Femoral arterial cannulation for surgical repair of stanford type A aortic dissection

BACKGROUND

The benefits and harms associated with femoral artery cannulation over other sites of arterial cannulation for surgical repair of acute Stanford type A aortic dissection (TAAD) are not conclusively established.

METHODS

We evaluated the outcomes after surgery for TAAD using femoral artery cannulation, supra-aortic arterial cannulation (i.e., innominate/subclavian/axillary artery cannulation), and direct aortic cannulation.

RESULTS

3751 (96.1%) patients were eligible for this analysis. In-hospital mortality using supra-aortic arterial cannulation was comparable to femoral artery cannulation (17.8% vs. 18.4%; adjusted OR 0.846, 95% CI 0.799-1.202). This finding was confirmed in 1028 propensity score-matched pairs of patients with supra-aortic arterial cannulation or femoral artery cannulation (17.5% vs. 17.0%, p = 0.770). In-hospital mortality after direct aortic cannulation was lower compared to femoral artery cannulation (14.0% vs. 18.4%, adjusted OR 0.703, 95% CI 0.529-0.934). Among 583 propensity score-matched pairs of patients, direct aortic cannulation was associated with lower rates of in-hospital mortality (13.4% vs. 19.6%, p = 0.004) compared to femoral artery cannulation. Switching of the primary site of arterial cannulation was associated with increased rate of in-hospital mortality (36.5% vs. 17.0%; adjusted OR 2.730, 95% CI 1.564-4.765). Ten-year mortality was similar in the study cohorts.

CONCLUSIONS

In this study, the outcomes of surgery for TAAD using femoral arterial cannulation were comparable to those using supra-aortic arterial cannulation. However, femoral arterial cannulation was associated with higher in-hospital mortality than direct aortic cannulation.

TRIAL REGISTRATION

ClinicalTrials.gov registration code: NCT04831073.

INCREASED DIAMETER AND STIFFNESS OF ELASTIC BUT NOT MUSCULAR ARTERIES IN MEN WITH ABDOMINAL AORTIC ANEURYSM

It has been proposed that formation of abdominal aortic aneurysm (AAA) is part of a systemic arterial dilatative disease. However, arteries in the upper extremity are scarcely studied and it remains unclear whether both muscular and elastic arteries are affected by the proposed systemic arterial dilatation. The aim of this study was to investigate diameter and stiffness of muscular and elastic arteries in arterial branches originating from the aortic arch. Twenty-six men with AAA (69 ± 4 years) and fifty-seven men without AAA (70 ± 5 years) were included in the study. Ultrasound was used to examine the distal and proximal brachial artery, axillary artery, and common carotid artery (CCA), and measurement of diameter and diameter change were performed with wall-tracking software. Blood pressure measurements were used to calculate local arterial wall stiffness indices. The AAA cohort presented larger arterial diameters in the CCA and axillary artery after adjustment for body surface area (p=0.002, respectively), while the brachial artery diameters were unchanged. Indices of increased stiffness in CCA (e.g., lower distensibility, p=0.003) were seen in subjects with AAA, after adjustments for body mass index and mean arterial blood pressure. This study supports the theory of a systemic arterial dilating diathesis in in peripheral elastic, but not in muscular, arteries. Peripheral elastic arteries also exhibited increased stiffness, in analogy with findings in the aorta in AAA.

Delayed development of a huge chest wall hematoma post pacemaker implantation: A case report

An 83-year-old Chinese man presented with a huge left chest wall hematoma and hemorrhagic shock 4 months after permanent pacemaker implantation. Computed Tomography of Angiogram of the left subclavian artery revealed a pseudoaneurysm. He underwent radiologically guided stenting followed by hematoma clearance. It is rare to have delayed formation of pseudoaneurysm at 4 months post pacemaker implantation. Radiologically guided stenting is the preferred treatment, followed by hematoma clearance. It is strongly advised against blind surgery for wound debridement or bleeding detection. Familiarizing with axillary vein anatomy, improving axillary vein cannulation skills, and detecting early complications of artery injury are key strategies in preventing pseudoaneurysm formation post pacemaker implantation.

Axillary artery pseudoaneurysm with concurrent distal thrombosis: a case report

This report details a case of axillary artery pseudoaneurysm with concurrent distal thrombosis, manifesting as acute upper extremity ischemia. The condition was successfully treated with a hybrid surgical approach, employing a covered stent graft and Fogarty balloon thrombectomy. We review the relevant literature on the management of this rare but critical vascular condition.

A Cadaveric Study on the High Origin of the Radial Artery

INTRODUCTION

Among the upper limb's vascular variations, the radial artery's high origin from the axillary artery is rare, and literature regarding the same is limited. Anomalous origin of radial artery can cause failure of radial approach to coronary angiography and reconstructive surgeries of upper limbs and hence is of clinical significance. With this background, the current cadaveric study was planned to describe the branching pattern of the axillary artery and its variations.

METHODS

We conducted this descriptive, cross-sectional study on sixty adult human cadaveric upper limbs at the anatomy departments of Government TD Medical College, Alappuzha, and Government Medical College, Thiruvananthapuram, over two years from 2021 to 2023. The axillary artery's branching pattern and termination were noted, and the prevalence of high origin of the radial artery from the axillary artery was documented.

RESULTS

High origin of radial artery from axillary artery was observed in four (6.70%) limbs and was higher than the prevalence reported in earlier literature. Among these variations, one was a female cadaver with a bilateral high origin of radial artery arising from the third part of the axillary artery. The other two were from separate male upper limbs, both from the right upper limb.

CONCLUSION

The prevalence of the high origin of the radial artery from the axillary artery was high compared to earlier reported literature. This calls for further research in the anatomy of arterial patterns of the upper limb to avoid complications during arterial procedures of the upper limb.

Hemodynamic Instability After Axillary Artery Rupture Following Inferior Glenohumeral Joint Dislocation: A Case Report

BACKGROUND Inferior shoulder dislocation is a rare type of glenohumeral joint dislocation. A serious complication to shoulder dislocation is axillary artery injury, which should be taken into consideration early to avoid potentially permanent damage. Literature on artery injury following inferior shoulder dislocation is sparse. CASE REPORT We report the case of a 71-year-old man with a traumatic inferior shoulder dislocation due to a fall. The patient had a medical history of stroke, and thus had a daily intake of 10 mg Warfarin. Previously, he had reported 2 anterior shoulder dislocations. The shoulder reduction was conducted under general anaesthesia after reduction with intravenous morphine sedation. Six hours after reduction, the patient showed signs of hemodynamic instability and a CT scan with contrast showed a suspected axillary artery rupture with a large hematoma in the right axilla. The artery rupture was confirmed with an arteriogram. The patient was successfully treated with an endovascular stent. After 3 months, the patient had normal neurovascular status in the right upper extremity and was continuing rehabilitation of the shoulder. CONCLUSIONS This case emphasizes the importance of proper recognition and awareness of artery injury after inferior shoulder dislocation. The symptoms of artery rupture after inferior shoulder dislocation can be immediate or have a late onset. The diagnostic modalities of CT scan with contrast or arteriogram should be performed with a low threshold of suspicion after reduction. With symptoms such as enlarging hematoma in the axilla, diminished radial and ulnar pulse, sudden pain from the axilla, or signs of hemodynamic instability after reduction, diagnostic modalities should be considered.

