The axillary artery is defined anatomically by the lateral margin of the first rib proximally and lateral edge of the teres major muscle distally. In its proximally protected location surrounded by the chest wall and pectoral and shoulder muscles, the axillary artery is protected from penetrating injury. Due to its anatomical location, the axillary artery may present a formidable challenge to the operative surgeon seeking direct surgical exposure for proximal control. The remainder of the mid- and distal axillary artery becomes more superficial and easily accessible heading toward the axilla. The pectoralis minor muscle serves as the gateway to the midaxillary artery and is draped over the anterior surface of the vessel. Along the length of the artery from proximal to distal are an increasing number of branch arteries to the chest wall and shoulder. Intimately associated with the third portion of the axillary artery are the major nerves to the arm, shoulder, and pectoral muscles. This close relationship underscores the likelihood of combined neurovascular injuries with wounding as well as inherent challenges in rapid, efficient exposure and repair without causing unnecessary iatrogenic injury.

The brachial artery runs with the median nerve along the anterior compartment of the arm. The profunda brachial branch joins the radial nerve and penetrates an intermuscular septum laterally becoming the radial collateral artery which is an important proximal collateral to the forearm following injury below the level of the mid-biceps. This important collateral may support distal viability in the setting of major arterial injury and allow time for more serious associated injuries to be addressed. The superior ulnar collateral artery accompanies the ulnar nerve at mid-brachium and penetrates the intermuscular septum medially. The brachial artery is accompanied by two veins: the basilic which is superficial at the antecubital level and then penetrates the fascia to join the brachial vein and the brachial vein with its numerous deep and superficial anastomoses which unite at the level of the lateral border of the teres major to become the axillary vein.

A timeless adage still holds that standard vessel exposure should not be altered or compromised by traumatic wounds with the principles of proximal and distal control obtained whenever possible in the safest and most familiar manner. The most proximal axillary artery beneath the clavicle and adjacent to the first rib presents a major problem for hasty exposure such that a more traditional proximal mediastinal or intrathoracic subclavian exposure might be suitable. In a modern practice, these morbid exposures lend themselves more appropriately to the promise and benefit of rapid and less invasive endovascular control such as balloon occlusion from brachial or femoral access. The Seldinger technique is used to access the femoral artery with a steep left anterior oblique projection of the chest and opacification of the aortic arch to demonstrate the origins of the great vessels. Depending on laterality, the innominate or left subclavian may be cannulated with the appropriate preformed catheter and selective hydrophilic glide wire and advanced toward the site of injury. Next, an exchange made for a stiffer support wire and a long, large-diameter sheath to support the appropriate diameter compliant occlusion balloon. This balloon can be gently inflated under fluoroscopy with the use of a stopcock to maintain inflation and arrest inflow. In special circumstances, the use of a long sheath near the site of injury may also afford the option of covered stent placement to seal extravasation, close an arteriovenous fistula, cover a pseudoaneurysm, or permit coil embolization of bleeding branch vessels.

The remainder of the mid- and distal axillary artery is more classically exposed with an incision two fingerbreadths below mid-lateral clavicle. This separates the underlying pectoralis major fibers with the neurovascular bundle beneath the clavipectoral fascia. Wider arterial exposure may be facilitated by dividing the attachment between the pectoralis minor and the coracoid process. The more distal axillary artery can be approached with an axillary incision and retraction of the lateral pectoralis border medially and coracobrachialis superiorly. In this position, the median nerve is encountered and needs to be gently mobilized. Being a superficial artery in the brachium lends the brachial artery to an easy exposure along the medial groove between the biceps and the triceps. The basilic vein, brachial vein, and median nerve must be identified and protected particularly during a hasty exposure to control bleeding.