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Sun Oct 24 16:18:54 BST 2004

In a message dated 10/24/2004 11:07:00 AM Eastern Daylight Time,  
DocRickFry at aol.com writes:

What  do you do to get proximal control?

What do you do if  you have to divide  the pectoralis major muscle?

What do you do  with a shreaded axillary  vein?

What conduit do you  use?

Some additional points I failed to mention in my previous post--
The clavicle can also be divided to expose the more proxiaml subclavian  
vessels near the chest wall--and it does not have to be sutured back, altho can  
be with wire.
The "shredded" axillary vein does not deserve any attention--ligate  
proximally and distally and do not worry about it, just like any vein in the  entire 
body--any vein can be ligated if needed for a critically ill or unstable  
patient to stop bleeding.  Those veins that more attention should be paid  to, and 
more effort made to repair due to greater risk of adverse sequelae, are  the 
popliteal, one internal jugular if both are injured, SMV and portal  vein.  
However,  even all of these can be ligated with still  relatively little risk of 
long term sequelae, and very little need to ever come  back for definitive 
repair, as long as certain accomodations are made, such as  fasciotomy, leg 
elevation, leaving abdomen open, to accomodate tissue  swelling.  Note that the 
axillary vein does not fall into this hi risk  category due to excellent 
collateral drainage from the upper extremity.   There is now over 20 years of abundant 
literature supporting this in civilian  trauma, and studies clearly showing 
higher mortality among those in whom  attempts were made to repair high risk 
veins compared to those in whom  veins were ligated--refs on request.
ERF

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