Blunt vascular injuries involving the upper extremity have been widely reported in athletes (1,2,6,8,12,13,18,21–24,26,28,30,33). However, most reports have focused on those participating in sports involved with repetitive overhead activity, such as baseball (6,8,13,21,24,28,30), volleyball (18), swimming (1), and tennis (21). While most proximal arteriopathies involve compression of the subclavian artery or axillary artery by the scalene and pectoralis minor muscles (21,22,28), humeral head (22,24), or cervical ribs (21), distal arterial occlusion occurs as a result of repetitive microtrauma to the superficial palmar arch (6,18,23). Arterial injury at sites other than the hand and shoulder girdle has received scant attention among the athletic population. Kostianen and Orava (18) reported two cases of arterial injury in the distal forearm caused by repetitive microtrauma sustained by volleyball players. Five cases of brachial artery injury were identified in a registry study of winter sport injuries but no information was available to determine the nature (blunt versus penetrating) of these injuries (10). To our knowledge, there have been no reported cases of brachial arteriopathy sustained as a result of blunt trauma during participation in American football. Furthermore, upper extremity arterial thrombosis caused by a single traumatic event has been previously unreported within the athletic population.
Traumatic brachial artery injuries constitute a large proportion of upper extremity peripheral arterial injuries because of the superficial position of the vessel in the arm (7). In one study of 189 upper extremity arterial injuries, 55% of cases involved the brachial artery (7). Most arterial injuries to the upper extremity are secondary to penetrating trauma; however, those injuries sustained via blunt trauma are more likely to lead to eventual amputation (7).
Because of its anatomic location and close proximity to nervous and osseous structures, brachial artery injury is combined with nerve and skeletal injuries in 65% (7). The brachial artery represents a continuation of the axillary artery, begins at the lower border of the teres major muscle, and terminates approximately 3 to 5 cm below the elbow skin crease, where the artery divides into the radial and ulnar arteries (32). Once the artery exits the axilla, the brachial artery is a relatively superficial structure and is covered only by skin, subcutaneous tissue, and deep fascia. Proximally, the artery is flanked by the humerus and median nerve laterally and ulnar and radial nerves medially. As it nears the elbow, the brachial artery courses anteriorly and is crossed by the median nerve, which assumes a position medial to the artery. These anatomic relationships render the brachial artery vulnerable to traumatic injury often associated with distal humerus fractures, elbow dislocations, and neurologic injury (7). Often, the severity and outcomes of injuries to these adjacent structures will govern the ultimate outcome after blunt vascular trauma to the brachial artery (29).
Despite its vulnerable superficial location, injury to the brachial artery, the major artery in the arm, does not always produce distal ischemia. The brachial artery has three main branches (profundi brachii, superior ulnar collateral, and inferior ulnar collateral arteries), which afford a collateral circulation that can maintain distal perfusion in cases of traumatic injury to the brachial artery (32) (Fig. 4). The profunda brachii artery, the most proximal branch, is accompanied by the radial nerve, courses posteriorly between the medial and long heads of the triceps muscle and participates in two important collateral anastomoses involving (a) axillary artery through its posterior circumflex humeral branch and (b) the radial recurrent artery via the profunda brachii's anterior branch. The superior ulnar collateral artery travels with the ulnar nerve posterior to the medial epicondyle and forms an anastomosis with the posterior ulnar recurrent artery, while the inferior ulnar collateral artery combines with the ulnar artery’s anterior recurrent branch to create a rich collateral network around the elbow.
Traumatic brachial artery injury can often be diagnosed clinically with a thorough history and physical exam (7). Many with brachial artery injury may have minimal symptoms particularly at rest. However, pain, numbness, and tingling of the distal extremity crescendos with increasing repetitive activity. Insensitivity to cold temperatures, especially when performing vigorous activity, is another common presenting symptom.
Physical examination should focus on not only identifying the injury but also determining if there is enough collateral flow to allow for adequate perfusion. When performing a vascular examination, the side of suspected injury should be compared with the uninjured limb. Physical examination signs of injury include absent or diminished radial, ulnar, and/or radial pulses; skin color changes; delayed capillary refill; palpable thrill or audible bruit; or, in the case of penetrating trauma, expanding or pulsatile hematoma (11). Of these, brachial artery injuries can be uncovered most reliably with pulse deficit. Assuming the contralateral limb is normal, the wrist-brachial index can be another useful test to provide objective evidence of arterial compromise. A threshold of less than 0.9 is an indication for invasive studies or operative exploration in equivocal cases.
While angiography is generally considered the criterion standard for the diagnosis of arterial injuries, other modalities, such as Doppler ultrasound, computed tomography angiography, and magnetic resonance arteriography, are gaining traction as equivalent testing in evaluating arterial flow (3,11). Doppler ultrasound is relatively inexpensive, readily available, and can provide flow data without injection of a contrast agent or radiation. In addition, Doppler ultrasonography provides a relatively inexpensive method of serially monitoring arterial flow on successive examinations. Computed tomography angiography has the advantage of being quick and providing detailed information but generally requires administration of an iodine-containing contrast agent and exposure to irradiation. Magnetic resonance arteriography eliminates irradiation exposure and risk of renal insult from contrast agent but is the most time-consuming and costly imaging modality (11).
