traumatic pseudoaneurysm of axillary artery combined with brachial plexus injury peng feng m.d....
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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