence of bilateral pneumothorax. Both pleura1 spaces apparently had been entered during the emergency tracheostomy. IntercostaI tubes were inserted into folIowing improvement both pIeural cavities; in his condition, he was operated upon. A transected axillary artery and Iacerated axihary vein were found and repaired. PostoperativeIy, a severe biIatera1 confluent pneumonia developed, as we11 as acute renal faiIure, resulting in death on the fifth postoperative day.
buckshot or smaI1 sharp objects have penetrated into the vicinity of a major artery, emergency arteriography can be heIpfu1 in estabhshing arteria1 injury [7,8]. The percutaneous injection of radiopaque dye into the subcIavian artery can be done with comparative ease and has been described in detaiI elsewhere [9]. SurgicaI exploration may be required in rare situations when the arteriogram appears equivoca1 or when there is a possibility of associated venous injury. It has been the policy on our vascuIar service to perform emergency repair of a11 major vessels which have been injured. Surgical exposure for the repair of these injured vessels usuaIIy has not been a probIem. It is important that wide incisions be made or that the site of injury be adequateIy extended to insure easy apphcation of proxima1 and dista1 occlusive clamps on the injured vessel Care must also be taken to make certain that al1 of the damaged vessel has been resected, and that any concomitant injury to the vein has been exposed for subsequent repair. Exposure of the innominate, subclavian and axiIIary arteries presents the greatest di&uIty. For exposure of the innominate and subcIavian vesseIs we have preferred the sternal spritting incision including resection of the proxima1 portion of the cIavicIe subperiosteahy as recommended by Shumacker [IO,II] and Cook and HaIIer [12’]. In the case of the axihary artery, an S-shaped incision is made centered over the axiIIa. (Fig. 2.) The tendon of the pectoraIis major muscIe may be transected for exposure of the proxima1 vessel. We have been surprised in reviewing these arteria1 injuries to the upper extremity to Iearn how we11 patients have fared following ligation. No patient who had Iigation of an injured artery to the arm has compIained of postoperative cIaudication preventing performance of his usua1 work. This does not mean, however, that primary repair is not desirabIe. During WorId War II, when acute arteriaI injuries were managed by Iigation, the incidence of gangrene of the lower extremity was twice that of the upper extremity [13]. Ziperman [14], during the Korean War, reported gangrene of the arm requiring amputation in Iess than IO per cent of patients having had brachial artery ligation whereas 50 per cent of patients having had ligation of the femora1
COMMENTS
The most important factor in acute arteria1 injuries to the upper extremity is prompt recognition. The classic signs of peripheral ischemia, such as pallor, coIdness and slow capihary fiIIing, must be carefuhy checked. The presence of a periphera1 p&e cannot be rehed upon to exclude injury since ten of fifty-four patients with acute arterial injury to the upper extremity, in this study, had a paIpabIe periphera1 pulse. This situation wilI occur most often with smaI1 side-waI1 lacerations or incomplete injury to the vessel and has been stressed by other authors [4-61. The presence of pulsating bleeding or an expanding or pulsating hematoma indicates arteria1 injury. In questionable cases in which injury has occurred over the neurovascular bundIe, or in which I47
Smith,
Foran
and Gaspar
FIG. 2. A, incision for exposure of innominate or subclavian incision for exposure of axiIIary artery. See text for details.
arteries. B, S-shaped
FIG. 3. A and B, technic for smaI1 artery anastomosis. GentIe diIatation of the cut end of the vesse1 using a mosquito forceps foIIowed by pIacing trianguIation sutures of fine siIk. C, reIief of arteriospasm by gentIe saline injection between occIuding vascuIar cIamps.
artery gangrene deveIoped requiring amputation of the leg. CoIIateraI circuIation to the arm is apparentIy much better than that to the Ieg. Since the technic of vascuIar suture is now we11 estabIished and in view of the wide availability of vascuIar instruments, we recommend the repair of the smaI1 arteries of the forearm
unIess the time required for this procedure wouId jeopardize the patient’s surviva1. DiIatation of the vesse1 by a curved mosquito forceps as Zustrated in Figure 3, and the appIication of trianguIation sutures of fine arteria1 silk as described by CarreI [2] aids in the ease of smaI1 vesse1 anastomosis. Arteriospasm can be troubIesome. Spasm 148
ArteriaI Injuries is apparentIy due to IocaI irritative mechanisms rather than reflex autonomic nervous stimuIation since experimenta evidence suggests that large arteries do not have vasoconstrictor innervation [15]. The appIication of topica 2.5 per cent papavarine solution as recommended by Kinmonth [16] or the injection of saIine soIution into an isolated spastic arteria1 segment as advised by Mustard and BuII [17] may be heIpfu1 in reestabIishing norma circuIation. (Fig. 3.) PeripheraI circulation was re-estabIished in 74 per cent of patients having had arteria1 favorabIy with repair. This figure compares the resuIts reported by other surgeons [I&201. The serious nature of vascular injuries is apparent by the frequency of shock on hospita1 entry. The reported incidence of shock with acute arteria1 injury is nearIy 50 per cent [r&21]. In twenty-four of the fifty-four patients in this study, hemorrhagic shock deveIoped. The mortaIity in patients with acute arteria1 injury is Iikewise high and ranges up to 15.5 per cent as reported by Ferguson, Byrd and McAfee [IS]. The two deaths in our series occurred in patients who experienced massive blood Ioss and who subsequentIy succumbed from serious pulmonary compIications. When a fracture is associated with a vascuIar injury, it is advisabIe to immobiIize the fracture by surgica1 means prior to repair of the injured vesse1. Mobility at the site of fracture or manipuIation during reduction may contribute to disruption of the ateria1 anastomosis. It is advisabIe to resect at Ieast I cm. of norma appearing vesse1 on either side of a gunshot injury. AIthough gross inspection reveals normaI-appearing arteria1 waI1, microscopic bIast injury to the intima may predispose to subsequent thrombosis at the site of injury [22-241. We prefer autogenous reversed vein grafts for the restoration of continuity in those patients with a vascuIar defect preventing end to end anastomosis. Experience to date indicates that this is the best method of restoring circuIation [5,22-261. Vein patch grafts may occasionaIIy be heIpfu1 in side waI1 injuries.