Acutely, the primary aim in treating those sustaining a traumatic brachial artery injury is the prevention of limb ischemia due to inadequate blood flow to support tissue oxygen and nutrient requirements. Cell death and irreversible changes can be seen in peripheral nerves and skeletal muscle within 6 h of arterial obstruction. Therefore, acute limb ischemia is a serious medical emergency and requires emergent therapy for limb salvage (9). The extent of ischemic injury depends on the duration and location of the arterial blockage, the amount of collateral flow, and the previous health of the involved limb (25). Prolonged limb ischemia beyond 12 h is associated with increased rates of amputation (7).
Because of a robust collateral circulation around the elbow, upper limb arterial occlusions are not usually limb-threatening like similar lower-limb injuries, which often require immediate thrombectomy and/or reconstruction to prevent end-tissue damage (5). The origin of the deep brachial artery is the key branching point in determining acuity of the upper extremity vascular insult: occlusions occurring proximal to the origin of the deep brachial artery result in distal limb ischemia due to lack of collateral supply, whereas those occlusions distal to the origin of the deep brachial artery produce less distal damage because of abundant antecubital collateral blood supply. Upper extremity congenital vascular variations exist in 20% to 30% of the population and may alter the expected clinical presentation of the injury (27).
While there is general consensus that acute injuries resulting in distal ischemia require prompt intervention, debate persists over the aggressiveness of treatment required for acute brachial artery injury in a viable arm. Because of the rich collateral flow, most of these injuries are presumably relatively asymptomatic and can be treated nonoperatively. However, it has been reported that delayed treatment of upper limb occlusions carries an 8% potential risk for amputation and residual functional impairment (4). It is worth noting that symptoms can exist in the setting of normal resting hemodynamics. In high-performance athletes, very high levels of activity may be necessary to elicit abnormal findings on exercise vascular laboratory testing (19). Indications for vascular reconstruction in these patients must be tailored to each individual’s symptoms. In this patient, the lack of symptoms even at high levels of activity obviated any need for intervention.
While penetrating trauma may prompt more urgent treatment, blunt trauma often represents a more complex problem because of the extent of injury to the vessel and adjacent soft-tissue injury (7,15). Options to treat arterial thrombosis caused by blunt trauma are based on the chronicity of the thrombosis, location and length of blocked segment, and magnitude of symptoms. If operative management is contemplated, surgical options include thrombectomy, bypass grafting, and/or excision of diseased segment with primary repair or interpositional grafting (9,16). Thrombectomy with or without angioplasty has limited utility, because of associated injury to arterial walls in traumatic cases (20), while excision of the disease segment may be too extensive to allow for direct end-to-end repair. Bypass grafting affords the ability to excise the injured artery and reestablish flow without creating any undue tension on the reconstruction. While this may often require an additional incision to harvest a vein conduit, excision of the injured segment combined with vein interposition grafting has become the mainstay of treatment to allow for adequate debridement of the injured artery wall, a tension-free anastomosis, and restoration of arterial flow (7,19,31). According to the results of a study of 89 patients undergoing grafting after blunt upper-extremity arterial injury, interposition grafts have an early patency of 93% and long-term patency of 98.6% among those followed up at 6 yr (14,19). Despite these promising results, grafting is limited by donor-site morbidity from vein harvest, potential need for prolonged anticoagulation in an athletic population prone to contact, and continued cold intolerance in up to 40% (17).
There is limited data regarding return to play after arterial injury. When treated nonoperatively, athletes traditionally have been allowed to return to play immediately provided they are not taking anticoagulants and avoid the inciting agent if a repetitive activity, such as volleyball “bump,” was thought to cause the occlusion (18). While no data exist on return to play after surgical treatment of brachial artery injury, Todd et al. reported on two major league pitchers who were allowed to begin range of motion at 6 wk, light throwing at 3 months, and full return to play 4 months after interpositional grafting of the axillary artery (30). Similarly, Duwayri et al. (8) permitted a cohort of overhead athletes who underwent axillary artery repair to begin vigorous upper-extremity physiotherapy after discontinuing anticoagulation and antiplatelet therapy and undergoing routine reimaging the anastomosis 6 wk postoperatively; most returned to full, unrestricted activity within 2 to 3 months after the procedure.
We presented the case of a football player who suffered blunt trauma to his arm causing occlusion of the brachial artery. Because of the late presentation and his limited symptomatology, he was treated nonoperatively and was able to continue to reach high levels of athletic success. This injury is rarely reported among athletes. A history of trauma, pain with repetitive activity, and/or cold intolerance combined with diminished or absent distal pulses should raise suspicion for this rare injury. Doppler ultrasonography can provide an inexpensive, noninvasive, and reliable method of detecting the location and severity of the occlusion. Due to the rich, collateral flow around the elbow, most brachial artery injuries, especially those distal to the take-off of the profunda brachii artery, can be managed nonoperatively, and, in fact, may recanalize with return of normal hemodynamics. In those with ischemia or persistent symptoms that necessitate surgical intervention, interposition vein grafting is the procedure of choice. Interposition grafting has a high (>90%) success rate and can be expected to allow athletes to return to play by 3 months after surgery.
None of the researchers or an affiliated institute has received (or agreed to receive) from a commercial entity something of value (exceeding the equivalent of US $500) related in any way to this manuscript or research. None of the researchers have any conflicts of interest related to this manuscript.
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