Prevalence of Axillary Artery Variants and Their Clinical Significance: A Scoping Review

Axillary artery (AA) variants occurred quite commonly, presenting clinical implications. A literature search yielded 523 results from which 13 parameters were extracted. Some of the AA variants found were the fusion of two or more branches into common trunks, like the fusion of anterior and posterior circumflex humeral arteries. Moreover, several branches were found to emerge from different points than expected, like the lateral thoracic artery's origin from the subscapular artery instead of the second part of the AA. The importance of the knowledge of the AA variations in clinical practice is undeniable and very useful when planning interventional procedures, as in the case of AA aneurysm treatment or in cases of fracture of the surgical neck of the humerus. The heterogeneity of data limited the possibility of a quantitative summary of data. Therefore, a more systemic study of AA variants based on the origin, course, and branching pattern is suggested. The aim of the current review is to summarize current data literature regarding the AA typical anatomy and its variants, with a focus on their prevalence and possible clinical implications.

Outcomes of Percutaneous Access to the First Versus Third Segment of Axillary Artery During Aortic Procedures

PURPOSE

This article aims at investigating the outcomes of percutaneous access via the first versus third axillary artery (AXA) segments with closure devices during aortic procedures.

MATERIALS AND METHODS

All patients receiving percutaneous AXA access closed with Perclose ProGlide device (Abbott, Santa Clara, California) from 2008 to 2021 were included in a retrospective multicenter registry (NCT: 04589962). Efficacy endpoint was the technically successful percutaneous procedure (no open conversion). Safety endpoints were stroke and access complications according to the Valve Academic Research Consortium-3 reporting standards. The first (AXA1) or third (AXA3) axillary puncture sites were compared.

RESULTS

A total of 412 percutaneous AXA accesses were included: 172 (42%) in AXA1 and 240 (58%) in AXA3. Left AXA was catheterized in 363 cases (76% of AXA1 vs 97% of AXA3, p<0.001) and 91% of fenestrated/branched endovascular repair (F/BEVAR) procedures were conducted from the left. A ≥12F internal diameter (ID) sheath was used in 49% of procedures. Open conversion rate was 1%, no major vascular complications occurred, and only one major non-vascular complication was recorded. Primary closure failure occurred in 18 AXA1 (11%) and 32 AXA3 accesses (13%), treated by covered (8.3%) or bare-metal (2.7%) stenting. Bailout stent patency was 100% at median follow-up of 12 months, with 6 of 6 stents still patent after >36 months of follow-up. Stroke rate was 4.4%. An introducer sheath >12F was independently associated with both access complications (p<0.001) and stroke (p=0.005), while a right-side access was associated with stroke only (p=0.034). Even after adjustment for covariates, AXA1 versus AXA3 showed an equal success rate (odds ratio [OR]=0.537, 95% confidence interval [CI]=0.011-1.22 for AXA3, p=0.104). The combination of AXA3 and a >10F introducer sheath provided worse outcomes compared with >10F sheaths through AXA1 (OR for success=0.367, 95% CI=0.176-0.767, p=0.008). This was not confirmed for >12F sheaths, associated with similar outcomes (p=0.31 AXA 1 vs AXA 3).

CONCLUSION

Major local complications with the percutaneous axillary approach and ≤12F sheaths are infrequent and solvable by complementary endovascular interventions. Stroke risk remains an issue. First and third AXA segments are both amenable for access with good results, but larger sheaths (12F) perform better in AXA1.

CLINICAL IMPACT

Percutaneous access with vascular closure devices at the first or third axillary artery (AXA) segments during aortic procedures is burdened by a negligible risk of open conversion. Local complications with the percutaneous axillary approach are infrequent and solvable by complementary endovascular interventions. First and third AXA segments are both amenable to access with excellent results, but larger sheaths (12F) perform better in the wider first AXA segment. In this setting, bailout stenting does not appear to be associated with mid-term stent occlusion.

The Coexistence of the Superficial Brachial Artery With the Common Origin of the Posterior Circumflex Humeral Artery and the Deep Brachial Artery

The brachial artery (ΒΑ) represents the axillary artery's extension as it distally progresses to the teres major muscle or beneath the tendon of the latissimus dorsi muscle. Throughout its course, the BA maintains continuous proximity to the median nerve. Occasionally, an artery located in front of the arm muscles may exhibit a slightly more lateral position than the BA, following a convoluted path, referred to as the superficial brachial artery (SBA). SBA variants are not uncommon and can impact neural structures as well. In the course of routine dissection on a formalin-embalmed donated cadaver through the Body Donation Program, the following notable findings were identified: a) a BA bilateral trifurcation, below the tendon of the latissimus dorsi muscle; b) a posterior circumflex humeral artery of low origin (brachial artery); c) the coexistence of an SBA with the main BA; d) a subscapular artery of high origin (second part of the axillary artery); e) an anterior circumflex humeral artery duplication. These BA variants, particularly those related to the SBA, hold significance in upper limb surgery and everyday clinical practice. In such cases, meticulous surgical dissection is crucial to prevent arterial injury, and in complex situations, preoperative imaging might be advisable. Additionally, it's important to note that concurrent neural variants may also be present, potentially complicating the surgical approach.

ABS-SMART (Aortic Balloon Supporting for Superior Mesenteric Artery Recanalization Technique): A New Technical Option for Recanalization of Complete Superior Mesenteric Artery Occlusion in Chronic Mesenteric Ischemia

OBJECTIVE

To report our experience with a new technique for recanalization of the superior mesenteric artery (SMA)/celiac trunk (CT) with complete occlusion at the origin.

TECHNIQUE

We describe our ABS-SMART (Aortic Balloon Supporting for Superior Mesenteric Artery Recanalization Technique) for recanalization of the CT and SMA in cases of complete occlusion of these arteries with a short or inexistent stump, which usually corresponds to chronic lesions with important calcification of the ostium.

CONCLUSION

The ABS-SMART is an alternative for the recanalization of visceral arteries in cases where other conventional techniques have failed. It is particularly useful in scenarios characterized by a short occlusion at the origin of the target vessel, with no entry stump or severe calcification at the origin.

CLINICAL IMPACT

Catheterization and recanalization of visceral stenoses may pose a challenge in some cases, as for example in the presence of a very narrow angle between the root or origin of the vessel and the aorta, as well as in the case of long and calcified stenoses, or when arteriography is unable to visualize the origin of the vessel. The present study describes our experience with the endovascular revascularization of visceral vessels using an aortic balloon-supported recanalization technique not previously described in the literature, that may be an effective alternative for the treatment of lesions of difficult access, such as total occlusion at the origin of the target vessel, with no entry stump or severe calcification at the origin of the SMA and CT, by improving the chances for technical success.

