Intraoperative Axillary Artery Injury as a Complication of Reverse Total Shoulder Arthroplasty

ABSTRACT Axillary artery injury as a result of total shoulder artroplasty is a fairly rare complication. Isolated clinical observations are described in foreign articles, there are no reports of domestic authors about this problem. There is a need for more extensive coverage of this problem in order to prevent similar situations in the future.

THE AIM of this publication is to present a clinical case of intraoperative axillary artery injury in the process of reverse shoulder arthroplasty, and the medium­ term result of surgical treatment after replacement of the artery defect with a synthetic graft.

MATERIAL AND METHODS We present a rare clinical case of intraoperative axillary artery injury in the process of reverse shoulder arthroplasty. After the replacement of the artery defect by a team of vascular surgeons, it was decided to continue the shoulder joint replacement surgery. In the postoperative period, computed tomography angiography revealed occlusion of the restored section of the axillary artery, but the presence of collateral blood flow distal to the injury zone, the preservation of active movements in the joints of the right upper limb, and the absence of sensitivity disorders in the right hand made it possible to refrain from repeated surgical intervention. When evaluating the medium­term results 15 months after surgical treatment, a significant limitation of the function of the right upper limb was noted in the complete absence of pain syndrome.

CONCLUSION The presented clinical case demonstrates the experience of managing a patient with simultaneous reverse shoulder arthroplasty and an intraoperatively damaged section of the axillary artery with the achievement of complete absence of pain syndrome with significant restriction of function in the remote period. Bearing in mind the possible damage to the main arteries, particularly in age­related patients, and the amount of medical care required in the event of this complication, it is recommended that medical care be provided in a multidisciplinary hospital with a team of vascular surgeons.

1. Egiazaryan KA, Cherkasov SN, Attaeva LZh. Monitoring of the implementation of the state policy in the field of industrial injuries’ prevention. Public Health and Health Care. 2016;3(21):31–35. (In Russ.)

2. McCormick F, Nwachukwu BU, Kiriakopoulos EBS, Schairer WW, Provencher MT, Levy J. In-hospital mortality risk for total shoulder arthroplasty: A comprehensive review of the medicare database from 2005 to 2011. Int J Shoulder Surg. 2015;9(4):110–113. PMID: 26622126 https://dоi.оrg/10.4103/0973-6042.167938

3. Bohsali KI, Bois AJ, Wirth MA. Complications of Shoulder Arthroplasty. J Bone Jt Surg. 2017;99(3):256–269. PMID: 28145957 https://dоi.оrg/10.2106/JBJS.16.00935

4. Barco R, Savvidou OD, Sperling JW, Sanchez-Sotelo J, Cofield RH. Complications in reverse shoulder arthroplasty. EFORT Open Rev. 2016;1(3):72–80. PMID: 28461931 https://dоi.оrg/10.1302/2058-5241.1.160003

5. Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: A systematic review. J Shoulder Elbow Surg. 2011;20(1):146–157. PMID: 21134666 https://dоi.оrg/10.1016/j.jse.2010.08.001

6. O’Neill DR, King JJ, Farmer KW. Reverse total shoulder arthroplasty after iatrogenic axillary artery injury: a case report. J Shoulder Elbow Surg. 2021;30(3):e121–e128. PMID: 33220415 https://dоi.оrg/10.1016/j.jse.2020.10.019

7. Wilkerson J, Napierala M, Shalhub S, Warme WJ. Axillary artery intimal dissection with thrombosis and brachial plexus injury after reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2019;28(12):e393–e397. PMID: 31636009 https://dоi.оrg/10.1016/j.jse.2019.07.044

8. Ghanem OM, Sacco J, Heitmiller RF, Gashti SM. Delayed Axillary Artery Occlusion after Reverse Total Shoulder Arthroplasty. Case Rep Orthop. 2016;2016:1–3. PMID: 27555975 https://dоi.оrg/10.1155/2016/5463514

9. Wingert NC, Beck JD, Harter GD. Avulsive axillary artery injury in reverse total shoulder arthroplasty. Orthopedics. 2014;37(1):e92–97. PMID: 24683665 https://dоi.оrg/10.3928/01477447-20131219-24

