Upper extremity vascular trauma can lead to significant functional morbidity and, when compared to lower extremity trauma, current prosthetics and functional devices are less refined. Based on recent civilian series and military reports, upper extremity arterial injury accounts for approximately 20% of all vascular injuries, with the brachial artery being most frequently injured, and 30% to 40% of extremity vascular injuries.1–8 Unfortunately, many otherwise well-trained surgeons are ill-prepared to handle these injuries because of limited exposure in training as well as in subsequent practice. The average number of open brachial artery exposures performed within a 5-year residency reported by United States (U.S.) graduating general surgery residents between 2009 and 2019 ranged from 0.0 to 0.2 cases, while repair of all peripheral vessels ranged from 0.7 to 1.2 cases (acgme.org). Vascular surgery fellows do not fare much better for brachial artery exposure with an average of 0.3 and 0.7 cases reported during years 2014 to 2019.
In both civilian and military literature, upper extremity vascular injuries most commonly occur in young males. The prevalence of extremity vascular injury in military cohorts specifically may be attributed to improvements in body armor, which has allowed for greater survival from torso trauma but leaves extremities vulnerable to injury. Similarly, the use of tourniquets and improved evacuation times has allowed for more patients with significant extremity vascular injuries to reach higher levels of care. Within the U.S. there have been concerted efforts to halt hemorrhage including the Stop the Bleed® Campaign (stopthebleed.org) and a widespread adoption of tourniquets by front line medical workers and first responders.
Penetrating trauma is more common than blunt mechanisms in upper extremity trauma, and in the U.S. these are typically gunshot wounds, stab wounds, and work-related accidental trauma.8,9 Blunt injuries are associated with increased morbidity and mortality likely caused by an increased number of associated nonvascular injuries and the transmission of extreme force through a relatively small amount of tissue. The brachial artery is most frequently affected, followed by forearm vessels and least commonly junctional zone vessels (which are discussed in more detail elsewhere).7,8
When compared to lower extremity arterial injuries, upper extremity injuries result in less morbidity and mortality as well as shorter hospital and intensive care unit (ICU) length of stay (LOS).9 The collateral network of the arm is rich and isolated brachial injury is often well tolerated, especially when the injury is below the profunda brachii vessel. In the civilian population, amputation following upper extremity arterial injury is relatively uncommon, with rates between 0% and 6% as reported in civilian literature.9–12 However, recent reports from combat experience have demonstrated rates of amputation in combat-related injury to be as high as 12%.6,7 This discrepancy may be related to complex mechanisms of injury unique to combat environments, including high energy ballistics, fragmentation and blast forces from explosives mechanisms that can ...