Variations in the Branching Pattern and Course of the Left Axillary Artery: A Cadaveric Case Report

The axillary artery is the primary arterial supply of the upper limb and functions as a key landmark in the region of the axilla. Anatomical variations in the axillary artery may arise from abnormal angiogenesis in the upper limb bud during embryological development. The routine dissection of the upper limb of an 88-year-old male cadaver revealed unilateral variations in the left axillary artery, including an abnormal anteromedial course with respect to the divisions and cords of the brachial plexus, while no variations were observed in the right axillary artery. Variations in branching were observed in each part of the artery. In the first part of the artery, variations included an accessory branch coursing towards the clavicle and another to the subscapularis muscle. A total of four branches arose from the second part of the artery: a thoracoacromial artery, an accessory pectoral branch, and two common trunks. The first common trunk gave off the alar thoracic artery, an accessory lateral thoracic artery, and the subscapular artery, which further gave off the thoracodorsal and lateral thoracic arteries, prior to continuing as the circumflex scapular artery. The second common trunk yielded the anterior and posterior circumflex humeral arteries prior to continuing as the profunda brachii artery. No branches arose from the third part of the artery. Awareness of variations in the course and branching patterns of the axillary artery as observed in this cadaveric donor is essential for anesthetic, radiographic, surgical, and other interventional procedures of the upper limb.

Cannulation-related adverse events of peripheral veno-arterial extracorporeal membrane oxygenation support in heart transplantation: Axillary versus femoral artery cannulation

BACKGROUND

In heart transplantation (HT), peripheral veno-arterial extracorporeal membranous oxygenation (VA-ECMO) is utilized preoperatively as a direct bridge to HT or postoperatively for primary graft dysfunction (PGD). Little is known about wound complications of an arterial VA-ECMO cannulation site which can be fatal.

METHODS

From 2009 to 2021, outcomes of 80 HT recipients who were supported with peripheral VA-ECMO either preoperatively or postoperatively were compared based on the site of arterial cannulation: axillary (AX: N = 49) versus femoral artery (FA: N = 31).

RESULTS

Patients in the AX group were older (AX: 59 years vs. 52 years, p = .006), and less likely to have extracorporeal cardiopulmonary resuscitation (0% vs. 12.9%, p = .040). Survival to discharge (AX, 81.6% vs. FA. 90.3%, p = .460), incidence of stroke (10.2% vs. 6.5%, p = .863), VA-ECMO cannulation-related bleeding (6.1% vs. 12.9%, p = .522), and arm or limb ischemia (0% vs. 3.2%, p = .816) were comparable. ECMO cannulation-related wound complications were lower in the AX group (AX, 4.1% vs. FA, 45.2%, p < .001) including the wound infections (2.0% vs. 32.3%, p < .001). In FA group, all organisms were gram-negative species. In univariate logistic regression analysis, AX cannulation was associated with less ECMO cannulation-related wound complications (Odds ratio, .23, p < .001). There was no difference between cutdown and percutaneous FA insertion regarding cannulation-related complications.

CONCLUSIONS

Given the lower rate of wound complications and comparable hospital outcomes with femoral cannulation, axillary VA-ECMO may be an excellent option in HT candidates or recipients when possible.

The spectrum of computed tomography findings in blunt trauma of the subclavian/axillary artery: a pictorial essay

Traumatic injuries of the subclavian and axillary arteries are uncommon but have high morbidity and mortality. In contrast to penetrating injuries, which are often lethal, blunt injuries present a wide and heterogeneous spectrum of imaging findings. If a vessel tear or transsection is a life-threatening circumstance, minor injuries might be overlooked in an emergency setting but could cause or aggravate the functional loss of a limb. The aim of this pictorial essay is to acquaint radiologists with the spectrum of imaging findings that could be encountered during the radiological evaluation of the subclavian/axillary artery (SAA) in trauma patients and offer tips and tricks to improve the diagnostic workup of patients with suspected blunt SAA injuries.

Rare high branching pattern from the first part of the right axillary artery

A 77-year-old female cadaver was observed to have a rare branching pattern of the right axillary artery (AA). The first part of the AA typically gives off only a superior thoracic artery (STA) but was observed to give off three branches in the case: a lateral thoracic artery (LTA), a thoracoacromial trunk, and a large common trunk (CT). The LTA travelled to provide a variant STA to the 1st and 2nd intercostal spaces. The CT provided an accessory LTA and accessory thoracodorsal artery before bifurcating into a subscapular artery (SA) and posterior humeral circumflex artery. As expected, the SA further divided into the circumflex scapular artery and thoracodorsal artery. A pectoral artery and the anterior humeral circumflex artery originated directly from the second and third parts of the AA, respectively. Knowledge of AA branching variations is of great clinical significance to anatomists, radiologists, and surgeons due to the high rate of injury to this artery.

Vascular Closure Devices For Axillary Artery Access: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the technical success and complication rates of vascular closure devices (VCDs) in the axillary artery.

MATERIALS AND METHODS

MEDLINE and Embase were searched independently by two reviewers to identify observational studies from inception through October 2021. The following outcomes were meta-analyzed: technical success, hematoma, dissection, pseudoaneurysm, infection, and local neurological complications. Complications were also graded as mild, moderate, and severe. A logistic regression evaluating the influence of sheath size for the outcome of technical success rate was performed using individual patient-level data.

RESULTS

Of 1496 unique records, 20 observational studies were included, totaling 915 unique arterial access sites. Pooled estimates were as follows: technical success 84.8% (95% confidence interval [CI]: 78%-89.7%, I2=60.4%), hematoma 7.9% (95% CI: 5.8%-10.6%, I2=0%), dissection 3.1% (95% CI: 1.3%-7.3%, I2=0%), pseudoaneurysm 2.7% (95% CI: 1.3%-5.7%, I2=0%), infection <1% (95% CI: 0%-5.7%, I2=20.5%), and local neurological complications 2.7% (95% CI: 1.7%-4.4%, I2=0%). There was a significant negative association between sheath size and technical success rate (odds ratio [OR]: 0.87 per 1 French (Fr) increase in sheath size, 95% CI: 0.80-0.94, p=0.0005). Larger sheath sizes were associated with a greater number of access-site complications (adjusted odds ratio [aOR]: 1.21 per 1 Fr increase sheath size, 95% CI: 1.04-1.40, p=0.013).

CONCLUSIONS

Off-label use of VCDs in the axillary artery provides an 85% successful closure rate and variable complication rate, depending on the primary procedure and sheath size. Larger sheaths were associated with a lower technical success and greater rate of access-related complications.

CLINICAL IMPACT

Safe arterial access is the foundation for arterial intervention. While the common femoral artery is a well established access site, alternative arterial access sites capable of larger sheath sizes are needed in the modern endovascular era. This article provides the largest synthesis to date on the use of vascular closure devices for percutaneous axillary artery access in endovascular intervention. It should serve clinicians with added confidence around this approach in terms of providing a reference for technical success and complications. Clinically, this data is relevant for patient consent purposes as well as for practice quality improvement in setting safety standards for this access site.

