Vascular Exposure: Upper Extremity

Vascular Exposure: Upper Extremity

David Ray Velez, MD

Table of Contents

Axillary Artery
Brachial Artery
Forearm

Can Consider a Single Line to Expose the Majority of the Upper Extremity Vessels – From Below the Clavicle, Down the Bicipital Sulcus, Obliquely Across the Antecubital Fossa, and Along the Radial Volar Forearm (Separate Incision Needed Only for the Ulnar Artery)

See Also:
*See Peripheral Vascular Injury

Axillary Artery

Access: Infraclavicular Exposure

Infraclavicular Exposure

  • Incision: Transverse Incision Below the Clavicle (Mid-Clavicle Laterally to the Deltopectoral Fascia)
  • Divide the Pectoralis Major Muscle 2 cm from the Humeral Insertion
    • Can Spare if Stable with No Active Bleeding (Retract Medially or Split)
  • Divide the Pectoralis Minor Muscle to View the Second Portion of the Axillary Artery
    • Can Use an Army-Navy Retractor to Elevate and Assist Division

May Require Division of Medial Clavicle for Proximal Exposure to Visualize the Subclavian Artery

Associations

  • Axillary Vein Generally Runs Inferior to the Artery
  • CAUTION: Brachial Plexus Can Be Easy to Confuse with the Artery

Infraclavicular Exposure

Brachial Artery

Exposure

  • Incision: Longitudinal Incision Over the Medial Bicipital Sulcus (Between the Biceps and Triceps Muscles)
  • The Neurovascular Bundle is Identified Between the Muscle Bellies

CAUTION: It is Easy to Confuse the Brachial Artery with the Median Nerve

Exposure of the Bifurcation

  • Extend the Incision Obliquely Laterally Across the Antecubital Fossa
  • Divide the Bicipital Aponeurosis (Dense Fibrous Extension of the Bicipital Tendon) to Expose the Bifurcation
  • CAUTION: The Exact Level of the Bifurcation is Extremely Variable

Brachial Artery Exposure

Forearm

Radial Artery Exposure

  • Incision: Along the Inferomedial Border of the Brachioradialis Muscle
    • Along the Radial Volar Forearm
  • Retract the Brachioradialis Muscle Laterally to Expose the Fat Pad
  • Proximal Radial Neurovascular Bundle is Identified in this Fat Pad
  • Can Extend the Proximal Incision Obliquely Across the Antecubital Fossa to Access the Brachial Artery/Bifurcation (May Have to Divide the Bicipital Aponeurosis)

Ulnar Artery Exposure

  • Incision: Separate Incision Along the Ulnar Volar Forearm
  • The Ulnar Neurovascular Bundle is Identified in the Fat Pad Between the Flexor Digitorum Superficialis and Flexor Carpi Ulnaris
  • Oblique Incision Over the Antecubital Fossa May Be Required for Proximal Access to the Bifurcation

Forearm Artery Exposure