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Axillary artery

The axillary artery is the principal blood vessel supplying oxygenated blood to the upper limb, originating as the direct continuation of the subclavian artery at the lateral border of the first rib and terminating as the brachial artery at the inferior border of the teres major muscle.^[1] It courses through the axilla, a region deep to the pectoralis minor muscle, where it is enclosed within the axillary sheath alongside the axillary vein and brachial plexus cords, providing essential vascular support to the shoulder girdle, arm, and surrounding structures.^[2] With an average length of approximately 11 cm, the artery is divided into three parts by its relation to the pectoralis minor: the first part proximal to the muscle, the second part deep to it, and the third part distal to it.^[1] The branches of the axillary artery are organized according to these divisions and supply critical musculoskeletal and integumentary tissues in the upper body. From the first part arises the superior thoracic artery, which nourishes the pectoral muscles and thoracic wall.^[2] The second part gives off the thoracoacromial artery—dividing into clavicular, pectoral, deltoid, and acromial branches to vascularize the pectoralis major, deltoid, and clavicular regions—and the lateral thoracic artery, which supplies the serratus anterior, pectoralis minor, and lateral thoracic wall including the mammary gland.^[3] In the third part, the subscapular artery (the largest branch) emerges, bifurcating into the circumflex scapular and thoracodorsal arteries to perfuse the subscapularis, latissimus dorsi, and scapular region; additionally, the anterior and posterior circumflex humeral arteries provide blood to the humeral head, shoulder joint, and deltoid muscle.^[1] Anatomically, the axillary artery maintains close relations with the brachial plexus, with its cords arranged laterally, posteriorly, and medially around the vessel, facilitating coordinated neurovascular function in arm movements.^[2] Clinically, its superficial position in the axilla renders it vulnerable to trauma, such as penetrating injuries or fractures, potentially leading to hemorrhage, ischemia of the upper limb, or compartment syndrome if compromised.^[1] Surgical interventions, including axillary artery bypass grafting or procedures for shoulder instability, often use it as a key landmark due to its consistent anatomy and high variability in branch origins (observed in up to 65% of cases).^[3]

Anatomy

Origin, course, and divisions

The axillary artery is defined as the direct continuation of the subclavian artery, commencing at the lateral border of the first rib.^[4] It traverses the axilla in a downward direction, enclosed within the axillary sheath—a connective tissue layer that also surrounds the cords of the brachial plexus—for a length of approximately 11 cm.^[5]^[4]^[1] The artery's path through the axilla positions it centrally within the region's vascular and neural structures, maintaining a relatively straight descent.^[2] It terminates distally by transitioning into the brachial artery at the inferior border of the teres major muscle.^[3] For anatomical description, the axillary artery is segmented into three parts based on its relation to the pectoralis minor muscle: the first part lies proximal to the muscle and typically gives rise to one branch; the second part passes posterior to the muscle and gives rise to two branches; the third part extends distal to the muscle and gives rise to three branches.^[2] This division facilitates standardized identification in surgical and imaging contexts.^[3]

Anatomical relations

The axillary artery is divided into three parts based on its positional relationship to the pectoralis minor muscle: the first part lies proximal (medial) to the muscle, the second part posterior to it, and the third part distal (lateral) to it.^[1] In its first part, the axillary artery is positioned proximal to (medial to) the pectoralis minor muscle, anterior to the serratus anterior covering the first intercostal space and upper ribs, and medial to the coracobrachialis muscle. The axillary vein runs parallel and medial to the artery throughout its course, while the cords of the brachial plexus relate closely: the lateral cord lies lateral and superior, the medial cord medial or posterior, and the posterior cord superolateral or posterior.^[2]^[3]^[4] The second part of the axillary artery lies directly posterior to the pectoralis minor muscle and lateral to the serratus anterior muscle overlying the upper six ribs. It is surrounded by the cords of the brachial plexus, which cross anterior, lateral, medial, and posterior to the vessel: specifically, the posterior cord is posterior, the lateral cord lateral, and the medial cord medial. The axillary vein remains parallel and medial to this segment.^[2]^[3]^[4] In the third part, the axillary artery is situated posterior to the subscapularis and teres major muscles, lateral to the proximal humerus, and anterior to the coracobrachialis muscle. The axillary vein continues parallel and medial, and the cords of the brachial plexus maintain their relations: lateral, medial, and posterior to the artery.^[2]^[4]^[3] These positional relationships are essential in delineating the boundaries of the axilla, a pyramidal space where the axillary artery forms the core of the neurovascular bundle (with the axillary vein and brachial plexus cords) enclosed within the axillary sheath; this bundle occupies the apex near the first rib and extends to the base formed by the axillary fascia, influencing the region's overall anatomical framework.^[1]^[6]^[7]

