Traumatic Traumatic

pseudoaneurysm of pseudoaneurysm of

axillary artery combined axillary artery combined

with brachial plexus injurywith brachial plexus injury

Peng Feng M.D.Peng Feng M.D.

Department of Hand Surgery, Department of Hand Surgery,

Huashan Hospital, Fudan Huashan Hospital, Fudan UniversityUniversity

TTraumatic raumatic PPseudoaneurysm of seudoaneurysm of

AAxillary xillary AArtery rtery (TPAA)(TPAA)BBrachial rachial PPlexus lexus IInjurynjury(BPI)(BPI)

TPAA combined with BPI TPAA combined with BPI

• extremely rare extremely rare

• reported only in a few cases.reported only in a few cases.

• The influence factors are unclear. The influence factors are unclear.

1999.6 -2009.4, 7 patients with TPAA + BPI 1999.6 -2009.4, 7 patients with TPAA + BPI

The cause of damageThe cause of damage

Neurological and vascular deficits Neurological and vascular deficits

Surgical findings of the nerves and vesselsSurgical findings of the nerves and vessels

The recovery function of pain, vessels and The recovery function of pain, vessels and

nervesnerves

Materials and MethodsMaterials and Methods

Materials and MethodsMaterials and Methods

Case No. Gender Age(year) Lateral side Cause of Injury

1 F 45 L A fall

2 M 16 L A Knife stab

3 F 18 L A Traffic accident

4 M 26 L A Knife stab

5 M 9 L A Traffic accident

6 M 40 L A Traffic accident

7 F 45 L A Glass stab

Average - 28.4 - -

Case No.

Thrill Mass

Radial Pulse

Fracture

WorkupHemachrome

(g/L)Ultrosound

(cm) CTA DSA

1 － + － 60 20*15 / /

2 ++ － － 128 7*5 / /

3 ± ± + 112 7*4.3 / +

4 ± + － 125 15*10 / /

5 ± － + 80 3*3.5 / /

6 + ＋ + 90 3.5*2.2 + /

7 ± ± － 119 3*2 + /

Materials and MethodsMaterials and Methods

ResultsResults - - Pain EvaluationPain Evaluation

Followed up 4.7 years (18 months-11 years)Followed up 4.7 years (18 months-11 years)

Pre-operation the characteristics of pain: Pre-operation the characteristics of pain:

1) Constant, Distending and Pulsating1) Constant, Distending and Pulsating

2) The pain became more intense with time2) The pain became more intense with time

3) Need analgesics to control the pain3) Need analgesics to control the pain

Postoperation All patients released painPostoperation All patients released pain

ResultsResults - Pain evaluation - Pain evaluation

Case No.

VAS

InitialOn Admission

to hospitalthe first day

after operationOn Discharge from hospital

Final follow-up

1 0 6 2 2 0

2 0 5 3 2 0

3 2 6 3 2 0

4 2 5 2 1 0

5 4 8 2 1 0

6 3 6 2 1 0

7 0 5 2 2 0

Average 1.6 5.9 2.3 1.6 0

ResultsResults - Vascular evaluation- Vascular evaluation

All patients retained radial artery pulseAll patients retained radial artery pulse

One patient consequently underwent One patient consequently underwent

endovascular therapy for an obstructed endovascular therapy for an obstructed

subclavian artery subclavian artery

Results Results - Neurological evaluation- Neurological evaluation

ContinuitiesContinuities of brachial plexus: of brachial plexus:

No. 4 patient partial severance injury of the No. 4 patient partial severance injury of the

medial cordmedial cord

ContusionContusion of brachial plexus: of brachial plexus:

Be observed in all of 7 patients. Be observed in all of 7 patients.