This therapeutic concept is most urgent in injuries invoIving the Iarger proxima1 vesseIs where hemorrhage frequently threatens survivaI. We11 estabIished incisions and current vascuIar surgica1 technics precIude equivocation in the management of injuries in this Iocation. Damage to periphera1 arteries of the arm and forearm shouId aIso be repaired immediateIy in order to restore optima1 circuIation unIess such emergency repair jeopardizes surviva1 of the patient. Ligation can be performed in injuries in this Iocation with minima1 risk of amputation. Arteriography is heIpfu1 in establishing the diagnosis of arteria1 injury in equivoca1 cases and wiI1 reduce the number of negative expIorations. CarefuI attention must be paid to the tota probIem of trauma in patients with acute arteria1 injury of the upper extremity since associated damage to nerves and tendons is the determining factor in restoration of function and rehabiIitation of the patient. REFERENCES
I. LAMBERT, W. S. Extract from a Letter from Lambert, W. S., Surgeon at NewcastIe upon Tyne, to Dr. Hunter. Medical Observations and Inquiries by a Society of Physicians in London, 2: 360, 1762. 2. CARREL, A. The surgery of bIood vesseIs. Bull. Jobns Honkins HOSD.. 18: 18. 1007. 3. HARBISON, S. P. The’ origins of GascuIar surgery: the Carrel-Guthrie letters. Surgery, 52: 406,1962. 4. SPENCER,A. D. The rehability of signs of periphera1 vascuIar injury. Surg. Gynec. ti Obst., 114: 490, 1962. 5. WHITAKER, W. G., JR., DURDEN, W. F. and FERGUSON, I. A. Acute arteria1 trauma. Surg. Gynec. & Obst., 99: 129, 1954. 6. CREECH, O., JR. Acute arteria1 injuries. Postgrad. Med.,.29: 581, 1961. 7. LUMPKIN, M. B., LOGAN, W. D., ~OUVES, C. M. and HOWARD. J. M. Arterionranhv as an aid in the diagnosis’ and IocaIizati& bf “acute arterial injuries. Ann. .%rg., 147: 353, 1958. 8. SINKLER, W. H. and SPENCER, A. D. The vaIue of peripheral arteriography in assessing acute vascuIar injuries. Arch. Surg., 80: 300, 1960. 9. GAFFNEY, C. J., HERSHEY, F. B. and ALLEN, W. E. Arteriography of the upper extremity. Surg. Gynec. @ Obst., 106: 63, 1958. IO. SHUMACKER,H. B., JR. Resection of the cIavicIewith particuIar reference to the use of bone chips in the periostea1 bed. Surg. Gynec. d Obst., 84: 245. 1947. I I. SHUMACKER,H. B., JR. Operative exposure of bIood vesseIs in superior anterior mediastinum. Ann. Surg., 127: 464, 1948. 12. COOK, F. W. and HALLER, A., JR. Penetrating injuries of the subcIavian vessels with associated
SUMMARY
Prompt recognition repair is recommended acute arteria1 injuries
and immediate surgica1 in the management of to the upper extremity.
‘49
Smith, Ven0U.s
COInphitiOnS.
Ann.
SUrg.,
155:
Foran and Gaspar 370,
1962. 13. DEBAKEY, M. E. and SIMEONE, F. A. Battle iniuries of the arteries in WorId War II: analvsis ” of2471 cases. Ann. Surg., 123: 534, 1946. 14. ZIPERMAN, H. H. Acute arterial injuries in the Korean War. Ann. Surg., 139: I, 1954. 15. KINMONTH, J. B., SIMEONE,F. A. and PERLOW,V. Factors affecting the diameter of Iarge arteries with particular reference to traumatic spasm. Surgery, 26: 452, 1949. 16. KINMONTH,J. B. Physiology and rehef of traumatic arteriaI spasm. hit. M. J., I: 59, 1952. 17. MUSTARD, W. T. and BULL, C. A reIiabIe method for reIief of traumatic vascuIar spasm. Ann. Surg., 155: 339, 1962. 18. FERGUSON, I. A., SR., BYRD, W. M. and MCAFEE, D. K. Experiences in the management of arteria1 injuries. Ann. Surg., 153: 980, yg6r. 19. MORRIS, G. C., JR., BEALL, A. C., JR., ROOF, W. R. and DEBAKEY, M. E. SurgicaI experience with 220 acute arteria1 injuries in civiIian practice. Am. J. Surg., gg: 775, 1960. 20. SINKLER, W. H. and SPENCER, A. D. The importance of earIy expIoration of vascular injuries. Surg. Gynec. CYOk., 107: 228, 1958. 21. HUGHES, C. W. The primary repair of wounds of major arteries: an anaIysis of experience in Korea in 1953. Ann. Surg., 141: 297, 1955. 22. HERSHEY, F. B. and SPENCER,A. D. SurgicaI repair of civilian arterial injuries. Arch. Surg., 80: 953, 1960. 23. JAHNKE, E. J. and SEELEY, S. F. Acute vascuIar injuries in the Korean War: an anaIvsis of 7;consecutive cases. Ann. Surg., 138: 158, x953. 24. SPENCER, F. C. and TOMPKINS, R. K. Management of acute arteria1 injuries. Postgrad. Med.,
25.
28: 476. 1960.