Branches

The axillary artery is conventionally divided into three parts based on its relation to the pectoralis minor muscle, with branches arising accordingly from each segment.^[1] From the first part, proximal to the pectoralis minor, arises the superior thoracic artery, a small vessel that emerges near the medial border of the pectoralis minor and ascends to contribute to the vascular supply of the upper thoracic wall.^[4]^[1] The second part, deep to the pectoralis minor, gives rise to two main branches: the thoracoacromial artery and the lateral thoracic artery. The thoracoacromial artery originates posteriorly and pierces the clavipectoral fascia to divide into four terminal branches—clavicular, pectoral, deltoacromial (or deltoid), and acromial—which distribute across the pectoral region, clavicle, and shoulder structures.^[1]^[4] The lateral thoracic artery arises along the lower border of the pectoralis minor, descending parallel to it to reach the lateral aspect of the thorax.^[1]^[4] The third part, distal to the pectoralis minor, produces three significant branches: the subscapular artery, anterior circumflex humeral artery, and posterior circumflex humeral artery. The subscapular artery is the largest branch of the axillary artery, originating from the axillary aspect and coursing along the posterior axillary wall; it promptly divides into the circumflex scapular artery, which winds around the lateral border of the scapula, and the thoracodorsal artery, which continues inferiorly along the latissimus dorsi muscle.^[1]^[4] The anterior circumflex humeral artery is a smaller vessel that passes anteriorly around the surgical neck of the humerus, while the larger posterior circumflex humeral artery travels posteriorly through the quadrangular space, accompanying the axillary nerve, to encircle the same region.^[1]^[4] These branches participate in key anastomotic networks that enhance collateral circulation. Notably, the circumflex scapular artery from the subscapular trunk contributes to the scapular anastomosis, interconnecting with branches from the subclavian and suprascapular arteries around the scapula. Additionally, the anterior and posterior circumflex humeral arteries form an anastomotic ring around the surgical neck of the humerus, linking with other brachial vessels.^[4]^[1]

Physiology

Blood supply and function

The axillary artery serves as the primary arterial conduit for the upper extremity, originating as a direct continuation of the subclavian artery at the lateral border of the first rib and extending through the axilla to become the brachial artery inferior to the teres major muscle, thereby delivering oxygenated blood to the shoulder, arm, and proximal forearm regions.^[1] This vessel ensures the metabolic demands of the upper limb are met by maintaining continuous pulsatile flow from the systemic circulation, with its course through the axilla facilitating efficient distribution to musculoskeletal structures essential for arm movement and stability.^[1] Its branches provide targeted blood supply to key anatomical territories, including the pectoral girdle for overall shoulder support, serratus anterior for scapular stabilization, latissimus dorsi for back and arm extension, deltoid for shoulder abduction, subscapularis for internal rotation, and the humerus for osseous nutrition.^[1] These territories receive nutrient-rich blood to support contractile activity and tissue maintenance, with the axillary artery's strategic positioning enabling rapid response to increased demands during physical exertion.^[1] The axillary artery contributes to collateral circulation through participation in the scapular and acromial anastomoses, forming interconnected networks around the scapula and shoulder that link branches from the subclavian and axillary arteries to provide redundant pathways for blood flow in the event of proximal occlusion.^[1] This anastomotic system enhances circulatory resilience, allowing alternative routes via vessels such as the suprascapular and circumflex scapular arteries to bypass potential blockages and sustain upper limb perfusion.^[1]^[8] Clinically, the pulse of the axillary artery is palpated at its third part, located deep in the axilla posterior to the pectoralis minor tendon, serving as a key site for assessing upper limb circulation and detecting peripheral vascular compromise.^[1] Hemodynamically, the artery exhibits a typical diameter of approximately 6.0 ± 1.1 mm (overall minimal luminal diameter), which supports adequate flow rates under normal systolic pressures.^[9] The pressure gradient from the aorta to the axillary artery is minimal, with an average systolic difference of -3.0 ± 4.0 mmHg, ensuring near-equivalent perfusion pressures to downstream brachial territories without significant energy loss.^[10]

