THE ELDERLY FRAGILE AXILLARY ARTERY – MANAGEMENT LESSONS LEARNED FROM FOUR SERIOUS IATROGENIC INJURIES

Abstract

Introduction: Injury to the distal third of the axillary artery is well recognised as a complication of proximal humeral fractures. However the risk of iatrogenic injury at shoulder surgery has not, to date, been fully appreciated.

Patients: Four female patients aged 59 and over who suffered iatrogenic injury to the axillary artery at the time of shoulder surgery are reported. Two occurred during surgery for planned elective shoulder arthroplasty, while two occurred while treating elderly patients who had previously sustained a 3 part proximal humeral fracture. In all 4 cases the injury probably started as an avulsion of the anterior or posterior humeral circumflex vessels.

Results: Vascular surgeons were called in urgently to help with the management of all 4 cases. In two cases the axillary artery was found to have extensive atheroma, was frail and, after initial attempts at end-to-end repair, it became clear that a reversed vein graft was required. Three patients had a satisfactory outcome after reconstruction, while one patient who had previously had local radiotherapy for malignancy, but was now disease free, developed a completely ischaemic upper limb and required a forequarter amputation to save her life.

Message: The axillary artery can be very frail in the elderly, is often diseased with atheroma, and is vulnerable to iatrogenic injury at surgery. If injury occurs at surgery, small bulldog clamps should be applied to the cut ends and a vascular surgeon should be called immediately. A temporary arterial shunt should be considered urgently to provide an early return of vascularisation to the limb and to prevent serious complications. The axillary artery is very difficult to repair, and, in our experience may require a vein graft. In addition, distal clearance of the main brachial artery with a Fogarty catheter which is an essential part of the management.