F. N., HUGHES, C. W., JAHNKE, E. J. and SEELEY, S. F. HomoIogous arterial grafts and autogenous vein grafts used to bridge Iarge arteria1 defects in man. Surgery, 33: 183. 1953. 26. HUGHES, C. W. ArteriaI repair during the Korean War. Ann. Surg., 147: 555, 1958. COOKE,
DISCUSSION
J. HOWARD PAYNE (Los Angeles, Calif.): I wish to congratuIate Doctors Smith, Gaspar and Foran on an extremely we11 prepared manuscript and Doctor Smith on the excehence of the presentation. I enjoyed reading the manuscript which is fiIIed with important data. I agree with them that the arteria1 circuIation in an arm is a great deaI different than that in the Ieg. The important difference is the extremeIy Iine coIIatera1 circuIation found in the shouIder and around the eIbow. The routes of coIIatera1 circuIation in the shouIder area are as foIIows: (I) transverse scapuIar to the thoraco-acromia1 to the circumffex humora to the deep brachial artery; (2) transverse scapuIar to the thoraco-acromia1 to the IateraI thoracic to the ascending branch of the profunda brachii to the
(3) interna mammary to the interCosta1 to the circumflex scapular through the ascending branch of the profunda brachia1 to the deep brachia1; and (4) descending branch of the transverse cervica1 through the circumflex scapuIar through the ascending branch of the profunda brachii to the profunda brachii. The pathways for the coIIatera1 circuIation around the eIbow are probabIy as foIIows: (I) profunda brachii through the radia1 recurrent to the radia1; (2) profunda brachii through the radia1 coIIatera1 branch of the profunda to the interosseous recurrent; (3) superior ulnar coIIatera1 to the posterior uInar recurrent to the uInar; and (4) inferior uInar coIIatera1 to the anterior uInar recurrent and anastomotic branches to the uInar. The coIIatera1 circuIation to the hand and fingers is poor if both radia1 and uInar artery are occIuded studies indicate or divided. PIethysmographic that the uInar artery is the major artery to the hand and fingers. In my personal experience, the axiIIary artery was the most frequent artery invoIved. As the authors indicated, and I agree, adequate exposure with proxima1 and dista1 contro1 of the injured artery is important. The sternal spIitting incision with resection of a portion of the cIavica1 provides adequate exposure of the innominate and subclavian arteries. Primary end to end anastomosis is the procedure of choice if at a11 possibIe after excising the gross and microscopic damage to the invoIved artery. Autogenous vein grafts are usefu1 in cIosing arterotomy incisions. This is especiaIIy true if the brachia1 artery has been badIy damaged during cardiac catheterization. With the increasing number of diagnostic procedures using the brachial artery, we wiI1 probabIy see more permanentIy damaged arteries. FortunateIy the arm has good coIIatera1 circuIation and rareIy wiI1 any part be Iost. The hand may be seriousIy jeopardized if the radia1 or uInar artery is used and damaged. There does not seem to be any situation which wouId caI1 for a bypass procedure. In repair of the smaI1 arteries of the upper extremity, interrupted sutures are indicated. AIso, it is here that the use of the operating microscope wouId be useful. FREDERIC SHIDLER (Men10 Park, Calif.): I enjoyed the paper very much, but there were a coupIe of questions I shouId Iike to ask the authors. These concern the Iate effects foIIowing suture of upper extremity arteries. I wouId be interested in knowing if you have observed any dilatation of the artery distal to the Iine of suture and whether or not a IongitudinaI repair of an artery is IikeIy to have more constriction than a transverse repair. FinaIIy, I wonder if anyone in the Association has observed an aneurysm appearing at the site of deep brachia1;
150
ArteriaI Injuries repair or distal to repair of one of the upper extremity arteries. JOHN F. HIGGINSON (Santa Barbara, CaIif.): Sometimes, one can be a little fortunate in handhng a situation that is presented, such as the man who attempted suicide. He was not entireIy accurate in his aim with the shotgun, and missed kiIling himseif. A pneumothorax developed, fortunately without tearing his Iung; most of the waI1 was torn from the Ieft part of the chest. The peIIet went through it and Ieft a broad band of axiIlary skin. Then the buIIet tore most of the tissues from the arm, and fractured the humerus. Because the humerus was fractured it was possible to take care of the torn artery which was injured in two pIaces. In one pIace, it was torn apart, with thrombosis distaIIy and proximaIIy; and in the second, two shotgun pellets were Iying in the lumen; thus, debridement was inevitabIe. These injuries required remova of sections of the vesse1 before we had a vesse1 to repair. This made the vesse1 too short, and brought up the possibiIity of using a prosthesis. In a smaI1 vesse1, known hazards are present. Since the humerus was fractured we first had the orthopedist who was on caI1, Waiter Graham, examine the patient, and remove severa inches more of the humerus and put a pin in it. This procedure produced a satisfactoriIy shortened arm, and permitted an end to end arteria1 anastomosis. Since the arm needs neither length nor stability, but mobibty, a satisfactory resuIt was obtained. He stiI1 has a pulse in the arm ten months later. After we had done a11 the repairs on the man, when he awakened, we Iearned that he had had, a year or two previously, a Ieft hemipIegia and he did not have much use of the Ieft upper extremity anyhow. MAX. R. GASPAR (Long Beach, CaIif.): I wouId Iike to mention something Dr. Smith did not have time to mention; namely, that you must watch out for Iarge hematomas; there is a tendency not to watch them. We say watch out for them, because they are IiabIe to be Iaden with “dynamite.” Most of these patients must have expIoratory surgery because of arterial wounds or more IikeIy venous injuries which we have not stressed at this time. As you noted, there were four arteriovenous fistu1a.s in the upper extremity wounds. This is a fairIy common compIication, wounding a Iarge vesse1 which is closely associated with a large vein.
It may not be necessary to resect the cIavicIe in a11 instances of innominate or subcIavian artery wounds, but certainIy a sterna1 spIitting incision and careful dissection is necessary for good exposure in this area. To answer some of the questions: We had onIy one patient who had a pIastic prosthetic graft. The brachia1 artery was damaged during catheterization and an aneurysm deveIoped. A Szilagyi type woven Dacron@ graft was used to bridge the defect after the aneurysm was resected. Eventually, the graft diIated and a false aneurysm developed at one of the anastomotic Iines. We resected the graft and put in a reversed vein graft which we would have preferred to use in the first pIace if we had operated upon the patient. PIastic grafts are not apt to work in traumatic injuries because the fieId is usuaIIy contaminated and one certainIy does not want to use this type of graft in an infected area. Dr. ShidIer, I do not recaI1 seeing diIatation or aneurysm formation dista1 to an area of repair or anastomosis. It wouId impIy, of course, stenosis and poststenotic diIatation. I wiI1 not say our patients do not have stenosis and poststenotic diIatation, but I do not recaI1 seeing it. Insofar as IongitudinaI repair is concerned, I do not beIieve one wouId want to do a IongitudinaI repair if there were danger of constricting the vesse1. CertainIy, the use of a vein patch graft is the idea1 technic here and wiI1 prevent stenosis. In Dr. Higginson’s interesting case, I beIieve we would have asked Dr. Graham to repair the fracture before we tried to repair the artery. Not a11 orthopedists are as gentIe as Dr. Graham, and they wiI1 sometimes tear apart a good anastomosis; thus, we prefer to have the fracture fixed first, and then repair the artery. As Dr. Smith mentioned, when we started studying these cases we had hoped we couId make a fairIy strong case for repair of a11 arteria1 wounds of the upper extremities. We stiI1 think it is a good pIan to restore norma anatomy, and we are happy to see residents have the opportunity to work with blood vesseIs, because they are often treating the traumatized emergency patient. However, we were surprised to Iearn how we11 patients have done when upper extremity arteries have been Iigated. Therefore, extraordinary efforts to repair traumatized arteries shouId not be made if the patient’s Iife wiI1 be endangered.