Anatomical variations

The axillary artery displays considerable anatomical variability in its origin, course, divisions, and branching patterns, with the classic configuration observed in only 17.7% to 37.5% of cases across cadaveric studies.^[11]^[12] These variations arise primarily from differences in the positioning relative to surrounding structures and atypical branching, affecting up to 82.3% of upper limbs in some cohorts.^[11] Variations in the origin and termination of the axillary artery include high origin from the subclavian artery, where the transition occurs proximal to the typical lateral border of the first rib, and low termination into the brachial artery, extending the axillary course beyond the inferior border of the teres major muscle. Such positional anomalies are relatively uncommon, though precise prevalence varies by population. The divisions of the axillary artery, conventionally defined relative to the pectoralis minor muscle (first part proximal, second part posterior, third part distal), are generally consistent, though atypical branching patterns occur in approximately 25-30% of cases.^[12]^[13] Branch anomalies are among the most frequent variations, often involving altered origins or duplications. The superior thoracic artery may be absent in rare instances, though it is conserved in over 97% of specimens; when absent, its territory is typically supplied by collateral branches from the subclavian.^[11] The thoracoacromial artery can be duplicated, splitting into deltoacromial and clavipectoral trunks, with a prevalence of about 5.1%.^[13] The subscapular artery occasionally arises from the proximal brachial artery rather than the third part of the axillary, a variant noted in up to 2-3% of cases, potentially altering downstream flow to the scapular region.^[11] Regarding the circumflex humeral arteries, a common trunk origin for the anterior and posterior branches occurs in 32% of cases, while independent origins or duplications of the posterior circumflex humeral artery are seen in 3-19% of specimens, contributing to variability in shoulder perfusion.^[12]^[13] Other notable branch shifts include the lateral thoracic artery originating from the subscapular artery in 20% of cases.^[13] These anatomical variations hold significant clinical relevance for surgical planning, particularly in procedures involving the axilla such as mastectomies, lymph node dissections, and vascular reconstructions, where unrecognized anomalies may lead to inadvertent injury or compromised flap viability.^[11]^[13] Preoperative imaging, such as angiography or ultrasound, is recommended to identify such deviations and mitigate risks.^[12]

Development

Embryological origins

The axillary artery derives primarily from the seventh cervical intersegmental artery, which forms the initial axial artery supplying the upper limb, in combination with the subclavian artery, whose proximal segment on the left arises from the seventh intersegmental artery off the dorsal aorta and on the right from the fourth aortic arch via the brachiocephalic trunk.^[14] This derivation occurs during weeks 4 to 8 of gestation, aligning with Carnegie stages 12 to 23 of embryonic development.^[15] Development initiates at stage 12 (approximately 26-30 days post-fertilization) with the emergence of a capillary plexus from the dorsal aorta, which penetrates and vascularizes the emerging upper limb bud.^[16] This plexus provides the foundational network for arterial formation, transitioning from diffuse dorsal aortic segments through selective remodeling into defined vessels.^[15] The subclavian artery contributes proximally via its connection to the aortic arches, while the seventh intersegmental artery extends laterally to support limb bud vascularization, establishing the continuity that becomes the axillary artery.^[14] Maturation follows a proximal-to-distal gradient, with key differentiation events shaping the axillary configuration. By stage 15 (31-35 days, early week 5), the capillary plexus enlarges to form the subclavian and axillary arteries as distinct trunks.^[15] Subsequent stages involve regression of superfluous channels and enlargement of primary pathways, culminating in the mature axillary artery by stage 23 (56-60 days).^[16] The axillary artery's role integrates with upper limb morphogenesis, particularly during the seventh week's 90-degree lateral rotation of the limb bud.^[17] This rotation, coupled with elongation of the limb, ensures optimal blood supply to the rotating girdle and proximal arm.^[18] Disruptions in this process can lead to positional anomalies, though the standard configuration reflects coordinated vascular and skeletal adaptation.^[15]