Hybrid Approach of a Complex Aneurysm of the Subclavian-Axillary-Brachial Axis: A Case Report

BACKGROUND

Upper extremity arterial aneurysms are a rare, potentially limb-threatening disorder. Due to its rarity, the best treatment modality and outcomes are not entirely established; however, there is a consensus that open surgery is the first-line treatment. We present a complex case of an arterial aneurysm of the subclavian-axillary-brachial axis adequately treated using a hybrid surgical and endovascular treatment.

CASE PRESENTATION

A 59-year-old man presented to the emergency department with acute ischemia of the right upper limb. An extensive thrombosed aneurysm of the subclavian-axillary-brachial axis was identified. The treatment was carried out in two stages. In the first phase, urgent limb revascularization was performed using the great saphenous vein to perform a subclavian-brachial artery bypass. Later, the aneurysm was excluded using a vascular plug and multiple coils. Successful treatment was achieved with no morbidity for the patient.

CONCLUSIONS

Although the gold standard for treating upper limb aneurysms is open surgery, endovascular techniques can be a significant adjunct, reducing treatment morbidity and even mortality.

Multicenter Experience of Upper Extremity Access in Complex Endovascular Aortic Aneurysm Repair

PURPOSE

Upper extremity access (UEA) for antegrade cannulation of aortic side branches is a relevant part of endovascular treatment of complex aortic aneurysms and can be achieved using several techniques, sites and sides. The purpose of this study was to evaluate different UEA strategies in a multicenter registry of complex endovascular aortic aneurysm repair (EVAR).

METHODS

In six aortic centers in the Netherlands, all endovascular aortic procedures from 2006 to 2019 were retrospectively reviewed. Patients who received upper extremity access during complex EVAR were included. Primary outcome was a composite endpoint of any access complication, excluding minor hematomas. Secondary outcomes were access characteristics, access complications considered individually, access reinterventions and incidence of ischemic cerebrovascular events.

RESULTS

417 patients underwent 437 UEA for 303 fenestrated/branched EVARs, and 114 chimney EVARs. Twenty patients had bilateral, 295 left-sided, and 102 right-sided UEA. 413 approaches were performed surgically and 24 percutaneously. Distal brachial access was used in 89 cases, medial brachial in 149, proximal brachial in 140 and axillary access in 59 cases. No significant differences regarding the composite endpoint of access complications were seen (DBA 11.3% vs. MBA 6.7% vs. PBA 13.6% vs. AA 10.2%; p=.29). Postoperative neuropathy occurred most after proximal brachial access (DBA 1.1% vs. MBA 1.3% vs. PBA 9.3 % vs. AA 5.1%; p=.003). There were no differences in cerebrovascular complications between access sides (right 5.9% vs. left 4.1% vs. bilateral 5%; p=.75). Significantly more overall access complications were seen after a percutaneous approach (29.2% vs. 6.8%; p=.002). In multivariate analysis the risk for access complications after open approach was decreased by male gender (OR 0.27; CI 95% 0.10 - 0.72; p= .009), while an increase in age per year (OR 1.08; CI 95% 1.004 - 1.179; p=.039) and diabetes mellitus type 2 (OR 3.70; CI 95% 1.20 - 11.41; p= .023) increased the risk.

CONCLUSION

Between the four access localizations, there were no differences in overall access complications. Female gender, diabetes mellitus type 2 and ageing increased the risk for access complications after surgical approach. Furthermore, a percutaneous upper extremity access resulted in higher complication rates than a surgical approach.

Delayed thrombosis of all upper limb arteries: A rare complication in the closed posterior elbow dislocation in the emergency department

Vascular injuries are one of the most feared complications of orthopedic emergencies such as fractures and dislocations. The proximity of neurovascular structures to most of the long bones and major joints makes them more vulnerable to injury. A proper and repeated clinical examination is always advised for early diagnosis and prompt management of these complications in the emergency department. We present a case of delayed extensive thrombosis of upper limb arteries, one of the rare complications of closed posterior elbow dislocation managed by surgical thrombectomy.

Brachial and axillary artery vascular access for endovascular interventions

OBJECTIVES

Endovascular access is usually achieved through the common femoral artery due to its large size and accessibility. Access through the upper extremity can however be necessary due to anatomic reasons, obesity, or peripheral arterial disease. The two main methods of access are surgical cutdown and percutaneous puncture. In this single-centre retrospective cohort study we compared complication risks for both surgical cutdown and percutaneous puncture of an upper arm approach.

MATERIALS AND METHODS

Data was obtained from patients receiving endovascular access through the brachial or axillary artery between 2005 and 2018. A total of 109 patients were included. Patient demographics including age, sex, medical history, smoking status, and actual medication were registered, as well as postoperative complications including hematoma, thrombosis, dissection, infection, pseudoaneurysm, nerve injury, reoperation, and readmission.

RESULTS

Access was achieved through surgical cutdown in 53% (n=58) and through percutaneous puncture in 47% (n=51) of patients. Fifty-eight percent (n=63) received access via the brachial artery and 42% (n=46) via the axillary artery. Complication rate was 25.0% (3 of 12) for surgical cutdown via the brachial artery, 29.4% (15 of 51) for percutaneous puncture via the brachial artery, and 10.9% (5 of 46) for surgical cutdown via the axillary artery. Major complication rate was 8.3% (1 of 12) for surgical cutdown via the brachial artery, 13.7% (7 of 51) for percutaneous puncture via the brachial artery, and 4.3% (2 of 46) for surgical cutdown via the axillary artery. There was no association between baseline patient characteristics and complication rate.

CONCLUSIONS

In this non-randomized retrospective study, surgical cutdown via the axillary artery was the safest option with fewest complications, but selection of patients may have blurred the results. Surgical cutdown and percutaneous puncture seem equally safe in terms of complication rate in the brachial artery.

Impella flow pump reinsertion after axillary graft thrombectomy: Technical points in replacing axillary Impella

Axillary Impella devices are increasingly employed for long-term support of patients with systolic heart failure and shock. Axillary access allows for awake support and ambulation, which carries an inherent risk of disconnection or malposition. We report a series of two cases where device replacement due to dysfunction and malposition can be completed safely through the original axillary graft using axillary graft thrombectomy, given that the clot burden could be a major source of morbidity to the patient.

Upper limb arterial pattern: clinical correlation and embryological perspective

Background

Variations in the upper limb arterial pattern are commonplace and necessitate complete familiarity for successful surgical and interventional procedures. Variance in the vascular tree may involve any part of the axis artery of the upper limb, including the axillary artery and brachial artery or its branches, in the form of radial and ulnar arteries, which eventually supply the hand via anastomosing arches.

Objectives

To study the peculiarities of the arterial pattern of the upper limb and to correlate them with embryological development.

Methods

The entire arterial branching of forty-two upper limbs of formalin fixed adult human cadavers was examined during routine dissection for educational purposes, conducted over a 3-year period in the Department of Anatomy, Lady Hardinge Medical College, New Delhi.