Injuries of the Upper Extremity*
LOUIS L. SMITH, M.D., ROBERT FORAN,
M.D. AND
From tbe Department of Surgey, School of Medicine, Loma Linda University and tbe Los Angeles County Hospital, Los Angeles, California.
This study constitutes a report of fifty-four acute arteria1 injuries involving the upper extremity, which occurred during a tweIve year period beginning in rggo. The object of this paper is to cIarify indications for surgical expIoration, provide information regarding the best methods for surgical management and to determine find1 resuIts of therapy.
ESPITE the fact that the first arteria1 injury was successfuIIy repaired by Mr. HaIIoweII at NewcastIe on Tyne, EngIand in 1759 [I] and considering that precise technics for the anastomosis of bIood vesseIs were perfected fifty-six years ago by CarreI [2] and Guthrie [3], present day management of acute arteria1 injuries has evoIved sIowIy. During the past two decades, conservatism in the management of this type of injury has given way to an aggressive approach stressing earIy diagnosis and immediate surgical repair. This change in management was initiated during WorId War II and was put to test during the Korean War. Previous reports of acute arteria1 trauma have incIuded both upper and Iower extremity injuries. Difference in circuIation and functionaI demand suggests that arteria1 injuries of the upper extremity should be considered separateIy from those occurring in the Iegs.
D
TABLE LOCATION
OF
FImY-FOUR OF
THE
UPPER
Fiftylfour acute arteria1 injuries to the upper extremity constitute the basis for this study. Forty-eight were in patients treated on the Loma Linda University VascuIar SurgicaI Service at the Los Angeles County HospitaI, and six were in private patients of ours. TabIe I shows the Iocation of these acute arteria1 injuriks. The vesse1 most frequentIy TABLE CAUSE
ARTERIAL
I
: 30 6 6
.
3
* Presented at the AnnuaI Meeting of the Pacific Coast Surgical Association, 1963. American Journal
of Surgery,
Volume
106, August
1963
THE
II
ACUTE UPPER
Laceration................................. Gunshot.. Fracture.................................. DisIocation shouIder.. . . . . (avulsion axiIIary artery) “Crutch thrombosis”. . . . (axillary artery) Crush injury forearm.. . Retrograde aortogram.. (brachial artery) Cardiac catheterization.. . (brachial artery) Cut-down injury.. . (radial artery)
No.
... .... .
FIFTY-FOUR
ARTERIAL
INJURIES
EXTREMITY
No.
Cause
INJURIES
.
OF
OF
EXTREMITY
Location
Innominate................................ SubcIavian................................ AxiIIary................................... BrachiaI................................... Radial.. . UInar..................................... Combined radia1 and uInar..
CLINICAL MATERIAL
I
ACUTE
MAX R. GASPAR, M.D., Los Angeles, California
I44
36
.
.
.
.
7 3
.
.
I
.
I
...
I I
... .
.
.. .
I I
PaIm Springs, California, February 3-6,
ArteriaI TABLE ASSOCIATED ARTERIAL
INJURIES
Injuries
III IN
INJURIES
FIFTY-FOUR OF
THE
ACUTE
UPPER
EXTREMITY
Data
Adjacent structures Nerves.................................. Tendons................................. Bone or joint.. Vein.......................,............ Arteriovenous fistula (acute). Gunshot wound of chest.. . SpinaI cord transection.. ... Gunshot wound of head.. .
No.
~8
i 5
4 I I I
injured was the brachia1 artery; there were thirty such injuries. The average age for the entire group of patients was thirty years; the oIdest was sixty-three and the youngest one year. There were thirty-six maIe and eighteen femaIe patients. The cause of these vascular injuries is shown in TabIe II. Sixteen of the thirty-six Iacerations were caused by either broken gIass windows or bottIes! Associated injuries were frequentIy encountered and are Iisted on TabIe III. It wiI1 be noted that twenty-eight patients had injury to adjacent nerves, making this the most frequent associated injury. Seven patients had injury to adjacent tendons and in four acute arteriovenous fistuIae deveIoped.
Frc. I. Emergency chest roentgenogram of a patient with an innominate artery stab wound. Note the widening of the right superior media&mm due to hematoma formation.
presence of a huge hematoma of the neck and shouIders and a mediastina1 hematoma on chest roentgenogram were heIpfu1 in the diagnosis of a subcIavian and innominate arteria1 injury respectiveIy. (Fig. I.) One patient with a crutch thrombosis of the axiIIary artery compIained of forearm and hand cIaudication with exercise. Arteriography was not routineIy used to estabIish the diagnosis of arteriai injury in this study aIthough its vaIue is we11 estabIished.