10. Wallace WA, Kalogrianitis S, Manning P, Clark D, McSweeney S. The elderly fragile axillary artery – management lessons learned from four serious iatrogenic injuries. Orthop Proc. 2011;93-B(SUPP_III):295–295. https://dоi.оrg/10.1302/0301-620X.93BSUPP_III.0930295a

11. Abbenhaus E, Kamineni S. Shoulder arthroplasty death with axillary artery and brachial plexus damage: lessons from a tragedy. JSES Int. 2020;4(1):133–137. PMID: 32195475 https://dоi.оrg/10.1016/j.jses.2019.09.001

12. Thiel R, Munjal A, Daly DT. Anatomy, Shoulder and Upper Limb, Axillary Artery. StatPearls Publishing; 2024. Available at: http://www.ncbi.nlm.nih.gov/books/NBK482174/[Accessed May 9, 2024]. PMID: 29489298

13. McFarland EG, Caicedo JC, Guitterez MI, Sherbondy PS, Kim TK. The anatomic relationship of the brachial plexus and axillary artery to the glenoid. Implications for anterior shoulder surgery. Am J Sports Med. 2001;29(6):729–733. PMID: 11734485 https://dоi.оrg/10.1177/03635465010290061001

14. Grzeda AL, Hicks AC, Cheadle GA, Sangroula D, Wayne EJ, Dwivedi AJ, et al. Endovascular Repair of Transected Axillary Artery via Snare Assisted Through and Through Femoral to Brachial Artery Access. Am Surg. 2022;88(7):1543–1545. PMID: 35337191 https://dоi.оrg/10.1177/00031348221083936

15. Egiazaryan KA, Ratyev AP, Tamazyan VО, Glazkоv KI, Ershоv DS. Results оf оsteоsynthesis оf prоximal humerus fractures with intramedullary nail and additiоnal suture fixatiоn оf tuberоsities. Pоlytrauma. 2019;(2):32–39. (In Russ.)

16. Egiazaryan KA, Ratyev AP, Gordienko DI, Grigoriev AV, Ovcharenko NV. Midterm Treatment Outcomes of Proximal Humerus Fractures by Intramedullary Fixation. Traumatology and Orthopedics of Russia. 2018;24(4):81–88. (In Russ.). https://dоi.оrg/10.21823/2311-2905-2018-24-4-81-88.

17. Egiazaryan KA, Ratyev AP, Ershov DS, Kuruch EA, Kuznetsov VN, Ovcharenko NV. Surgical Treatment of Humerus Fracture-Dislocations: Medium-Term Results. Traumatology and Orthopedics of Russia. 2020;26(4): 68–79. (In Russ.). https://dоi.оrg/10.21823/2311-2905-2020-26-4-68-79

18. Cooper C, Melton LJ. Epidemiology of osteoporosis. Trends Endocrinol Metab TEM. 1992;3(6):224–229. PMID: 18407104 https://dоi.оrg/10.1016/1043-2760(92)90032-v

19. Johnston CB, Dagar M. Osteoporosis in Older Adults. Med Clin North Am. 2020;104(5):873–884. PMID: 32773051 https://dоi.оrg/10.1016/j.mcna.2020.06.004

20. Yu B, Wang CY. Osteoporosis and periodontal diseases – An update on their association and mechanistic links. Periodontol 2000. 2022;89(1):99–113. PMID: 35244945 https://doi:10.1111/prd.12422

21. Van der Loo B, Koppensteiner R, Lüscher TF. How do blood vessels age? Mechanisms and clinical implications. VASA Z Gefasskrankheiten. 2004;33(1):3–11. PMID: 15061041 https://dоi.оrg/10.1024/0301-1526.33.1.3

22. O’Rourke MF. Arterial aging: pathophysiological principles. Vasc Med Lond Engl. 2007;12(4):329–341. PMID: 18048471 https://dоi.оrg/10.1177/1358863X07083392

23. Melis B, DeFranco M, Lädermann A, Molé D, Favard L, Nérot C, et al. An evaluation of the radiological changes around the Grammont reverse geometry shoulder arthroplasty after eight to 12 years. J Bone Joint Surg Br. 2011;93(9):1240–1246. PMID: 21911536 https://dоi.оrg/10.1302/0301-620X.93B9.25926

24. Bents RT. Axillary artery thrombosis after humeral resurfacing arthroplasty. Am J Orthop Belle Mead NJ. 2011;40(7):E135–137. PMID: 22013579