Histology and microstructure

The axillary artery, as a large elastic artery, exhibits a trilaminar wall structure typical of major conductance vessels, consisting of the tunica intima, tunica media, and tunica adventitia.^[19]^[20] The innermost tunica intima comprises a continuous monolayer of flattened endothelial cells resting on a subendothelial layer of loose connective tissue, including collagen and elastin fibers, which supports the endothelium and facilitates a smooth, non-thrombogenic surface for blood flow.^[20]^[21] These endothelial cells play critical roles in vasoregulation by releasing vasoactive substances such as nitric oxide for vasodilation and endothelin for vasoconstriction, while also providing antithrombotic properties through the expression of anticoagulants like thrombomodulin and prostacyclin to inhibit platelet aggregation and clot formation.^[22]^[23] The middle tunica media is the thickest layer in elastic arteries like the axillary, dominated by concentric fenestrated lamellae of elastin fibers interspersed with smooth muscle cells and collagen, enabling the vessel to stretch during systole and recoil during diastole to accommodate pressure fluctuations in the upper limb circulation.^[20]^[21] This high elastin content distinguishes elastic arteries from smaller muscular branches, where the media features fewer elastic lamellae and more circumferentially arranged smooth muscle for localized resistance control under lower pressure gradients.^[19]^[20] The outermost tunica adventitia consists primarily of dense collagenous connective tissue with scattered elastin fibers and fibroblasts, providing tensile strength and anchoring the artery to surrounding structures; it also houses the vasa vasorum for nutrient supply to the outer wall layers.^[20]^[21] Sympathetic nerve fibers, originating from the autonomic nervous system, course through the adventitia and adventitial-medial border, innervating smooth muscle cells to mediate vasoconstriction via norepinephrine release, thereby regulating vascular tone in response to systemic demands. This mature microstructure derives from embryonic mesenchymal precursors that differentiate into the vascular layers during upper limb development.^[24]

Clinical aspects

Trauma and injuries

Trauma to the axillary artery can occur through penetrating or blunt mechanisms, with penetrating injuries often resulting from stab wounds or gunshots and blunt injuries typically associated with high-energy impacts leading to shoulder dislocations or proximal humerus fractures.^[25] In a review of 44 cases at an urban trauma center, penetrating and blunt trauma were equally represented, highlighting the diverse etiologies of these injuries.^[25] Axillary artery laceration or disruption occurs in approximately 1% of shoulder dislocations and less than 1% of proximal humerus fractures, though the exact incidence remains variable due to underreporting in low-energy trauma.^[26]^[27] The third part of the axillary artery is particularly vulnerable owing to its close proximity to the humeral head and brachial plexus, increasing the risk of concurrent neurovascular compromise during such injuries. Clinical signs of axillary artery injury often manifest as acute limb ischemia, characterized by the "6 P's": pain, pallor, paresthesia, paralysis, poikilothermy (coolness), and pulselessness, with a pulsatile hematoma indicating active hemorrhage in penetrating cases.^[28] Risk factors include high-velocity blunt force and anatomical relations that tether the vessel, predisposing it to stretch or transection.^[25] Initial management prioritizes hemostasis through direct pressure or proximal control, followed by urgent vascular repair to restore perfusion and prevent limb loss, with endovascular or open techniques selected based on injury extent and stability.^[29] In reported series, timely revascularization achieves high success rates, exceeding 95%, underscoring the importance of rapid intervention.^[25]