DIAGNOSIS
CIassic signs of ischemia of the hand and forearm, such as paIIor, cooIness and sIow capiIIary fiIIing, were heIpfu1 in establishing a diagnosis of arterial injury. Absence of the periphera1 puIse was not aIways a &able diagnostic sign. Ten patients in this series presented at the hospita1 with a paIpabIe peripheral puIse despite the presence of proxima1 arteria1 injury. AImost without exception these were side-waI1 Iacerations of the vesse1 which aIIowed dista1 circulation. Two patients, having had transected radia1 arteries, had periphera1 radia1 puIses apparentIy due to exceIIent coIIatera1 circuIation. BIeeding of massive proportions was frequentIy observed and shock was present in twenty-four patients. The finding of a to and fro bruit over the site of injury established the diagnosis of an acute arteriovenous fistuIa in four patients. The
SURGICAL
MANAGEMENT
TabIe IV shows the operative procedure used, if any, in the management of these acute arteria1 injuries to the upper extremity. It wiI1 be noted that resection of the damaged segment of vessel foIIowed by end to end anastomosis was the operative procedure most frequentIy used. TweIve patients had Iigation of the injured vesse1, a procedure used with greater frequency during the earIy period of this study. Two patients were not subjected to operation. One was of interest: a twentythree year oId man presented with an absent radia1 puIse thought to be due to thrombosis of the dista1 brachia1 artery caused by an associated fracture of the humerus. No surgica1 procedure was performed; however, four months Iater he had a radia1 puIse. I45
Smith, TABLE OPERATIVE
PROCEDURES ARTERIAL
FIFTY-FOUR OF
No.
..
REPAIRS
FOR
ACUTE UPPER
IN
31 12
4 2 1 I
.
TABLE FAILURE
A periphera1 puIse was restored in twentyeight of thirty-eight patients having surgica1 repair of their injured artery. The apparent cause of faiIure to estabIish circulation in the ten patients in whom a periphera1 puIse ws not established is Iisted in TabIe v. Three patients who had repair of smai1 vesseIs in the forearm did not have a postoperative puIse recorded on the hospita1 record; and even though they had viabIe hands, they were Iisted as having had thrombosis at the site of injury. In one patient with a contaminated compound fractujre of the humerus and an associated brachia1 artery injury, a wound infection deveIoped at the site of a successfu1 arteriaI anastomosis resuIting in disruption of the suture line and secondary hemorrhage one week Iater. The brachia1 artery was Iigated, and the arm was amputated to contro1 exsanguinating hemorrhage. Twenty-one patients with viabIe extremities had Iimitation of function due to some degree of paraIysis or sensory deficit in the hand as a result of associated nerve damage at the time of origina trauma. A paIpabIe puIse was restored in fifteen of these patients. Thus, nerve deficit and not arteria1 insuffIciency became the limiting factor in rehabiIitation in this Iarge group. In three patients Aexion contractures deveIoped foIIowing associated tendon repairs which limited hand function despite successfu1 arterial reconstruction. It is of interest that in none of the tweIve patients having had Iigation of the injured artery developed postoperative arteria1 ins&iciency Iimiting norma function. AI1 were apparentIy abIe to perform their usua1 job without significant hand or arm cIaudication. IncIuded in this group were one axiIIary and three brachia1 artery injuries. Two deaths occurred in this series and are unusual. One was in a thirty-one year oId woman who sustained muItipIe gunshot wounds of head, right shouIder and chest and Ieft arm. The right axillary artery was expIored because of massive hemorrhage and the presence of an acute arteriovenous f%tuIa. A partiaIIy transected axiIIary vein was ligated together with severa branches of the axiIIary artery which were bIeeding. A Iaceration of the right puImonary vein was repaired through a thoracotomy incision at surgery. The patient bIed
EXTREMITY
End to end anastomosis. Ligation................................... LateraI suture repair.. Veingraft................................. Thrombectomy............................. Fasciotomy................................ Amputation. . ..
OF
Gaspar RESULTS
ACUTE
THE
Procedure
CAUSE
and
IV IN
INJURIES
UPPER
Foran
..
.
I
v
THIRTY-EIGHT
ARTERIAL
SURGICAL
INJURY
OF
THE
EXTREMITY
No.
Cause
Thrombosis at site of injury.. . . Postoperative death. . Arterial spasm.. Thrombosed “run off”. Infection, hemorrhage, amputation.
5 2 I
.
.
I I
A primary supracondylar amputation was performed in a nineteen year oId woman with a severeIy cornminuted compound fracture of the distaI humerus. The brachia1 artery was avulsed at the time of injury. Amputation was required due to extensive bony and soft tissue destruction. A dorsa1 and volar forearm fasciotomy was performed in a twenty-seven year oId man who had sustained an associated crush injury to the forearm during an attempted suicide by the ingestion of pheno1. CircuIation was restored to the forearm, and he survived a temporary episode of renaI faiIure as weI1. An axillary thrombectomy was performed on a fifty-six year oId man in whom thrombosis deveIoped due to trauma of a poorIy fitting homemade crutch which he used because of a previous thigh amputation. Operation discIosed thrombosis of the axiIIary as we11 as the brachia1 arteries. He was treated by thromhectomy with retrograde flushing of the artery without restoration of a periphera1 p&e. He continued to have exercise cIaudication in the arm foIIowing operation. 146
ArteriaI
Injuries
massiveIy in the postoperative period from the axihary wound and reoperation was necessary. A Iaceration of the subclavian artery was found and repaired. She continued to bIeed into the right side of the chest which required re-exploration of the chest. A cardiac arrest developed during induction of anesthesia from which she was resuscitated. She died, however, the fohowing day of cerebral anoxia and pulmonary edema. The second death occurred in a twenty-one year old man with a stab wound of the Ieft axihary artery. He was treated for severe shock in the emergency room of another hospital. The massive nature of the hemorrhage is attested by the fact that 2 units of AIbumisol,@ 2 units of pIasma and 12 units of blood were required to stabilize his bIood pressure prior to transfer to the County Hospital An emergency tracheotomy was performed during this period of emergency resuscitation because of acute respiratory obstruction. The patient presented in acute respiratory distress on admission to the Los AngeIes County Hospital due to the presence of bilateral pneumothorax. Both pleura1 spaces apparently had been entered during the emergency tracheostomy. IntercostaI tubes were inserted into folIowing improvement both pIeural cavities; in his condition, he was operated upon. A transected axillary artery and Iacerated axihary vein were found and repaired. PostoperativeIy, a severe biIatera1 confluent pneumonia developed, as we11 as acute renal faiIure, resulting in death on the fifth postoperative day.
