Brachial artery reconstruction examples.

1. Plastic and Reconstructive Surgery • January 2012
approach and the adequate investigation and planning potential to be limb or life threatening, occurs when
of perforator flap options. disruption of the vessel wall leads to extravasation of
DOI: 10.1097/PRS.0b013e3182365e9c blood and formation of a hematoma that is contained
Warren M. Rozen, M.B.B.S., B.Med.Sc., Ph.D. by the surrounding tissues.1 Although there are mul-
tiple causes, most cases are the result of penetrating
Iain S. Whitaker, M.A.Cantab., M.B.B.Chir., Ph.D. injuries, such as gunshot or stab wounds, or intrave-
Jeannette W. C. Ting, M.B.B.S., Grad.Dip.Surg.Anat. nous drug abuse.1,3 Pseudoaneurysm of the brachial
G. Gleda Ang, M.B.B.S., B.Med.Sc. artery often presents as an expanding, painful mass,
with overlying erythema and induration. There may
Rafael Acosta, M.D. be a palpable thrill or audible bruit, decreased tem-
Jack Brockhoff Reconstructive Plastic Surgery Research perature, or cyanosis.1,3,4 In addition, the distal
Unit extremity may demonstrate loss of pulses and pares-
Department of Anatomy and Cell Biology
thesias from compression of the median nerve.1–5
University of Melbourne
Parkville, Victoria, Australia
Arterial thrombi may develop within the pseudoan-
eurysm, leading to embolic events distally, resulting
Correspondence to Dr. Rozen in terminal ischemia, gangrene, and amputations.4
Jack Brockhoff Reconstructive Plastic Surgery Research A 42-year-old, right-hand-dominant woman with a
Unit history of intravenous drug abuse presented to the
Room E533
emergency department with pulsatile bleeding from a
Department of Anatomy
University of Melbourne small wound in her left antecubital fossa. She com-
Grattan Street plained of a dark, raised, tender “scab” in this area, and
Parkville 3050, Victoria, Australia a similar lesion in the right antecubital fossa (Fig. 1);
warrenrozen@hotmail.com both had been present for several months. On the
morning of presentation, she reported picking the le-
DISCLOSURE sion on the left, and blood began “squirting” from the
There was no source of funding for this article. The area.
authors declare that there is no source of financial or other Examination of the right arm demonstrated a 3-cm
support or any financial or professional relationships that subcutaneous mass in the antecubital fossa with a
might pose a competing interest. 1-cm lesion on the skin. No cyanosis was noted dis-
tally on the right, with normal range of motion and
REFERENCES sensibility.
1. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction Examination of the left arm revealed no palpable
with a transverse abdominal island flap. Plast Reconstr Surg. radial or ulnar pulse at the wrist and cyanotic-appearing
1982;69:216–224. fingers to the metacarpophalangeal joint. She had full
2. Ribuffo D, Marcellino M, Barnett GR, Houseman ND, Scuderi range of motion of her fingers and wrist and dimin-
N. Breast reconstruction with abdominal flaps after abdomi- ished median nerve sensibility, and her forearm com-
noplasties. Plast Reconstr Surg. 2001;108:1604–1608. partment was soft but tender distal to the mass. Re-
3. Jandali S, Nelson JA, Wu LC, Serletti JM. Free transverse rectus moval of the left pressure dressing, placed in the field,
abdominis myocutaneous flap for breast reconstruction in
revealed active arterial bleeding. A tourniquet was
patients with prior abdominal contouring procedures. J Re-
constr Microsurg. 2010;26:607–614.
placed, and she was taken immediately to the operating
4. Karanas YL, Santoro TD, Da Lio AL, Shaw WW. Free TRAM room for surgical exploration.
flap breast reconstruction after abdominal liposuction. Plast In the operating room, control of the proximal and
Reconstr Surg. 2003;112:1851–1854. distal brachial artery was performed first, followed by
5. Rozen WM, Garcia-Tutor E, Alonso-Burgos A, Corlett RJ, Tay- identification of the median nerve and volar forearm
lor GI, Ashton MW. The effect of anterior abdominal wall scars fasciotomy. The pseudoaneurysm was dissected from a
on the vascular anatomy of the abdominal wall: A cadaveric very friable and adherent vascular bed. The lesion was
and clinical study with clinical implications. Clin Anat. 2009; 5 cm in diameter and eroded, with an associated thick-
22:815–822.
Management of Bilateral Brachial Artery Supplemental digital content is available for
Pseudoaneurysms in an Intravenous Drug User this article. Direct URL citations appear in the
Sir: printed text; simply type the URL address into
W e write to you concerning a case of bilateral
brachial artery pseudoaneurysms secondary to
intravenous drug abuse, one of which required emer-
any Web browser to access this content. Click-
able links to the material are provided in the
HTML text of this article on the Journal’s Web
gent repair for uncontained rupture. Arterial pseu- site (www.PRSJournal.com).
doaneurysm, a rare but serious condition with the
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2. Volume 129, Number 1 • Viewpoints
Fig. 1. Preoperative photograph depicting the mass in the right ante-
cubital fossa.
ened and stiff vascular wall extending 1 cm on either
side. The lesion stopped 1 cm proximal to the bifur-
cation of the radial and ulnar arteries. The diseased
artery was resected, the bed was debrided, and an 8-cm
´
saphenous vein graft was used for bypass. After 90 minutes
of tourniquet time, she had return of distal pulses and
resolution of cyanosis. (See Video, Supplemental Digital
Content 1, which shows a ruptured pseudoaneurysm of
the left brachial artery, http://links.lww.com/PRS/A443.
