11 Axillary Vessels
11 Axillary Vessels
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The present video describes in detail the surgical exposure of the axillary vessels and demonstrates the damage control approach to an axillary artery injury.
Segment:1 Anatomy and General Principles.
The axillary vessels start under the middle of the clavicle and curve downwards, deep under the deltopectoral groove. Part of the vessels is under the pectoralis minor muscle.
The vein is below and more superficial than the artery. Note the cephalic vein crossing over the pectoralis minor muscle and joining into the proximal axillary vein.
Segment:2 Positioning and Landmarks.
The patient is positioned supine, with the arm abducted 45 degrees and the head slightly tilted to the opposite side. The key external landmark is the clavicle.
The mid-point of the clavicle is where the incision starts.
It then curves downwards into the deltopectoral groove to reach the axilla. The skin and subcutaneous tissue are incised, bound to the fascia. The first muscle identified is the pectoralis major. It can be spread in the direction of its fibers, but this is not ideal in the trauma setting. Dividing it provides a better exposure. We dissect the upper and lower border of the muscle to identify its insertion.
The fibers are then divided two to three centimeters from the insertion on the humerus bone. Stay sutures are placed on the edges of the divided pectoralis major muscle, and the muscle is retracted medially.
Segment:4 Identification of Pectoralis Minor.
Underlying the pectoralis major, we find the pectoralis minor muscle, with its fibers running perpendicularly to the pectoralis major. The insertion of this muscle is on the coracoid process.
This muscle is the key anatomical landmark for the axillary artery. It divides the artery in three parts medial to the pectoralis minor is the first part, the second part is underlying the muscle, and the third part is lateral to the muscle. Lateral to the pectoralis minor, we find inferiorly and superficially the axillary vein. Overlying the axillary artery is the brachial plexus.
Superiorly and posteriorly, we find the third part of the axillary artery.
Segment:5 Division of Pectoralis Minor.
Once the insertion of the pectoralis minor is identified, it is divided perpendicularly to its fibers to expose the second part of the axillary artery. Two stay sutures are placed in a similar fashion on both ends of the muscle to retract it inferiorly. This maneuver exposes the second part of the axillary artery with its two branches, the thoracoacromial trunk and the lateral thoracic artery.
Overlying the artery is the brachial plexus. Inferiorly and superficially is the axillary vein, which you can see going underneath the clavicle where it becomes a subclavian vein.
Segment:6 Axillary Artery Injury.
This image demonstrates the transaction of the axillary artery secondary to penetrating injury. Proximal and distal control were obtained. We pulled our clamps, with care taken not to injure the brachial plexus and axillary vein.
Segment:7 Damage Control.
In a damage control situation, a temporary shunt can be placed to restore flow. In this case, we use the largest argyle shunt that accommodates the vessel, a size 12 French. The shunt is kept long and secured in place with 2-0 silk ties. The ties are placed proximally and distally on the vessel, and then tied together to prevent shunt displacement. In summary, the axillary vessels are accessed
by an infraclavicular incision that starts at the middle third of the clavicle.
The first muscle encountered and divided is the pectoralis major. Underneath is the pectoralis minor, which marks the incision between the first, second, and third portion of the axillary artery. The vein is found inferiorly and superficially. The brachial plexus is closely related to the artery and associated nerve injuries are not infrequent.