buckshot or smaI1 sharp objects have penetrated into the vicinity of a major artery, emergency arteriography can be heIpfu1 in estabhshing arteria1 injury [7,8]. The percutaneous injection of radiopaque dye into the subcIavian artery can be done with comparative ease and has been described in detaiI elsewhere [9]. SurgicaI exploration may be required in rare situations when the arteriogram appears equivoca1 or when there is a possibility of associated venous injury. It has been the policy on our vascuIar service to perform emergency repair of a11 major vessels which have been injured. Surgical exposure for the repair of these injured vessels usuaIIy has not been a probIem. It is important that wide incisions be made or that the site of injury be adequateIy extended to insure easy apphcation of proxima1 and dista1 occlusive clamps on the injured vessel Care must also be taken to make certain that al1 of the damaged vessel has been resected, and that any concomitant injury to the vein has been exposed for subsequent repair. Exposure of the innominate, subclavian and axiIIary arteries presents the greatest di&uIty. For exposure of the innominate and subcIavian vesseIs we have preferred the sternal spritting incision including resection of the proxima1 portion of the cIavicIe subperiosteahy as recommended by Shumacker [IO,II] and Cook and HaIIer [12’]. In the case of the axihary artery, an S-shaped incision is made centered over the axiIIa. (Fig. 2.) The tendon of the pectoraIis major muscIe may be transected for exposure of the proxima1 vessel. We have been surprised in reviewing these arteria1 injuries to the upper extremity to Iearn how we11 patients have fared following ligation. No patient who had Iigation of an injured artery to the arm has compIained of postoperative cIaudication preventing performance of his usua1 work. This does not mean, however, that primary repair is not desirabIe. During WorId War II, when acute arteriaI injuries were managed by Iigation, the incidence of gangrene of the lower extremity was twice that of the upper extremity [13]. Ziperman [14], during the Korean War, reported gangrene of the arm requiring amputation in Iess than IO per cent of patients having had brachial artery ligation whereas 50 per cent of patients having had ligation of the femora1
COMMENTS
The most important factor in acute arteria1 injuries to the upper extremity is prompt recognition. The classic signs of peripheral ischemia, such as pallor, coIdness and slow capihary fiIIing, must be carefuhy checked. The presence of a periphera1 p&e cannot be rehed upon to exclude injury since ten of fifty-four patients with acute arterial injury to the upper extremity, in this study, had a paIpabIe periphera1 pulse. This situation wilI occur most often with smaI1 side-waI1 lacerations or incomplete injury to the vessel and has been stressed by other authors [4-61. The presence of pulsating bleeding or an expanding or pulsating hematoma indicates arteria1 injury. In questionable cases in which injury has occurred over the neurovascular bundIe, or in which I47
Smith,
Foran
and Gaspar
FIG. 2. A, incision for exposure of innominate or subclavian incision for exposure of axiIIary artery. See text for details.
arteries. B, S-shaped
FIG. 3. A and B, technic for smaI1 artery anastomosis. GentIe diIatation of the cut end of the vesse1 using a mosquito forceps foIIowed by pIacing trianguIation sutures of fine siIk. C, reIief of arteriospasm by gentIe saline injection between occIuding vascuIar cIamps.
artery gangrene deveIoped requiring amputation of the leg. CoIIateraI circuIation to the arm is apparentIy much better than that to the Ieg. Since the technic of vascuIar suture is now we11 estabIished and in view of the wide availability of vascuIar instruments, we recommend the repair of the smaI1 arteries of the forearm
unIess the time required for this procedure wouId jeopardize the patient’s surviva1. DiIatation of the vesse1 by a curved mosquito forceps as Zustrated in Figure 3, and the appIication of trianguIation sutures of fine arteria1 silk as described by CarreI [2] aids in the ease of smaI1 vesse1 anastomosis. Arteriospasm can be troubIesome. Spasm 148
ArteriaI Injuries is apparentIy due to IocaI irritative mechanisms rather than reflex autonomic nervous stimuIation since experimenta evidence suggests that large arteries do not have vasoconstrictor innervation [15]. The appIication of topica 2.5 per cent papavarine solution as recommended by Kinmonth [16] or the injection of saIine soIution into an isolated spastic arteria1 segment as advised by Mustard and BuII [17] may be heIpfu1 in reestabIishing norma circuIation. (Fig. 3.) PeripheraI circulation was re-estabIished in 74 per cent of patients having had arteria1 favorabIy with repair. This figure compares the resuIts reported by other surgeons [I&201. The serious nature of vascular injuries is apparent by the frequency of shock on hospita1 entry. The reported incidence of shock with acute arteria1 injury is nearIy 50 per cent [r&21]. In twenty-four of the fifty-four patients in this study, hemorrhagic shock deveIoped. The mortaIity in patients with acute arteria1 injury is Iikewise high and ranges up to 15.5 per cent as reported by Ferguson, Byrd and McAfee [IS]. The two deaths in our series occurred in patients who experienced massive blood Ioss and who subsequentIy succumbed from serious pulmonary compIications. When a fracture is associated with a vascuIar injury, it is advisabIe to immobiIize the fracture by surgica1 means prior to repair of the injured vesse1. Mobility at the site of fracture or manipuIation during reduction may contribute to disruption of the ateria1 anastomosis. It is advisabIe to resect at Ieast I cm. of norma appearing vesse1 on either side of a gunshot injury. AIthough gross inspection reveals normaI-appearing arteria1 waI1, microscopic bIast injury to the intima may predispose to subsequent thrombosis at the site of injury [22-241. We prefer autogenous reversed vein grafts for the restoration of continuity in those patients with a vascuIar defect preventing end to end anastomosis. Experience to date indicates that this is the best method of restoring circuIation [5,22-261. Vein patch grafts may occasionaIIy be heIpfu1 in side waI1 injuries.