The video demonstrates preoperative physical examina-
tion findings, operative repair of a left brachial artery
pseudoaneurysm, and a postoperative arteriogram.)
An arteriogram obtained 4 weeks postoperatively
demonstrated a patent left bypass graft and a tortuous
pseudoaneurysm of the right brachial artery (Fig. 2),
which was repaired electively in a similar fashion several
Video 1. Supplemental Digital Content 1 shows a ruptured pseudo-
weeks later. (See Video, Supplemental Digital Content
aneurysm of the left brachial artery, http://links.lww.com/PRS/A443.
2, which shows a pseudoaneurysm of the right brachial
The video demonstrates preoperative physical examination findings, artery, http://links.lww.com/PRS/A444 . The video dem-
operative repair of a left brachial artery pseudoaneurysm, and a post- onstrates preoperative physical examination findings, a
operative arteriogram. preoperative arteriogram, and operative repair of the
right brachial artery pseudoaneurysm.)
DOI: 10.1097/PRS.0b013e3182365e84
Fig. 2. Preoperative arteriogram demonstrating the right brachial
artery pseudoaneurysm.
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3. Plastic and Reconstructive Surgery • January 2012
and tumors. If a direct tensionless coaptation cannot be
achieved, other techniques can be used to obtain the
best possible functional outcome. Traditionally, autog-
enous nerve grafts have been the criterion standard for
bridging such defects.1 However, it has been demon-
strated that, when the gap is less than 3 cm, vein conduit
grafts yield excellent results without the comorbidities
associated with harvesting a donor nerve.2
The theory behind the success of the vein graft is the
creation of a patent conduit that allows a neurotrophic
matrix to collect, allows axons to migrate, and prevents
scar tissue ingrowth. Meticulous alignment of the nerve
and tubulization of the vein graft underpin this theory
and are the aims of repair.3,4
Video 2. Supplemental Digital Content 2 shows a pseudoaneu- However, accurate tubulization and alignment re-
rysm of the right brachial artery, http://links.lww.com/PRS/A444. quire the surgeon to be equipped with advanced mi-
The video demonstrates preoperative physical examination find- crosurgical skills and, ideally, to be operating with an
assistant. Here, we outline the transluminal stay stitch,
ings, a preoperative arteriogram, and operative repair of the right
a technique that can provide excellent support in sit-
brachial artery pseudoaneurysm.
uations where there is no assistant and also help those
trainees with limited experience in microsurgery.
Ryan M. Wilson, M.D. The stitch works by achieving temporary alignment
and stability between the venous conduit and the nerve.
W. Thomas McClellan, M.D. This stability then allows anastomosing sutures to be
Department of Surgery precisely performed.
West Virginia University School of Medicine
Morgantown, W.Va. Step 1: Align the two ends of the nerve correctly. Using
Correspondence to Dr. McClellan
an 8-0 nylon suture, take an epineural bite of the
Morgantown Plastic Surgery Associates proximal nerve ending.
1085 Van Voorhis Road, Suite 350 Step 2: Pass the suture through the lumen of the vein
Morgantown, W.Va. 26505 graft. It may be necessary to straighten the needle
wtmcclellan@hotmail.com first and use the forceps to grasp the needle from
inside the lumen.
DISCLOSURE Step 3: Take a bite through the epineurium of the
The authors have no financial interests in this research corresponding point on the distal portion of the
project or in any of the techniques or equipment used in this study. nerve ending so that the correct alignment is
achieved (Fig. 1).
REFERENCES Step 4: Tie the two ends of this suture and apply
1. Gow KW, Mykytenko J, Patrick EL, Dodson TF. Brachial artery appropriate tension to stabilize the vein graft.
pseudoaneurysm in a 6-week-old infant. Am Surg. 2004;70:518–521. Step 5: Place 9-0 nylon anastomosing sutures to
2. Yetkin U, Gurbuz A. Post-traumatic pseudoaneurysm of the achieve tubulization according to normal tech-
brachial artery and its surgical treatment. Tex Heart Inst J. nique.
2003;30:293–297. Step 6: Cut the transluminal stay stitch and pull the
3. Siu WT, Yau KK, Cheung YS, et al. Management of brachial suture out (Fig. 2).
artery pseudoaneurysms secondary to drug abuse. Ann Vasc
Surg. 2005;19:657–661.
4. Tan KK, Chen K, Chia KH, Lee CW, Nalachandran S. Surgical
management of infected pseudoaneurysms in intravenous
drug abusers: Single institution experience and a proposed
algorithm. World J Surg. 2009;33:1830–1835.
5. Wahlgren CM, Lohman R, Pearce BJ, Spiguel LR, Dorafshar
A, Skelly CL. Metachronous giant brachial artery pseudoan-
eurysms: A case report and review of the literature. Vasc En-
dovasc Surg. 2007;41:467–472.
Interposition of Autogenous Venous Nerve
Conduit: The Transluminal Stay Stitch
Sir:
P eripheral nerve neurotmesis is a common finding
for the plastic surgeon. It can occur following acute
trauma injury or after surgical excision of neuromas
Fig. 1. Step 3: take a bite through the epineurium of the corre-
sponding point on the distal portion of the nerve ending, so that
the correct alignment is achieved.
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