The brachial artery lies in the groove between the biceps and triceps muscles. The proximal brachial artery lies medial to the humerus and moves anterior as it progresses distally. At the antecubital fossa, it runs under the aponeurosis of the biceps muscle and typically bifurcates just below the elbow into the radial and ulnar arteries (Figure 37.1).

The brachial artery is surrounded by two concomitant brachial veins, which run on either side of the artery. At the upper part of the arm, their confluence forms the axillary vein.

The profunda brachial artery is a large branch that arises from the proximal third of the brachial artery and communicates with collateral circulation to the lower arm (Figure 37.2). Due to these collaterals, the lower arm may have adequate perfusion despite injury to the distal two thirds of the brachial artery.

Figure 37.1 The brachial artery lies in the groove between the biceps and triceps muscles. Note the close anatomical relationship with the median and ulnar nerves. In the upper arm, the median nerve is anterolateral to the artery and at the middle it crosses over to course posteromedial to the artery. The artery bifurcates into the ulnar and radial arteries under the bicipital aponeurosis, at the antecubital fossa.

Figure 37.2

(a) Anatomy of the major branches of the brachial artery and the superficial and deep veins of in the arm.

(b) Paired brachial veins run on either side of the brachial artery.

The basilic vein courses in the subcutaneous tissue in the medial aspect of the lower arm. At the mid arm, it penetrates the fascia to join one of the brachial veins.

The cephalic vein is entirely in the subcutaneous tissues, courses in the deltopectoral groove, and joins the junction of the brachial and axillary veins.

In the upper arm, the median nerve courses anterolateral to the brachial artery. It then crosses over the artery and lies posteromedial to the brachial artery as they pass under the aponeurosis of the biceps muscle.

In the upper half of the arm, the ulnar nerve lies posterior to the brachial artery. In the mid arm, the nerve pierces the intermuscular septum and courses posteriorly away from the artery, behind the medial epicondyle.

Almost all significant vascular injuries are diagnosed based on clinical examination.

“Hard signs” of vascular injury include pulsatile bleeding, an expanding or pulsatile hematoma, a palpable thrill, audible bruit, absent or very diminished peripheral pulse, and/or distal ischemia. These signs are strong indications for immediate operative exploration. Patients with blunt trauma or shotgun injuries with multiple pellets may benefit from preoperative CT or formal angiography.

“Soft signs” of vascular injury include minor bleeding, stable small hematomas, and an ankle-brachial index (ABI) less than 0.9. In these cases, arterial evaluation by duplex or CT angiogram should be performed.

Hemorrhage from the brachial artery can be temporarily controlled using direct digital compression or a proximal tourniquet.

Ligation of the brachial artery is associated with a high incidence of limb loss and should not be performed. In patients in extremis, a temporary shunt and delayed reconstruction should be considered.

In the event of a mangled extremity, flow is established with a temporary shunt, followed by wound debridement, external fixation of the fracture, and finally, delayed definitive vascular repair.

Brachial artery injuries can be managed with primary repair or autologous vein graft reconstruction. In general, synthetic grafts should be avoided for arterial reconstruction below the shoulder because of poor long-term patency rates.

Completion angiogram should be considered if there is any concern regarding distal flow.

Patients with brachial artery injuries, especially those with prolonged ischemia or associated venous injuries, should be monitored for compartment syndrome with serial clinical examinations, compartment pressure monitoring, and serial blood creatine kinase (CK) levels. Fasciotomy should be considered in appropriate cases.

Routine prophylactic fasciotomy is not indicated and may increase morbidity.

A vascular tray.

A sterile tourniquet should be in the field for proximal control.

A sterile ultrasound probe should be available for perfusion monitoring and saphenous vein mapping.

Fogarty catheters: 3 F should be available for thrombectomy.

Heparin solution: 5,000 units of heparin in 100 mL of normal saline for regional heparinization after clot clearance.

An array of shunt sizes should be available to restore blood flow in case immediate repair or reconstruction is not possible. Argyle shunts ranging from 8 to 14 F should be adequate for most injuries.

If an angiogram is to be performed, fluoroscopy, an 18G butterfly needle, and water-soluble contrast should be available.