Free Functional Muscle Transfer in Brachial Plexus Injury Patients With Subclavian Artery Injury Using Arteriovenous Loop Grafts

Abstract

Background: Free functional muscle transfer (FFMT) for brachial plexus injury (BPI) requires adequate donor arterial flow for successful anastomosis. However, concomitant BPI and subclavian artery injury are not uncommon. Arteriovenous (AV) loop graft is one of the methods used to extend vessels to areas with vascular depletion. This case series aims to report the feasibility and outcomes of AV loop grafts for FFMT in BPI patients with subclavian artery injury. Patients and Methods: This longitudinal descriptive report included adult patients with BPI and concomitant subclavian artery injury. Patients with adequate intra-operative thoracoacromial and/or thoracodorsal arterial flow, sufficient for FFMT without the need for an AV loop graft, were excluded. Results: Of the 10 initially enrolled patients, three were excluded: two for adequate intra-operative arterial flow, and one for extensive adhesions around the external jugular vein, precluding the index surgery. Seven patients, with a median age of 37 years, mostly male and injured in motorcycle accidents, were included. Four patients underwent a single-stage operation (AV loop graft and FFMT simultaneously), while three patients underwent a two-stage operation. Success rates were 100% for the single-stage operation and 33% for the two-stage operation. The two-stage operation led to increased operative time, extended hospital stays, and anastomosis mismatch challenges. Successful cases regained gracilis muscle motor power for elbow flexion, achieving grade III-IV within 13–29 months. Conclusion: FFMT with AV loop graft for BPI patients with subclavian artery injury is feasible and effective. Despite complex microsurgical requirements, these procedures significantly restore limb functionality when standard FFMT operations are insufficient. Trial Registration: ClinicalTrials.gov identifier: NCT06437990.