1. Traumatic pseudoaneurysm of axillary artery combined with brachial plexus injury Peng Feng M.D. Department of Hand Surgery, Huashan Hospital, Fudan University

2. Traumatic Pseudoaneurysm of Axillary Artery (TPAA) Brachial Plexus Injury(BPI) TPAA combined with BPI extremely rare extremely rare reported only in a few cases. reported only in a few cases. The influence factors are unclear. The influence factors are unclear.

3. 1999.6 -2009.4, 7 patients with TPAA + BPI  The cause of damage  Neurological and vascular deficits  Surgical findings of the nerves and vessels  The recovery function of pain, vessels and nerves Materials and Methods

4. Case No.GenderAge(year)Lateral sideCause of Injury 1F45LA fall 2M16LA Knife stab 3F18LA Traffic accident 4M26LA Knife stab 5M9LA Traffic accident 6M40LA Traffic accident 7F45LA Glass stab Average-28.4--

5. Case No. Thrill Mass Radial Pulse Fracture Workup Hemachrome (g/L) Ultrosound (cm) CTADSA 1 － + － 6020*15// 2+ －－ 1287*5// 3 ±± +1127*4.3/+ 4 ± + － 12515*10// 5 ± － +803*3.5// 6+ ＋ +903.5*2.2+/ 7±± － 1193*2+/ Materials and Methods

6. Results - Pain Evaluation  Followed up 4.7 years (18 months-11 years)  Pre-operation the characteristics of pain: 1) Constant, Distending and Pulsating 1) Constant, Distending and Pulsating 2) The pain became more intense with time 2) The pain became more intense with time 3) Need analgesics to control the pain 3) Need analgesics to control the pain  Postoperation All patients released pain

7. Results - Pain evaluation Case No. VAS Initial On Admission to hospital the first day after operation On Discharge from hospital Final follow-up 106220 205320 326320 425210 548210 636210 705220 Average1.65.92.31.60

8. Results - Vascular evaluation  All patients retained radial artery pulse  One patient consequently underwent endovascular therapy for an obstructed subclavian artery

9. Results - Neurological evaluation  Continuities of brachial plexus: No. 4 patient partial severance injury of the medial cord No. 4 patient partial severance injury of the medial cord  Contusion of brachial plexus: Be observed in all of 7 patients. Be observed in all of 7 patients.

10.  The recovery of motor function: Good in 5 cases, fair in 2 cases Good in 5 cases, fair in 2 cases These 2 cases were medial cord injury These 2 cases were medial cord injury  The recovery of sensory function: good in all patients good in all patients Results - Neurological evaluation

11. （ + ） Thrill Mass （ + ） （ + ） Radial Pulse （ + ） Muscle power of Shoulder and elbow joint: 0 X-ray Left clavicular fracture Case No.6 Male ， 40y ， 7 days after a traffic accident

12. CTA: pseudoaneurysm of left axillary artery Case No.6

13. Laceration at anterior wall of AA Case No.6

14. Surgical techinique Control the Control the blood supply of the pseudoaneurysm subclavian artery axillary artery

15. Laceration at anterior wall of AA Clavicular fracture Surgical techinique

16. Brachial plexus neurolysis Vessel wall repair directly ★ ▲ ◆ Surgical techinique ORIF of fracture

17. Follow-up after 3 months Radial Pulse （ ++ ）

18. Follow-up after 15 months Radial Pulse （ ++ ）

19.  Atypical symptom – expanding hematoma/continuous thrill/diminished radial artery pulse pressure may be absent or unclear in this region expanding hematoma/continuous thrill/diminished radial artery pulse pressure may be absent or unclear in this region  Constant pain – distending and pulsating Clinical feature and diagnosis of TPAA Discussion

20.  Ultrasound Cheap, non-invasive, perform at the bedside perform at the bedside  CTA Non-invasive, 3-D  DSA I nvasive, time consuming, associated with complications associated with complications Discussion Clinical feature and diagnosis of TPAA

21.  The two patients with fair motor function results were the medial cord injury patients  The affected cord of brachial plexus Prognosis of BPI Discussion

22.  Pseudoaneurysm without nerve injures Endovascular treatment Endovascular treatment  TPAA combined with BPI Operative treatment ？ Operative treatment ？ Endovascular treatment first ? Endovascular treatment first ? Endovascular treatment or operative treatment? Discussion

23. Operative treatment : Operative treatment :  Vessel ： vessel repair  Brachial plexus ： neurolysis/nerve repair  Fracture ： ORIF  Surgical risk  Clinical experience Endovascular treatment or operative treatment? Discussion

24. Endovascular treatment first : Endovascular treatment first :  Stage- Ⅰ： Endovascular treatment  Stage- Ⅱ： operative treatment  It should be undertaken as soon as possible Endovascular treatment or operative treatment? Discussion

25. Stage- Ⅰ Endovascular treatment

26. Abandon the posterior cord which was embedded in the hard scar and performed a 6-cm length of cable nerve graft. the hematoma in the pseudoaneurysm becomes organization and forms a solid mass after endovascular therapy operative treatment after 1 month

27. Conclusions  Constant and expansive pain  Ultrasound +CTA  Operative treatment

28. Thank you