BRACHIAL ARTERY REPAIR IN TRAUMA PATIENTS - OUTCOME ANALYSIS

Introduction: analyse out brachial artery injury repair Methods: This is a prospective All patients admitted with upper limb vascular trauma with brachial artery injury (n=27) included in our study. Results: Though graft thrombosis or anastomotic thrombosis seen in two patients,on 3 rd or 4 th post operative day, the limb salvage rate is 100% in our study. Conclusion: Since brachial artery injury commonly occurs in young individuals timely intervention saves the upper limb in most cases so that they can do their works which is essential for their family because they are the breadwinners of the family.


Materials & Methods:-
This is a prospective study from August 2015 to May2018, and it is an ongoing study.All patients admitted with upper limb vascular trauma and Brachial artery Repair done were included in our study.Those Patients whose limbs were completely mangled and were unable to reconstruct by our Plastic surgery team, undergone primary amputation as a life saving measure are not included in this study. Most of our patients in the age group of 15 to 45 years (20 patients, 20/27=74%),more than 45 years 3 patients,(3/27=11%) and less than 14 years 4 patients,(4/27=15%).There are 23 male patients( 23/27=85%) and 4 female patients(4/27=15%).

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Most of the patients are in younger age group, so no comorbids in most of the patients, only two patients whose age were 47 and 51 had Diabetes Mellitus. Our patients were evaluated by clinical examination (Hard and Soft signs) and using Hand Held Doppler.Hand held Doppler was our main tool and we have not done CT angiogram in the emergency situations. Using Hand held Doppler, no flow was seen in 4 patients (4/27=15%), wrist pressure lessthan 50 mmHg seen in 20 patients (20/27=74%) and wrist pressure more than 50 mmHg in 3 patients (3/27=11%).
In all patients we used Revese Saphenous Vein as conduit, if interposition graft or extra anatomical bypass planned. Synthetic grafts were not used to prevent infection.Interposition Reverse Vein Saphenous graft were done in 21 patients (24/27=89%), primary end to end anastomosis done in 3 patients when the defect was less than 2 centimeters (

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We did fasciotomies in most of patients,for those who had no flow status and those who were presented after 12 hours.We did skin cover by relaxing incisions,and Split Skin Graft primarily or secondarily.
Skin cover with primary Split Skin Graft after Brachial Artery Repair - figure 5 and figure 6.  Most of our patients were presented more than 6 hrs of injury,arterial repair done first,followed by fracture stabilisation and nerve repair later by orthopedic surgeon and plastic surgeon.
We are using Hand Held Doppler only in determing the procedure.We haven't used Colour Doppler or CT Angiogram in emergency settings. We have ligated the veins in case of venous injury,we didn't repair veins,it doesn't affect limb salvage. Faciotomy done in majority of cases ( > 6 hr, associated venous injury). If both radial and ulnar artery injured with brachial artery we repair both, because palmar arch integrity could't be assesed pre operatively. If one artery (either radial or ulnar) injured with brachial artery and palmar arch intact, we repair brachial artery and then we ligate the injured forearm vessel,if palmar arch incomplete we repair the injured forearm artery along with brachial artery repair.
Though graft thrombosis was seen in 2 patients,limb was salvaged. One patient was in younger age,severely crushed upper limb from mid arm but hand viable and brachial artery injured proximal to profunda brachi,we did extra anatomical bypass from axillary artery to distal brachial artery, graft thrombosis occurred in 4 th day at distal anastomosis and we did extension bypass to radial artery, that was also thrombosed in next two days, but he has developed collateral flow in posterior interosseous artery,and limb salvaged. Another patient, aged more than 45 years, whose injury was beyond profunda brachii, had wrist pressure more than 50mmhg,smoker and uncontrolled Diabetic,graft was thrombosed on 3 rd day, but the limb was salvaged. With all these efforts we achieved high limb salvage rate comparable to others,in our institution.

Conclusion:-
Since upper limb vascular trauma with brachial artery injury commonly occurs in young individuals Brachial Artery Repair along with Orthopedic and Plastic Surgery management saves the upper limb in most cases in our institution, so that they can do their works which is essential for their family because they are the breadwinners of the family.