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Dr. Setthabutr Eaupanitcharoen, M.D. Trauma Division, Department of surgery, Maharat Nakornratchasima hospital, Nakornratchasima Thailand
This patient lost control of his motorcycle and collided with a tree. The main point of impact was his left shoulder. Following the accident his left shoulder was swollen and he was unable to move his left arm with loss of sensation from shoulder to hand. There was no fracture or dislocation seen on the AP or trans-scapular radiographs. His radial, brachial and axillary pulses were not palpable. However they were all present on doppler. A CT angiogram was performed which showed a 3 cm loss in continuity of the second part of the left axillary artery. The patient was then transferred directly to theatre, where the thrombosed section of artery was excised and an anastomosis between the 1st and 3rd part of the left axillary artery was performed. At the time of this article submission the patient was four days post surgery, having had no complications post procedure thus far. The radial and brachial pulses remain impalpable but the post-op angiogram done immediately following theatre shows normal contrast filling from the axillary artery to the radial artery. The patient's left arm was warm and capillary refill time was under two seconds.
Title image: At point of admission, the picture shows the patients bruised left shoulder.
Image 2: Radiograph showing antero-posterior view of left shoulder.
Image 3: Radiograph showing transcapular view of left shoulder.
Image 4: The CT angiogram showing the abnormal section of the left axillary artery.
Image 5: At time of operation - Following an infraclaviclar incision through the deltopectoral fascia and division of pectoralis minor muscle near its origin, the left axillary artery was exposed. Here we see the first blue vascular sling encircling the 1st part of the axillary artery, the second blue sling in the middle, is placed around the thrombosed section, and the red sling encircles the 3rd part of the axillary artery. The Pectoralis minor muscle was divided near its insertion (held by the black suture) and the brachial plexus was noted to be intact at this point.
Image 6: The thrombosed segment, 3 cm long, place adjacent to the brachial plexus.
Image 7: The reversed saphenous vein graft between the 1st and 3rd parts of the axillary artery. The proximal and distal parts of the injured arterial segment were ligated near the anastomosis.
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