Results

The study found: 1) One case in which a common trunk arose from the third part of the axillary artery, which immediately splayed into four branches (2.4%); 2) High division of the brachial artery into ulnar and radial arteries, in 3 cases (7.1%); 3) Pentafurcation of the brachial artery into ulnar, interosseus, radial, and radial recurrent arteries and a muscular twig to the brachioradialis in 1/42 cases (2.4%); 4) Incomplete Superficial Palmar arch in 3/42 cases (7.1%); and 5) Presence of a median artery in 2/42 case(4.8%)

Conclusions

This study observed and described the varied arterial patterns of the upper limb and identified the various anomalous patterns, supplementing the surgeon’s armamentarium in various surgical procedures, thereby helping to prevent complications or failures of reconstructive surgeries, bypass angiography, and many similar procedures.

Unusual Presentation of a Severe COVID-19 Case With Axillary Artery Thrombosis

The coronavirus disease 2019 (COVID-19) pandemic has been evolving since early 2020 with high critical care mortality and morbidity. High mortality rates have been linked largely to respiratory failure. Hypercoagulability status induced by the massive inflammatory storm has led to a high rate of thrombotic events, whether arterial or venous, contributing to COVID-19 mortality especially in critically ill patients. Thrombotic events might be the presenting feature of the disease or might happen during hospitalization. In this case report, we describe a case of a 67-year-old male with severe COVID-19 pneumonia who was found on presentation to have left axillary artery thrombosis requiring embolectomy; the case was managed successfully. We reviewed the pathophysiology of hypercoagulability associated with COVID-19, clinical implications, and most recent treatment recommendations.

[Surgical treatment of a post-traumatic giant pseudoaneurysm of the axillary artery: a case report]

A false aneurysm of the axillary artery is an extremely rare complication of a lesion of this vessel. As few as several dozens of similar cases have been described in the available literature. We herein report a clinical case concerning surgical treatment of a 41-year-old patient who after a knife-inflicted injury had developed a 66x67 mm pseudoaneurysm of the axillary artery. The treatment consisted of several stages, thus requiring 2 hospitalizations. The first stage included an attempt to resect the aneurysm in an open fashion, followed by deployment of stent grafts in the axillary artery to exclude the aneurysm from circulation. The second stage consisted in elimination of the aneurysmal cavity, followed by decompression of the branches of the brachial plexus and the axillary vein. The patient was discharged on postoperative day 10 after the second surgical intervention.

[Surgical treatment of giant false aneurysm of the axillary artery]

Vascular damage is an important aspect in the structure of injuries. Untimely medical care in patients with peripheral artery damage is often followed by development of false aneurysm. This event may be complicated by aneurysm rupture and bleeding, peripheral arterial thromboembolism, hematoma infection and neuropathy following adjacent nerved compression. We report surgical treatment of a patient with giant false aneurysm of the left axillary artery following a knife wound 1 year ago. The patient did not appeal for qualified medical care and ensured haemostasis at home. The patient underwent surgery under endotracheal anaesthesia. Debridement of hematoma, closure of arterial wall defect and wound drainage were carried out through an approach in the upper and middle third of the left shoulder.

Percutaneous Axillary Access for Placement of Microaxial Ventricular Support Devices: The Axillary Access Registry to Monitor Safety (ARMS)

Supplemental Digital Content is available in the text.

Background:

There has been increasing utilization of short-term mechanical circulatory support devices for a variety of clinical indications. Many patients have suboptimal iliofemoral access options or reasons why early mobilization is desirable. Axillary artery access is an option for these patients, but little is known about the utility of this approach to facilitate short-term use for circulatory support with microaxial pump devices.

Methods:

The Axillary Access Registry to Monitor Safety (ARMS) was a prospective, observational multicenter registry to study the feasibility and acute safety of mechanical circulatory support via percutaneous upper-extremity access.

Results:

One hundred and two patients were collected from 10 participating centers. Successful device implantation was 98% (100 of 102). Devices were implanted for a median of 2 days (interquartile range, 0–5 days; range, 0–35 days). Procedural complications included 10 bleeding events and 1 stroke. There were 3 patients with brachial plexus–related symptoms all consisting of C8 tingling and all arising after multiple days of support. Postprocedural access site hematoma or bleeding was noted in 9 patients. Device explantation utilized closure devices alone in 61%, stent grafts in 17%, balloon tamponade facilitated closure in 15%, and planned surgical explant in 5%. Duration of support appeared to be independently associated with a 1.1% increased odds of vascular complication per day ([95% CI, 0.0%–2.3%] P=0.05).

Conclusions:

Percutaneous axillary access for use with microaxial support pumps appears feasible with acceptable rates of bleeding despite early experience. Larger studies are necessary to confirm the pilot data presented here.

Ruptured axillary artery pseudoaneurysm following an anterior glenohumeral dislocation: A case report

Vascular injuries following anterior shoulder dislocations are rare, with an estimated incidence of 1-2%. The formation of an axillary artery pseudoaneurysm secondary to vascular trauma is a possible late complication and frequently underdiagnosed since it may remain asymptomatic for many years. A rupture of a pseudoaneurysm may occur either from the dislocation itself or after forceful reduction attempts. A ruptured pseudoaneurysm of the axillary artery is a medical emergency and may result in significative upper-limb morbidity or even patient mortality. Nowadays, endovascular techniques have progressively gained ground for the treatment of such lesion, especially in an emergency context. In the present article, the authors present the case of a 77-years-old male patient with a rupture of a pseudoaneurysm of the left axillary artery after repeated forceful reductions of an anterior glenohumeral dislocation and its treatment with percutaneous endovascular stenting.

Axillary artery cannulation for veno-arterial extracorporeal membrane oxygenation support in cardiogenic shock

Objective

To review the outcomes of axillary artery (AX) and femoral artery (FA) cannulation for veno-arterial extracorporeal membraneous oxygenation (VA-ECMO).

Methods

From 2009 to 2019, 371 patients who were supported with VA-ECMO for cardiogenic shock were compared based on the arterial cannulation site: AX (n = 218) versus FA (n = 153).

Results

Patients in the AX group were older (61 years vs 58 years, P = .011), had a greater prevalence of peripheral vascular disease (13.8% vs 5.2%, P = .008), and were less likely to have undergone cardiopulmonary resuscitation preoperatively (18.8% vs 36.6%, P < .001). Other characteristics were similar between groups, as were in-hospital outcomes, including survival to discharge (60.6% vs 56.9%), cerebrovascular accidents (12.4% vs 10.5%), cannulation-related bleeding (15.1% vs 17%), and length of VA-ECMO support (6 days). The incidence of leg ischemia (6.9% vs 15.7%, P = .006), limb ischemia related to VA-ECMO cannulation (0% vs 10.5%), the need to switch the cannulation site (4.6% vs 14.7%), and wound complications (WCs; 2.8% vs 15%) including infection and additional procedure were significantly greater in the FA group (P < .001). In multiple logistic regression analysis, FA cannulation and primary graft failure after heart transplantation were independent risk factors for cannulation-related WC. In subgroup analysis among patients with primary graft failure, WCs were more prevalent in FA cannulation (3.6% vs 39.1%, P = .001).