This therapeutic concept is most urgent in injuries invoIving the Iarger proxima1 vesseIs where hemorrhage frequently threatens survivaI. We11 estabIished incisions and current vascuIar surgica1 technics precIude equivocation in the management of injuries in this Iocation. Damage to periphera1 arteries of the arm and forearm shouId aIso be repaired immediateIy in order to restore optima1 circuIation unIess such emergency repair jeopardizes surviva1 of the patient. Ligation can be performed in injuries in this Iocation with minima1 risk of amputation. Arteriography is heIpfu1 in establishing the diagnosis of arteria1 injury in equivoca1 cases and wiI1 reduce the number of negative expIorations. CarefuI attention must be paid to the tota probIem of trauma in patients with acute arteria1 injury of the upper extremity since associated damage to nerves and tendons is the determining factor in restoration of function and rehabiIitation of the patient. REFERENCES
I. LAMBERT, W. S. Extract from a Letter from Lambert, W. S., Surgeon at NewcastIe upon Tyne, to Dr. Hunter. Medical Observations and Inquiries by a Society of Physicians in London, 2: 360, 1762. 2. CARREL, A. The surgery of bIood vesseIs. Bull. Jobns Honkins HOSD.. 18: 18. 1007. 3. HARBISON, S. P. The’ origins of GascuIar surgery: the Carrel-Guthrie letters. Surgery, 52: 406,1962. 4. SPENCER,A. D. The rehability of signs of periphera1 vascuIar injury. Surg. Gynec. ti Obst., 114: 490, 1962. 5. WHITAKER, W. G., JR., DURDEN, W. F. and FERGUSON, I. A. Acute arteria1 trauma. Surg. Gynec. & Obst., 99: 129, 1954. 6. CREECH, O., JR. Acute arteria1 injuries. Postgrad. Med.,.29: 581, 1961. 7. LUMPKIN, M. B., LOGAN, W. D., ~OUVES, C. M. and HOWARD. J. M. Arterionranhv as an aid in the diagnosis’ and IocaIizati& bf “acute arterial injuries. Ann. .%rg., 147: 353, 1958. 8. SINKLER, W. H. and SPENCER, A. D. The vaIue of peripheral arteriography in assessing acute vascuIar injuries. Arch. Surg., 80: 300, 1960. 9. GAFFNEY, C. J., HERSHEY, F. B. and ALLEN, W. E. Arteriography of the upper extremity. Surg. Gynec. @ Obst., 106: 63, 1958. IO. SHUMACKER,H. B., JR. Resection of the cIavicIewith particuIar reference to the use of bone chips in the periostea1 bed. Surg. Gynec. d Obst., 84: 245. 1947. I I. SHUMACKER,H. B., JR. Operative exposure of bIood vesseIs in superior anterior mediastinum. Ann. Surg., 127: 464, 1948. 12. COOK, F. W. and HALLER, A., JR. Penetrating injuries of the subcIavian vessels with associated
SUMMARY
Prompt recognition repair is recommended acute arteria1 injuries
and immediate surgica1 in the management of to the upper extremity.
‘49
Smith, Ven0U.s
COInphitiOnS.
Ann.
SUrg.,
155:
Foran and Gaspar 370,
1962. 13. DEBAKEY, M. E. and SIMEONE, F. A. Battle iniuries of the arteries in WorId War II: analvsis ” of2471 cases. Ann. Surg., 123: 534, 1946. 14. ZIPERMAN, H. H. Acute arterial injuries in the Korean War. Ann. Surg., 139: I, 1954. 15. KINMONTH, J. B., SIMEONE,F. A. and PERLOW,V. Factors affecting the diameter of Iarge arteries with particular reference to traumatic spasm. Surgery, 26: 452, 1949. 16. KINMONTH,J. B. Physiology and rehef of traumatic arteriaI spasm. hit. M. J., I: 59, 1952. 17. MUSTARD, W. T. and BULL, C. A reIiabIe method for reIief of traumatic vascuIar spasm. Ann. Surg., 155: 339, 1962. 18. FERGUSON, I. A., SR., BYRD, W. M. and MCAFEE, D. K. Experiences in the management of arteria1 injuries. Ann. Surg., 153: 980, yg6r. 19. MORRIS, G. C., JR., BEALL, A. C., JR., ROOF, W. R. and DEBAKEY, M. E. SurgicaI experience with 220 acute arteria1 injuries in civiIian practice. Am. J. Surg., gg: 775, 1960. 20. SINKLER, W. H. and SPENCER, A. D. The importance of earIy expIoration of vascular injuries. Surg. Gynec. CYOk., 107: 228, 1958. 21. HUGHES, C. W. The primary repair of wounds of major arteries: an anaIysis of experience in Korea in 1953. Ann. Surg., 141: 297, 1955. 22. HERSHEY, F. B. and SPENCER,A. D. SurgicaI repair of civilian arterial injuries. Arch. Surg., 80: 953, 1960. 23. JAHNKE, E. J. and SEELEY, S. F. Acute vascuIar injuries in the Korean War: an anaIvsis of 7;consecutive cases. Ann. Surg., 138: 158, x953. 24. SPENCER, F. C. and TOMPKINS, R. K. Management of acute arteria1 injuries. Postgrad. Med.,
25.
28: 476. 1960.
