External landmarks: The axillary vessels start at the middle of the clavicle, course deep under the deltopectoral groove, and end at the lateral border of the axilla.

The axillary artery is divided by the pectoralis minor into three parts: the first part is proximal to the muscle and gives one branch. The second part is under the muscle, is surrounded by the cords of the brachial plexus, and gives two branches. The third part lies lateral to the muscle, is surrounded by the nerves of the brachial plexus, and gives three branches.

The axillary vein is the continuation of the basilic vein. Prior to its transition to the subclavian vein, the cephalic vein joins it. Its middle segment lies under the pectoralis minor muscle, inferior to the axillary artery.

Ligation of the axillary artery is associated with a high incidence of limb loss and should not be performed. In critically unstable patients, temporary shunting with delayed reconstruction should be considered.

Vascular reconstruction can be done with either a saphenous vein graft or a synthetic graft.

A standard vascular tray.

Periosteal elevators and Doyen Raspatory may be needed for clavicular resection and exposure of the distal suclavian vessels. See Chapter 9 Subclavian Vessels.

The patient should be in the supine position, with the injured arm abducted from the body at about 30°. The head is slightly turned to the opposite side.

Figure 10.1 The axillary vessels start under the middle of the clavicle and curve downward, deep under the deltopectoral groove. Part of the vessels is under the pectoralis minor muscle. The vein is below and more superficial to the artery. Note the cephalic vein crossing over the pectoralis minor muscle and draining into the proximal axillary vein.

The neck, arm, and entire chest should be fully prepped. The groin should be included in the surgical field in case a vein harvest is needed.

The incision starts just below the middle of the clavicle, and courses over the deltopectoral groove.

In very proximal injuries the incision should start at the sternoclavicular junction, course directly over the medial half of the clavicle and, at the middle of the clavicle, curve downward into the deltopectoral groove. The clavicle may have to be divided to allow proximal vascular control (see Chapter 9 subclavian vessels).