Conclusions

AX cannulation for VA-ECMO is a safe and effective alternative to FA cannulation. It can be considered especially for patients with limited groin access, peripheral vascular disease, or for primary graft failure after heart transplant.

Scapulothoracic dissociation and blunt vertebral vascular injury: case report

Case Description:

A 24-year-old male suffers from a motor vehicle accident with penetrating neck trauma and concomitant closed left cervicothoracic trauma.

Clinical Findings:

High impact trauma causing hypovolemic shock, left zone I penetrating neck trauma, ischemia due to blunt trauma to the axillary vessels, and brachial plexus injury. Transection of the vertebral artery on angiotomography. Diagnosed with scapulothoracic dissociation and vertebral artery trauma.

Treatment and outcome:

Axillary arteriovenous reconstruction, fasciotomies, non-surgical approach of the vertebral artery trauma, and deferred treatment of the brachial plexus trauma were performed. Survival of the patient and his limb, with major neurologic sequelae

Clinical Relevance:

The case presented here is an example of scapulothoracic dissociation with associated trauma to the vertebral artery, injuries that are uncommon and associated with high morbidity and mortality. Early recognition of the injuries and a multidisciplinary approach for this complex case by surgical board reviews at various levels within the course of care were key determinants in the patient’s improved prognosis. This case report presents an analysis of the diagnostics, treatment, and course; considering in-hospital care and the decision-making process as determinants for the prognosis in a polytrauma patient.

Proximal arterial cannulation in thoracic aortic surgery-Literature review

Surgery on thoracic aorta is complex with a number of approaches being required depending on the pathology and anatomy that is specific to each patient and therefore, careful planning is required to ensure successful outcomes. Among the key factors that determine a satisfactory and safe operation is the choice of arterial cannulation site to establish cardiopulmonary bypass and deliver brain protection adequately. Direct proximal aortic cannulation is the gold-standard method for elective aortic root surgery and traditionally femoral arterial cannulation has been used in complex aortic surgeries such as redo or acute pathologies; however, axillary and innominate artery (IA) cannulation has evolved dramatically and several centers are currently using proximal cannulation sites as the default cannulation choice in elective and emergency settings of complex thoracic aortic surgeries. The evidence behind cannulating the IA is growing; however, it is yet to be well established through large studies or trial to confirm its superiority to other methods of central cannulation techniques.

Endovascular Repair for Ruptured Axillary Artery Aneurysm Proximal to Hemodialysis Access

Axillary artery aneurysms are uncommon and potentially high-risk lesions threatening the upper extremities. In hemodialysis patients, arteriovenous fistulae creation rarely triggers aneurysmal degeneration and arterial aneurysms in inflow arteries. These aneurysms are usually treated by surgical repair. However, this may lead to complications because of the anatomical complexity surrounding aneurysms of axillary arteries. We report a patient undergoing hemodialysis who had a ruptured ipsilateral axillary artery aneurysm proximal to vascular access. We successfully treated it by endovascular repair with the GORE Excluder AAA contralateral leg endoprosthesis, approaching from the left brachial artery proximal to the shunt. No complications occurred during 15 months after the endovascular repair.

A Detailed Analysis of the Blood Supply to the Subscapularis Muscle

This study aimed to provide a comprehensive description of the arterial supply to the subscapularis (SSC) muscle. This will provide critical information for various surgical procedures. Ten specimens of embalmed Korean cadavers were dissected and subjected to modified Sihler's method to reveal the branching pattern of the arteries surrounding the subscapularis, and its intramuscular blood supply. The SSC muscle was generally supplied by branches from the subclavian artery (suprascapular artery, supraSA; circumflex scapular artery, CxSA; and dorsal scapular artery, dSA) and the axillary artery (subscapular artery, subSA; lateral thoracic artery, LTA; posterior circumflex humeral artery, PCxHA; and a branch of the axillary artery, AAbr). The anterior aspect of the muscle was supplied by the subSA, LTA, CxSA, supraSA, and AAbr. The posterior aspect of the muscle was supplied by the supraSA, PCxHA, and subSA. The dSA was more scarcely distributed than the other arteries. In two cases, the dSA supplied the portion of the muscle near the medial border of the scapular. The anterior side of the muscle tendon was supplied by the CxSA, and its posterior side was supplied by the PCxHA. The subSA can be considered to be the main branch supplying the SSA based on its distribution area of arteries. It was mostly situated within the lower region of the SSC. After distributing to the anterior surface of the SSC, some branches of the subSA reached the posterior surface as perforating branches. Clin. Anat. 32:642-647, 2019. © 2019 Wiley Periodicals, Inc.

Axillary artery pseudoaneurysm and distal ulnar embolization in collegiate pitcher: a case report and review

Twenty five-year-old pitcher presented with acute right middle and index finger numbness and coolness. Angiogram showed a 5mm axillary pseudoaneurysm and near complete occlusion of ulnar and common interosseous artery, ulnar side of the palmar arch, and ulnar digital artery. Patient deferred surgery, treatment with tPA and heparin succeeded in reperfusion.

Blood supply and vascularity of the glenoid labrum: Its clinical implications

BACKGROUND

Tears of the glenoid labrum are common after dislocation of the glenohumeral joint. The outcome for healing or surgical reconstruction of the glenoid labrum relies on the extent of its vascularization. This study aims to evaluate the glenoid labrum blood supply and to determine its regional vascularity.

MATERIALS AND METHODS

A total of 140 shoulders (30 male and 40 female cadavers) were examined: mean age 81.5 years, range 53-101 years. All blood vessels around the glenohumeral joint were dissected and recorded. Ten specimens with the glenoid labrum and fibrous capsule attached were randomly selected and detached at the glenoid neck and subjected to decalcification. Sections (10-20 μm) were cut through the whole thickness of each specimen from the centre of the glenoid fossa perpendicular to the glenoid labrum at 12 radii corresponding to a clock face superimposed on the glenoid. Sections were stained using haematoxylin and eosin and then examined.

RESULTS

The blood supply to the glenoid labrum is by direct branches from the second part of the axillary artery, subscapular, circumflex scapular and anterior circumflex humeral and posterior circumflex humeral arteries, as well as branches of muscular arteries supplying the surrounding muscles.

CONCLUSION

This study shows that the glenoid labrum has a rich blood supply suggesting that, regardless of the types of the glenoid labrum lesions or their management, an excellent outcome for glenoid labrum healing and joint stability is possible. The observations also suggest that the blood supply to the glenoid labrum is sufficient, enabling its reattachment.