F. N., HUGHES, C. W., JAHNKE, E. J. and SEELEY, S. F. HomoIogous arterial grafts and autogenous vein grafts used to bridge Iarge arteria1 defects in man. Surgery, 33: 183. 1953. 26. HUGHES, C. W. ArteriaI repair during the Korean War. Ann. Surg., 147: 555, 1958. COOKE,
DISCUSSION
J. HOWARD PAYNE (Los Angeles, Calif.): I wish to congratuIate Doctors Smith, Gaspar and Foran on an extremely we11 prepared manuscript and Doctor Smith on the excehence of the presentation. I enjoyed reading the manuscript which is fiIIed with important data. I agree with them that the arteria1 circuIation in an arm is a great deaI different than that in the Ieg. The important difference is the extremeIy Iine coIIatera1 circuIation found in the shouIder and around the eIbow. The routes of coIIatera1 circuIation in the shouIder area are as foIIows: (I) transverse scapuIar to the thoraco-acromia1 to the circumffex humora to the deep brachial artery; (2) transverse scapuIar to the thoraco-acromia1 to the IateraI thoracic to the ascending branch of the profunda brachii to the
(3) interna mammary to the interCosta1 to the circumflex scapular through the ascending branch of the profunda brachia1 to the deep brachia1; and (4) descending branch of the transverse cervica1 through the circumflex scapuIar through the ascending branch of the profunda brachii to the profunda brachii. The pathways for the coIIatera1 circuIation around the eIbow are probabIy as foIIows: (I) profunda brachii through the radia1 recurrent to the radia1; (2) profunda brachii through the radia1 coIIatera1 branch of the profunda to the interosseous recurrent; (3) superior ulnar coIIatera1 to the posterior uInar recurrent to the uInar; and (4) inferior uInar coIIatera1 to the anterior uInar recurrent and anastomotic branches to the uInar. The coIIatera1 circuIation to the hand and fingers is poor if both radia1 and uInar artery are occIuded studies indicate or divided. PIethysmographic that the uInar artery is the major artery to the hand and fingers. In my personal experience, the axiIIary artery was the most frequent artery invoIved. As the authors indicated, and I agree, adequate exposure with proxima1 and dista1 contro1 of the injured artery is important. The sternal spIitting incision with resection of a portion of the cIavica1 provides adequate exposure of the innominate and subclavian arteries. Primary end to end anastomosis is the procedure of choice if at a11 possibIe after excising the gross and microscopic damage to the invoIved artery. Autogenous vein grafts are usefu1 in cIosing arterotomy incisions. This is especiaIIy true if the brachia1 artery has been badIy damaged during cardiac catheterization. With the increasing number of diagnostic procedures using the brachial artery, we wiI1 probabIy see more permanentIy damaged arteries. FortunateIy the arm has good coIIatera1 circuIation and rareIy wiI1 any part be Iost. The hand may be seriousIy jeopardized if the radia1 or uInar artery is used and damaged. There does not seem to be any situation which wouId caI1 for a bypass procedure. In repair of the smaI1 arteries of the upper extremity, interrupted sutures are indicated. AIso, it is here that the use of the operating microscope wouId be useful. FREDERIC SHIDLER (Men10 Park, Calif.): I enjoyed the paper very much, but there were a coupIe of questions I shouId Iike to ask the authors. These concern the Iate effects foIIowing suture of upper extremity arteries. I wouId be interested in knowing if you have observed any dilatation of the artery distal to the Iine of suture and whether or not a IongitudinaI repair of an artery is IikeIy to have more constriction than a transverse repair. FinaIIy, I wonder if anyone in the Association has observed an aneurysm appearing at the site of deep brachia1;
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ArteriaI Injuries repair or distal to repair of one of the upper extremity arteries. JOHN F. HIGGINSON (Santa Barbara, CaIif.): Sometimes, one can be a little fortunate in handhng a situation that is presented, such as the man who attempted suicide. He was not entireIy accurate in his aim with the shotgun, and missed kiIling himseif. A pneumothorax developed, fortunately without tearing his Iung; most of the waI1 was torn from the Ieft part of the chest. The peIIet went through it and Ieft a broad band of axiIlary skin. Then the buIIet tore most of the tissues from the arm, and fractured the humerus. Because the humerus was fractured it was possible to take care of the torn artery which was injured in two pIaces. In one pIace, it was torn apart, with thrombosis distaIIy and proximaIIy; and in the second, two shotgun pellets were Iying in the lumen; thus, debridement was inevitabIe. These injuries required remova of sections of the vesse1 before we had a vesse1 to repair. This made the vesse1 too short, and brought up the possibiIity of using a prosthesis. In a smaI1 vesse1, known hazards are present. Since the humerus was fractured we first had the orthopedist who was on caI1, Waiter Graham, examine the patient, and remove severa inches more of the humerus and put a pin in it. This procedure produced a satisfactoriIy shortened arm, and permitted an end to end arteria1 anastomosis. Since the arm needs neither length nor stability, but mobibty, a satisfactory resuIt was obtained. He stiI1 has a pulse in the arm ten months later. After we had done a11 the repairs on the man, when he awakened, we Iearned that he had had, a year or two previously, a Ieft hemipIegia and he did not have much use of the Ieft upper extremity anyhow. MAX. R. GASPAR (Long Beach, CaIif.): I wouId Iike to mention something Dr. Smith did not have time to mention; namely, that you must watch out for Iarge hematomas; there is a tendency not to watch them. We say watch out for them, because they are IiabIe to be Iaden with “dynamite.” Most of these patients must have expIoratory surgery because of arterial wounds or more IikeIy venous injuries which we have not stressed at this time. As you noted, there were four arteriovenous fistu1a.s in the upper extremity wounds. This is a fairIy common compIication, wounding a Iarge vesse1 which is closely associated with a large vein.
It may not be necessary to resect the cIavicIe in a11 instances of innominate or subcIavian artery wounds, but certainIy a sterna1 spIitting incision and careful dissection is necessary for good exposure in this area. To answer some of the questions: We had onIy one patient who had a pIastic prosthetic graft. The brachia1 artery was damaged during catheterization and an aneurysm deveIoped. A Szilagyi type woven Dacron@ graft was used to bridge the defect after the aneurysm was resected. Eventually, the graft diIated and a false aneurysm developed at one of the anastomotic Iines. We resected the graft and put in a reversed vein graft which we would have preferred to use in the first pIace if we had operated upon the patient. PIastic grafts are not apt to work in traumatic injuries because the fieId is usuaIIy contaminated and one certainIy does not want to use this type of graft in an infected area. Dr. ShidIer, I do not recaI1 seeing diIatation or aneurysm formation dista1 to an area of repair or anastomosis. It wouId impIy, of course, stenosis and poststenotic diIatation. I wiI1 not say our patients do not have stenosis and poststenotic diIatation, but I do not recaI1 seeing it. Insofar as IongitudinaI repair is concerned, I do not beIieve one wouId want to do a IongitudinaI repair if there were danger of constricting the vesse1. CertainIy, the use of a vein patch graft is the idea1 technic here and wiI1 prevent stenosis. In Dr. Higginson’s interesting case, I beIieve we would have asked Dr. Graham to repair the fracture before we tried to repair the artery. Not a11 orthopedists are as gentIe as Dr. Graham, and they wiI1 sometimes tear apart a good anastomosis; thus, we prefer to have the fracture fixed first, and then repair the artery. As Dr. Smith mentioned, when we started studying these cases we had hoped we couId make a fairIy strong case for repair of a11 arteria1 wounds of the upper extremities. We stiI1 think it is a good pIan to restore norma anatomy, and we are happy to see residents have the opportunity to work with blood vesseIs, because they are often treating the traumatized emergency patient. However, we were surprised to Iearn how we11 patients have done when upper extremity arteries have been Iigated. Therefore, extraordinary efforts to repair traumatized arteries shouId not be made if the patient’s Iife wiI1 be endangered.