Pathological conditions

The axillary artery is susceptible to several non-traumatic pathological conditions, primarily involving degenerative, inflammatory, and embolic processes that can compromise upper limb perfusion. These conditions are relatively uncommon compared to those affecting lower extremity arteries, owing to the artery's protected anatomical position and robust collateral circulation, but they can lead to significant morbidity if untreated.^[30] Axillary artery aneurysms represent a rare form of peripheral arterial aneurysm, accounting for less than 1% of all such lesions. Non-traumatic etiologies include atherosclerosis, which promotes aneurysmal dilation through progressive vessel wall weakening, as well as connective tissue disorders and infectious processes. Patients typically present with a palpable axillary mass, local pain, or symptoms of distal embolization, such as digital ischemia or cyanosis in the hand.^[31]^[30]^[32] Thrombosis of the axillary artery often arises from atherosclerotic plaque formation, particularly in the proximal segments where turbulent flow may accelerate intimal damage and thrombus propagation. Embolic occlusion, another key mechanism, frequently originates from cardiac sources like atrial fibrillation or mural thrombi, resulting in acute upper limb ischemia characterized by pallor, paresthesia, and diminished pulses.^[33]^[34]^[35] Vasculitis, notably Takayasu arteritis, can involve the axillary artery, often at its junction with the subclavian artery, leading to inflammatory thickening, stenosis, or aneurysmal changes due to granulomatous infiltration of the vessel wall. This condition predominantly affects young women and manifests with arm claudication, absent pulses, or bruit over the affected area.^[36]^[37] Atherosclerotic disease in the axillary artery manifests as plaque accumulation, predominantly in its first and second segments, driven by endothelial dysfunction, lipid deposition, and chronic inflammation. This can cause luminal narrowing and predispose to superimposed thrombosis.^[34] Untreated pathological conditions of the axillary artery carry risks of distal embolization to the brachial or radial arteries, potentially causing hand ischemia or digital gangrene, particularly in cases of prolonged occlusion. In severe instances, such as embolic events without prompt intervention, limb-threatening complications including tissue necrosis may ensue.^[38]^[39]

Diagnostic and surgical considerations

Diagnostic imaging plays a crucial role in evaluating the axillary artery for pathology, with Doppler ultrasound serving as an initial noninvasive tool to assess blood flow velocity and detect stenoses or occlusions.^[40] This modality allows real-time evaluation of arterial patency and is particularly useful in outpatient settings for suspected vascular compromise.^[41] Computed tomography angiography (CTA) provides high-resolution three-dimensional visualization of the axillary artery, its branches, and surrounding soft tissues, making it the preferred method for trauma assessment and preoperative planning.^[42] CTA techniques involve supine positioning with the arm extended overhead, contrast injection at 4-5 mL/s, and multidetector scanning from the aortic arch to fingertips, enabling detection of pseudoaneurysms, extravasation, and collaterals.^[43] Magnetic resonance angiography (MRA) excels in characterizing soft tissue relations and vascular wall inflammation without ionizing radiation, using contrast-enhanced or non-contrast sequences like time-of-flight for non-urgent evaluations such as thoracic outlet syndrome.^[43] Conventional arteriography remains the gold standard for detailed preoperative assessment of the axillary artery, offering high-fidelity imaging of branches, collaterals, and distal runoff to guide interventions.^[44] This invasive technique involves catheter-based contrast injection, providing therapeutic options alongside diagnostics in complex cases.^[45] Surgical access to the axillary artery typically employs the deltopectoral approach, utilizing an incision along the deltopectoral groove to expose the vessel while minimizing brachial plexus disruption.^[46] The procedure begins with a horizontal infraclavicular incision 2 cm below the clavicle's midpoint, followed by retraction of the pectoralis major to isolate the artery without direct nerve manipulation.^[46] Common operative procedures include endarterectomy for localized plaque removal, though it is less frequently applied to the axillary artery due to its anatomical constraints.^[47] Bypass grafting, often using autologous saphenous vein, reconstructs flow around occlusions, with the graft anastomosed proximally to the axillary artery and distally to the brachial or radial artery.^[48] Endovascular stenting addresses stenoses or injuries via percutaneous access, deploying self-expanding nitinol stents to restore patency with reduced invasiveness compared to open repair.^[49] Perioperative risks encompass brachial plexus or axillary nerve injury from retraction or positioning. Compartment syndrome in the arm may arise from reperfusion injury post-revascularization, necessitating vigilant monitoring and prompt fasciotomy if pressures exceed 30 mmHg.^[50]

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[54]
Compartment Syndrome Due to Reperfusion Injury from an Axillary ...
Introduction. Compartment syndrome is a surgical emergency that occurs when the pressure within a muscular compartment rises higher than the perfusion pressure.