Variations in the origin and course of the suprascapular artery: case report and literature review

The suprascapular artery is normally a branch of the thyrocervical trunk of the subclavian artery. During dissection of the left upper limb of a female cadaver, aged 70 years and fixed in 10% formalin solution, the suprascapular artery was observed aberrantly arising from the first part of the axillary artery. Later, it coursed obliquely behind the clavicle bone and brachial plexus to reach the suprascapular notch, where it was accompanied by the suprascapular nerve. Then, both suprascapular nerve and artery anomalously traversed beneath the transverse scapular ligament. It then irrigated the supraspinatus muscles and took part in the anastomosis around the scapula. On the contralateral side there was no abnormality. Variations in the origin and course of suprascapular artery are of immense value to orthopedic and vascular surgeons, angiographists, and anatomists.

Abnormal Communication between Lateral Thoracic Artery and Anterior Circumflex Humeral Artery - a Case Report

Variations in the branching pattern of axillary artery are observed by many anatomists all over the world. A unique bilateral variation in the axillary artery was observed during the routine dissection of the upper limbs on an approximately 65 year old male cadaver. An abnormal communicative channel was observed between lateral thoracic artery and anterior circumflex humeral artery. It passed between the two roots of median nerve. Arterial anomalies in the upper limb are due to defective remodelling of vascular plexus of the upper limb bud during embryogenesis. Knowledge of variations in axillary artery is quintessential for surgeons, radiologists and anaesthesiologists to avoid treacherous complications during procedures.

Recannulation of the axillary artery in aortic and complex cardiac surgery

OBJECTIVES

Axillary artery cannulation has been used as an alternative site for cardiopulmonary bypass during surgery for aortic dissections and aneurysmal disease of the ascending aorta and arch. This study reports our experience with reusing the axillary artery for cardiopulmonary bypass during complex aortic and cardiac surgical procedures.

METHODS

This was a retrospective review of a single surgeon's experience of recannulating the axillary artery for redo operations in complex aortic surgery. Seven patients over a 7-year period have undergone recannulation of their axillary arteries. The old Dacron graft stump was either excised and a new graft was anastamosed to the axillary artery or a new end-to-side anastamosis was performed either proximal or distal to the original graft stump.

RESULTS

There were no deaths, strokes, or postoperative complications. In one patient, axillary cannulation was aborted intraoperatively due to high-line pressures, suggesting a local dissection. The other patients all had adequate perfusion via the recannulated axillary artery and there were no complications associated with its reuse.

CONCLUSIONS

Recannulation of the axillary artery is easily achievable and should be considered in redo aortic and complex cardiac surgery.

Axillary versus innominate artery cannulation for antegrade cerebral perfusion in aortic surgery: design of the Aortic Surgery Cerebral Protection Evaluation (ACE) CardioLink-3 randomised trial

INTRODUCTION

Neurological injury remains the major cause of morbidity and mortality following open aortic arch repair. Systemic hypothermia along with antegrade cerebral perfusion (ACP) is the accepted cerebral protection approach, with axillary artery cannulation being the most common technique used to establish ACP. More recently, innominate artery cannulation has been shown to be a safe and efficacious method for establishing ACP. Inasmuch as there is a lack of high-quality data comparing axillary and innominate artery ACP, we have designed a randomised, multi-centre clinical trial to compare both cerebral perfusion strategies with regards to brain morphological injury using diffusion-weighted MRI (DW-MRI).

METHODS AND ANALYSIS

110 patients undergoing elective aortic surgery with repair of the proximal arch requiring an open distal anastamosis will be randomised to either the innominate artery or the axillary artery cannulation strategy for establishing unilateral ACP during systemic circulatory arrest with moderate levels of hypothermia. The primary safety endpoint of this trial is the proportion of patients with new radiologically significant ischaemic lesions found on postoperative DW-MRI compared with preoperative DW-MRI. The primary efficacy endpoint of this trial is the difference in total operative time between the innominate artery and the axillary artery cannulation group.

ETHICS AND DISSEMINATION

The study protocol and consent forms have been approved by the participating local research ethics boards. Publication of the study results is anticipated in 2018 or 2019. If this study shows that the innominate artery cannulation technique is non-inferior to the axillary artery cannulation technique with regards to brain morphological injury, it will establish the innominate artery cannulation technique as a safe and potentially more efficient method of antegrade cerebral perfusion in aortic surgery.

TRIAL REGISTRATION NUMBER

NCT02554032.

Anatomical variations of median nerve formation, distribution and possible communication with other nerves in preserved human cadavers

Formation, distribution and possible communication of the median nerve are essential to know in treatment and surgeries of various conditions of injuries e.g. repair or reconstruction of the median nerve post traumatic accident. In the present study, 44 upper limbs were dissected. Root forming the median nerve, the median nerve in relation with the axillary artery and communication of the median nerve with other nerves were noted.

Preferential short cut or alternative route: the transaxillary access for transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) has gained widespread acceptance as a treatment option for patients at high risk for conventional aortic valve replacement. The most commonly used access site for TAVI is the common femoral artery. Yet, in a significant number of patients the transfemoral access is not suitable due to peripheral vascular disease of the lower extremity. In these cases the transaxillary approach can serve as an alternative implantation route. By considering the anatomical requirements and providing an adequate endovascular "safety-net" during the procedure the transaxillary TAVI approach results in excellent procedural and clinical outcome. However, whether the transaxillary access for TAVI is superior to other non-transfemoral approaches (e.g., transapical or direct aortic) needs to be studied in the future in a prospective randomized trial.

Role of TGF-β Signaling in Remodeling of Noncoronary Artery Aneurysms in Kawasaki Disease

Coronary artery aneurysms (CAA) remain an important complication of Kawasaki disease (KD), the most common form of pediatric acquired heart disease in developed countries. Potentially life-threatening CAA develop in 25% of untreated children and 5% of children treated with high-dose intravenous immunoglobulin during the acute phase of the self-limited vasculitis. Noncoronary artery aneurysms (NCAA) in extraparenchymal, muscular arteries occur in a minority of patients with KD who also have CAA, yet little is understood about their formation and remodeling. We postulated that activation of the transforming growth factor-β (TGF-β) pathway in KD may influence formation and remodeling of aneurysms in iliac, femoral, and axillary arteries, the most common sites for NCAA. We studied a resected axillary artery from one adult and endarterectomy tissue from the femoral artery from a second adult, both with a history of CAA and NCAA following KD in infancy. Histology of the axillary artery aneurysm revealed destruction of the internal elastic lamina and recanalization of organized thrombus, while the endarterectomy specimen showed dense calcification and luminal myofibroblastic proliferation. Immunohistochemistry for molecules in the TGF-β signaling pathway revealed increased expression of TGF-β2, TGF-β receptor 2, and phosphorylated SMAD3. These findings suggest ongoing tissue remodeling of the aneurysms decades after the acute injury and demonstrate the importance of the TGF-β signaling pathway in this process.

The Clinical Significance of Ulnar Artery Morphology in Artificial Arterial-Venous Fistula for Hemodialysis

BACKGROUND

The ulnar artery is a terminal branch of the brachial artery. The aim of this study is to provide comprehensive data concerning the morphology of the ulnar artery, with clinical implications for surgeons.

METHODS

The current study includes the dissection of 68 upper limb specimens. It investigates the characteristics of the ulnar artery such as the internal diameter, external diameter, wall thickness, and distance of the ulnar artery origin.