The recovery of The recovery of motor functionmotor function::

Good in 5 cases, fair in 2 casesGood in 5 cases, fair in 2 cases

These 2 cases were These 2 cases were medial cord injurymedial cord injury

The recovery of The recovery of sensory functionsensory function::

good in all patients good in all patients

Results Results - Neurological evaluation- Neurological evaluation

Thrill Mass （（ ++ ））

Radial Pulse （（ ++ ））

Muscle power of Muscle power of Shoulder and elbow Shoulder and elbow

joint: 0joint: 0

X-rayX-ray

Left clavicular

fracture

Case No.6

MaleMale ，， 40y40y ，， 7 days after a traffic 7 days after a traffic accident accident

CTA: pseudoaneurysm of left CTA: pseudoaneurysm of left

axillary artery axillary artery

Case No.6

Laceration at anterior wall of AA

Case No.6

Surgical techinique

Control the Control the blood supply of the

pseudoaneurysm

subclavian

artery

axillary

artery

Laceration at

anterior wall

of AA

Clavicular

fracture

Surgical techinique

Brachial plexus

neurolysis

Vessel wall repair directly

★★ ▲▲ ◆◆

Surgical techinique

ORIF of fracture

Follow-up after 3 months

Radial Pulse Radial Pulse （（ ++

++ ））

Follow-up after 15 months

Radial Pulse Radial Pulse （（ ++

++ ））

Atypical symptom Atypical symptom – –

expanding hematoma/continuous expanding hematoma/continuous

thrill/diminished radial artery pulse pressure thrill/diminished radial artery pulse pressure

may may be absent or unclear be absent or unclear in this regionin this region

Constant pain Constant pain – distending and pulsating– distending and pulsating

Clinical feature and diagnosis of Clinical feature and diagnosis of TPAATPAA

Discussion

UltrasoundUltrasound Cheap, non-invasive, Cheap, non-invasive,

perform at the bedside perform at the bedside

CTACTA Non-invasive, 3-D Non-invasive, 3-D

DSADSA I Invasive, time consuming, nvasive, time consuming,

associated with complications associated with complications

Discussion

Clinical feature and diagnosis of Clinical feature and diagnosis of TPAATPAA

The two patients with fair motor function The two patients with fair motor function

results were the medial cord injury results were the medial cord injury

patientspatients

The affected cord of brachial plexus The affected cord of brachial plexus

Prognosis of BPIPrognosis of BPI

Discussion

Pseudoaneurysm without nerve injuresPseudoaneurysm without nerve injures

Endovascular treatmentEndovascular treatment

TPAA cTPAA combined with BPIombined with BPI

Operative treatment Operative treatment ？？

Endovascular treatment first ?Endovascular treatment first ?

Endovascular treatment orEndovascular treatment or operative treatment? operative treatment?

Discussion

Operative treatment Operative treatment : : VesselVessel ：： vessel repairvessel repairBrachial plexusBrachial plexus ：： neurolysis/nerve neurolysis/nerve repairrepair

FractureFracture ：： ORIFORIF

Surgical riskSurgical risk

Clinical Clinical

experienceexperience

Endovascular treatmentEndovascular treatment or operative treatment? or operative treatment?

Discussion

Endovascular treatment firstEndovascular treatment first: :

Stage-ⅠStage-Ⅰ ：： Endovascular treatmentEndovascular treatment

Stage-ⅡStage-Ⅱ ：： operative treatmentoperative treatment

It should be undertaken as soon as possibleIt should be undertaken as soon as possible

Endovascular treatment orEndovascular treatment or operative treatment? operative treatment?

Discussion

Stage-ⅠStage-Ⅰ

Endovascular Endovascular treatmenttreatment

Abandon the posterior cord which was embedded in the hard scar and performed a 6-cm length of cable nerve graft.the hematoma in the pseudoaneurysm becomes organization and forms a solid mass after endovascular therapy

operative treatment operative treatment

after 1 monthafter 1 month

Conclusions

Constant and expansive painConstant and expansive pain

Ultrasound Ultrasound +CTA+CTA

Operative treatment Operative treatment

Thank Thank

you you