Start by placing the patient in the supine position with the arm abducted slightly (no more than 30°). The arm should be supported by a mobile board. Make sure that the chest, neck, shoulder, arm, and hand are included in the sterile field. Also, the ipsilateral or contralateral leg should be prepped in the event a vein conduit needs to be harvested. The incision is placed below, parallel, and at the middle of the clavicle. The incision is then curved down slightly over the deltopectoral groove. You should make a very generous incision, especially if the extent of injury is not known. This will later facilitate obtaining proximal and distal control of the vessel. Electrocautery is used to dissect through the subcutaneous tissue and the fascia over the pectoralis major muscle. Use a self-retaining retractor to keep the skin wound open here, especially if you are limited with surgical assistants. The axillary vessels are deep to the pectoralis major and minor muscles. Whether you want to divide the muscle or split the muscle for retraction depends on the status of the injured vessel and whether there is ongoing active bleeding that requires rapid control. If you encounter active bleeding, rapid and wide exposure is absolutely necessary. In this situation, you should divide the pectoralis major muscle with electrocautery approximately 2 cm from its attachment to the humerus. You can use a tonsil or a Kelly clamp placed deep to the muscle to facilitate its division. Next, you should divide the pectoralis minor tendon close to its insertion into the coracoid process (Fig. 65.2b). This can be rapidly accomplished by sliding an Army-Navy retractor behind the muscle and elevating it for easy visualization and division. The pectoralis minor muscle will withdraw the tendon inferomedially, exposing the axillary vessels as well as the brachial plexus (Fig. 65.2a). You will find the axillary vein inferior to the artery. In the absence of active bleeding, you should split the pectoralis major muscle in the line of its fibers using a Kelly clamp. You can use another self-retaining retractor to keep the muscle split, or have a colleague help retract the muscle with two Army-Navy retractor or two small Richardson retractors. Proceed with dividing the pectoralis minor tendon as described above to achieve adequate exposure to the axillary vessels.

Although the techniques and anatomy for exposure of the axillary vessels are relatively straightforward and simple when demonstrated in textbooks or on a cadaver, this can be incredibly challenging to even the most experienced surgeon in select cases. A quick assessment of the body habitus can give you a reliable guide to the likely difficulty of exposure. Obesity can be a primary contributor to difficult exposure for this and any vascular injury, but the most difficult patients for axillary artery exposure tend to be large but physically fit males with well-developed pectoral musculature. It is important in these patients to make a generous skin incision and extend as needed, to open the subsequent layers completely so as to avoid digging a deeper and narrower hole as you approach the artery, and to be prepared to abandon this exposure in favor of a more proximal subclavian artery exposure to gain inflow control.

Management of the injury depends on the hemodynamic status of the patient and the mechanism of the injury (stab wound versus gunshot wound). Your goals are to stop the hemorrhage and restore arterial flow and limb perfusion. For arterial injuries that are actively bleeding, you need to gain proximal and distal control using vascular clamps. Medium-sized bulldog clamps are very effective and do not take up the same space as traditional vascular clamps. By using a generous incision, a large length of the vessel can be easily exposed and you should have no trouble obtaining control. In patients who are in extremis, a temporary intravascular shunt can be placed easily, followed by wound packing and transfer back to the intensive care unit. There are multiple commercial shunts available; the simplest of these are the flexible PVC tube shunts (Argyle) routinely used in carotid surgery. Choose the largest shunt that fits the vessel lumen and insert it through the injury proximally and distally. Ensure that the shunt is well secured to the artery by a 3-0 silk suture at the proximal and distal end. This maneuver is rarely needed with civilian peripheral vascular injuries. Although it has been described, ligation of the artery in this setting should be avoided.

For the vast majority of patients, you can safely repair the injured vessel. Make sure you have Fogarty catheters available (usually size 3 and 4) and plenty of heparinized saline that can be flushed into the open vessel. For stab wound injuries, simple repair of the vessel without any debridement is all you need to do. First you should remove any distal clot by catheter thrombectomy (start with the size 3 Fogarty first, and if it is too small, the size 4 Fogarty catheter should suffice) (Fig. 65.3). You should flush the proximal and distal ends of the open vessel with heparinized saline. This local heparinization is adequate enough to preclude the use of systemic heparinization. The vessel is usually not completely transected and you can repair the injury using a 6-0 Prolene suture in an interrupted fashion. Even with full transection of the vessel, you can perform an end-to-end anastomosis either in a running or interrupted fashion using a 6-0 Prolene suture (Fig. 65.4a, b). With gunshot injuries, you have to debride the injured artery back to the healthy intima (Fig. 65.5), making a simple repair usually impossible and requiring the use of an interposition graft. The choice of whether to use an autologous proximal saphenous vein graft or a prosthetic polytetrafluoroethylene (PTFE) graft is determined by the physiologic status of the patient, the presence of an appropriate size-matched vein, and your personal preference as the operating surgeon. To date there is no evidence for the superiority of either one. Once you decide on a conduit, the anastomoses are constructed using a 6-0 Prolene suture (Fig. 65.4). Make sure to remember to perform catheter thrombectomy and infuse local heparinized saline as described above. Once the repair is complete, you should perform a completion angiogram to assess the anastomosis and distal runoff. Fill a 20-cc syringe with contrast solution and attach it to a large angiocatheter. Insert the angiocatheter proximal to the anastomosis and occlude the inflow by placing a bulldog clamp more proximally. Complete the on-table angiogram either using a static x-ray film or fluoroscopy. An alternative approach to assess the anastomosis for patency and any missed intimal defects or other problems is to perform an on-table duplex ultrasonography, which is an excellent modality if available at the treating facility.