Revascularisation Beyond the Golden Hour: Managing Traumatic Brachial Artery Injuries in a Developing Country

Background: Brachial artery injuries are common in upper limb trauma and require timely repair to prevent ischemia and limb loss. In developing countries like India, delayed presentation is frequent due to limited access to specialised care, inadequate infrastructure and delays in multidisciplinary coordination, complicating timely revascularisation. This study aimed to evaluate limb salvage outcomes and factors influencing prognosis in patients undergoing delayed repair of traumatic brachial artery injuries. Methods: This prospective study included 30 male patients (ages 18-58 years) with traumatic brachial artery injuries treated over 2 years. All patients presented more than 6 hours after injury. Emergency surgical repair was performed using either primary anastomosis or reversed vein grafts, with the great saphenous vein used in 14 patients and upper limb veins in others. Associated nerve and tendon injuries were repaired simultaneously. Fasciotomy was performed in 20 patients. Patients were followed up at regular intervals (2 weeks to 6 months), and outcomes were assessed in terms of limb salvage, complications and secondary procedures. Results: Out of 30 patients, 26 limbs (86.6%) were salvaged, and 4 (13.4%) required above-elbow amputation due to gangrene. Most patients (20/30) presented between 12 and 24 hours, with one case successfully revascularised at 92 hours post-injury. Ten patients underwent primary repair; 20 required vein grafting. Concomitant nerve injury was found in 26 patients, primarily affecting the median nerve (16 patients). Fasciotomy helped prevent irreversible ischemic damage. Two patients developed acute kidney injury, and 10 required negative pressure wound therapy followed by skin grafting. Conclusions: Delayed surgical repair of brachial artery injuries, even beyond conventionally accepted ischemic time thresholds, can achieve high limb salvage rates. However, systemic limitations in developing countries continue to pose major challenges to achieving timely intervention and optimal outcomes. Level of Evidence: Level IV (Therapeutic).