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.
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).
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.
1.Hueston JT, McConchie IH. A compound pectoral flap. Aust N Z J Surg.
2.Ariyan S. The pectoralis major myocutaneous flap: A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg.
3.Kim JY, Ross MI, Butler CE. Reconstruction following radical resection of recurrent metastatic axillary melanoma. Plast Reconstr Surg.
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