Secondary Logo

Journal Logo

How to Repair and Cover a RupturedAxillary Artery

Silverman, Adam T., M.D., M.S.; Taylor, John M., M.D.; Ciervo, Alfonso C., M.D.

Plastic and Reconstructive Surgery: December 2009 - Volume 124 - Issue 6 - p 449e-451e
doi: 10.1097/PRS.0b013e3181bcf54a
VIEWPOINTS
Free

Departments of Plastic and Reconstructive Surgery and Vascular Surgery, Monmouth Medical Center, Long Branch, N.J.

Correspondence to Dr. Taylor, Monmouth Medical Center, 300 Second Avenue, Long Branch, N.J. 07740

Back to Top | Article Outline

Sir:

Rupture of the axillary artery is a rare entity and is usually related to either shoulder dislocation or proximal fracture of the humerus. This is the first documented case in the English language literature of an axillary artery rupture caused by a chronic radiation wound that was treated successfully with a stent graft. A pectoralis major myocutaneous flap was used to provide a vascularized pedicle of soft tissue and skin coverage to a large axillary defect.

A 76-year-old man presented with a chronic axillary wound. Twenty-five years previously, he had undergone wide local excision of a melanoma of the left forearm and radiation therapy to the axilla. The wound measured approximately 6 × 4 cm and was 3 cm deep. The wound was very fibrotic but did not appear to be infected. His initial treatment encompassed moist local wound care, and a more aggressive approach was postponed because of a recent massive myocardial infarction.

However, he experienced severe hemorrhage from the left axillary artery. Primary repair of the axillary artery was unsuccessful despite attempts at débridement to “healthy” appearing arterial wall. An endovascular repair by means of the brachial artery, in the antecubital space, was performed with a covered 8-mm × 4-cm stent (Fluency; Bard, Inc., Tempe, Ariz.). Inspection of the wound identified the axillary artery with a portion of the stent exposed (Fig. 1). A layer of rehydrated acellular dermal allograft (AlloDerm; LifeCell Corp., Branchburg, N.J.) was placed at the base of the wound to prevent desiccation, and a continuous irrigation system to the axilla was started with a normal saline antibiotic solution.

Fig. 1.

Fig. 1.

The patient was returned to the operating room for a left pectoralis major myocutaneous flap with a small distal skin paddle to fit the axillary defect. The pectoralis major myocutaneous flap was raised on the thoracoacromial vascular pedicle and tunneled subcutaneously into the left axilla. The muscle was used to provide complete vascularized coverage of the axillary artery, and the skin paddle was inset into the surrounding débrided wound edges. The latissimus dorsi muscle was not used because of a severely diseased thoracodorsal artery evident on computed tomographic angiography. At his last follow-up visit 6 months postoperatively, the axilla was well healed and without signs of infection (Fig. 2).

Fig. 2.

Fig. 2.

Myocutaneous flaps provide an excellent vascularized pedicle of soft tissue with skin coverage. The pectoralis major myocutaneous flap was first described in 1968 by Hueston and McConchie for the repair of an anterior chest wall defect.1 The flap was popularized by Ariyan for reconstruction of the head and neck.2 More recently, the pectoralis major myocutaneous flap was used to reconstruct the axilla of four patients who had melanoma recurrence after axillary dissection.3

We used the pectoralis major myocutaneous flap to cover an exposed axillary artery stent graft. This flap provided excellent bulk and protection from desiccation and further trauma to the axillary vessels. The pectoralis major myocutaneous flap is a mainstay in head and neck reconstruction because it provides an excellent vascularized pedicle of soft tissue with skin coverage. One must include the pectoralis major myocutaneous flap in one's repertoire and consider its value in reconstructing the axilla.

Adam T. Silverman, M.D., M.S.

John M. Taylor, M.D.

Alfonso C. Ciervo, M.D.

Departments of Plastic and Reconstructive Surgery and Vascular Surgery

Monmouth Medical Center

Long Branch, N.J.

Back to Top | Article Outline

REFERENCES

1.Hueston JT, McConchie IH. A compound pectoral flap. Aust N Z J Surg. 1968;38:61–63.
2.Ariyan S. The pectoralis major myocutaneous flap: A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg. 1979;63:73–81.
3.Kim JY, Ross MI, Butler CE. Reconstruction following radical resection of recurrent metastatic axillary melanoma. Plast Reconstr Surg. 2006;117:1576–1583.

Section Description

GUIDELINES

Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:

Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.

We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2009American Society of Plastic Surgeons