RESULTS

In this study, the ulnar artery arose distal to the superior margin of the head of the radius in 82.65% of cases. The angle degree of the ulnar artery with respect to the brachial artery ranges from to 8° to 30°. The internal and external diameters of the ulnar artery were found to decrease gradually from proximal to distal in both genders. The external and internal diameters of the ulnar artery are greater in males than in females. In all cases, the external and internal diameters and the thickness of the ulnar artery at three levels were found to be greater in the right ulnar artery than the left.

CONCLUSION

The right ulnar artery may be the appropriate choice for artificial arterial-venous fistula for haemodialysis. Due to its wide diameter, the proximal part of the radial artery is a suitable site for the artificial arterial-venous fistula immediately below the origin prior to its profound course. Therefore, it is an easy access for artificial arterial-venous fistula for surgeons. The radiologists must alert the surgeons for surgical modification in the case of high brachial bifurcation.

Association between screw prominence and vascular complications after clavicle fixation

Context:

Fixation of clavicle fractures has become more common to prevent symptomatic malunion and nonunion. The subclavian and axillary vessels are in close proximity to the medial two-thirds of the clavicle, placing them at risk from prominent metalware. Injury to these major vessels has the potential to be life or limb-threatening. Despite this anatomical risk, iatrogenic vascular injury associated with clavicle fixation is rare.

Aims:

The aim of this study was to identify risk factors associated with modern fixation techniques in reported cases of vascular injury after clavicle fixation.

Materials and Methods:

A literature search was performed, and all identified cases of iatrogenic vascular injury associated with prominent clavicle fixation were analyzed. Clinical details, the total length of the prominent screws and the distance that they protruded from the far cortex were recorded.

Results:

Five cases were identified; there were four pseudoaneurysms and one arteriovenous fistula. The total length of the offending screw was identifiable in two cases, measuring 26 and 30 mm. The length of screw prominence was identifiable in 3 cases (8, 10 and 10 mm). The pseudoaneurysms presented at 2-10 years following clavicle fixation. Three of these cases developed limb-threatening ischemia.

Conclusions:

Vascular complications associated with clavicle fixation are uncommon but potentially limb-threatening. Several associated factors are identified. The authors provide a number of detailed recommendations aimed at preventing these complications.

Left ventricular assist device outflow graft: alternative sites

We describe three alternative approaches for the left ventricular assist device (LVAD) outflow graft during implantation of the LVAD. The supraceliac abdominal aorta, innominate artery and left axillary artery were employed as alternative sites for the LVAD outflow graft in the setting of a heavily calcified ascending aorta or a hostile chest wall and mediastinum. The first approach involved the use of the supraceliac abdominal aorta. Given that the patient had a history of multiple previous breast surgeries and chest wall radiation for breast cancer treatment, a left subcostal incision was employed as a sternotomy-sparing approach. The second approach was the use of the innominate artery in a patient with a porcelain ascending aorta. The patient underwent pulmonary valve replacement, right ventricle outflow tract reconstruction and tricuspid valve annuloplasty in addition to the LVAD implantation. The third approach was the use of the left axillary artery. This patient had a history of LVAD implantation and subsequently developed infection with pseudoaneurysm formation at the aortic anastomosis of the outflow graft. We conclude that the supraceliac abdominal aorta, the innominate artery and the left axillary artery are potential alternative routes for the LVAD outflow graft in the settings of heavily calcified ascending aorta or a hostile chest wall and mediastinum. Although the described alternative approaches are safe and viable options, we highly recommend utilizing these approaches only in selected patients with significantly higher risks and hazards to the standard surgical approach.

Through-and-through wire technique for endovascular damage control in traumatic proximal axillary artery transection

Repair of blunt shoulder trauma with transection of the subclavian or proximal axillary artery poses a surgical challenge, especially in instable patients. Endovascular treatment for initial damage control in arterial transection has evolved as a promising technique to improve outcome, but technical success can be limited in cases of complete transection as the lesion cannot be passed by a guidewire. This report describes an endovascular approach using a through-and-through brachial-femoral wire to control complete traumatic transection of the proximal axillary artery in a hemodynamically unstable patient. Endovascular therapy is used as a bridging method for open surgical repair three days later under optimized conditions with an interdisciplinary team. The brachial-femoral guidewire technique helps to overcome limitations in endovascular therapy in patients with blunt traumatic transection of thoracic outlet arteries.

Variant origin of an arterial trunk from axillary artery continuing as profunda brachii artery--a unique arterial variation in the axilla and its clinical implications

Background

Axillary artery is known to show different variations mostly in its branching pattern. Similarly, the origin of profunda brachii is often encountered with abnormality. Therefore, when the vascular variations in the upper limb persist, mostly it is confined to its branching pattern followed by its variant origin. But, among all the reported variations of profunda brachii, its variant origin from the 3rd part of the axillary artery with common trunk for the branches of axillary artery is unique.

Case Details

We report here an anomalous origin of profunda brachii as continuation of an arterial trunk arising from 3rd part of the axillary artery. This common trunk at its commencement passed between 2 roots of median nerve and gave branches of 3rd part of axillary artery before it continued as profunda brachii artery. The further course and branching pattern of profunda brachii were normal.

Conclusion

Since the axillary artery is next choice of artery for arterial canulation in cardiopulmonary bypass procedures, prior knowledge of existence of such variation in its branching pattern helps in avoiding possible diagnostic or interventional therapeutic errors.

Anatomic and flow dynamic considerations for safe right axillary artery cannulation

OBJECTIVES

Neuroprotection is of paramount interest in cardiac surgery. Right axillary artery cannulation is well established in aortic surgery because it significantly improves survival and outcome, but malperfusion of the right brain after direct cannulation has been reported. Anatomically, 4 vessel segments are potentially amenable for cannulation of the subclavian and axillary arteries. Clinical studies vary widely in dissection sites and cannulation techniques. We investigated critical flow dynamics in the right brain caused by arterial inflow after direct cannulation and specified cannulation positions that provide optimal cerebral perfusion.

METHODS

Distances from the lateral margin of the axillary artery and the subclavian artery to the origin of the vertebral artery were measured in 14 human corpses by a flexible ruler. We calculated the hemodynamics within the vertebral artery, depending on different positions of the cannula tip, in a computer-calculated model.

RESULTS

The mean distance from the axillary artery to the vertebral artery was 8.5 cm, and the mean distance from the subclavian artery to the vertebral artery was 6.7 cm. Computed flow calculations demonstrated reversed flow in the vertebral artery when the cannula tip was positioned too close to its orifice. To ensure safe supra-aortic flow, a cannula can be inserted securely up to 6.0 cm into the axillary artery and 4.2 cm into the subclavian artery.

CONCLUSIONS

Direct cannulation of the right axillary artery can lead to cerebral malperfusion, caused by an obstruction of the vertebral artery's orifice by the arterial cannula or a subclavian steal phenomenon due to flow reversal. The safety of direct axillary artery cannulation can be improved by a well-considered dissecting site and insertion length of the cannula.