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Axillofemoral Bypass Graft Fracture
Axillofemoral Bypass Graft Fracture Steven G. Friedman, MD, Kimlyn C. Long, MD, and Larry A. Scher, MD, Manhasset, New York
Since the introduction of axillofemoral bypass more than 30 years ago, there have been numerous reports demonstrating the value of this procedure in patients with aortoiliac occlusive disease who are too ill to undergo direct reconstruction. Along with the increasing use of axillofemoral bypass have come the usual graft-related complications including thrombosis, hematoma formation, and infection. A more unusual occurrence, however, is disruption of the axillary anastomosis with formation of a false aneurysm. We report herein a case in which the body of an axillofemoral graft fractured just distal to the axillary anastomosis resulting in complete disruption of the graft. (Ann Vasc Surg 1996;10:490-492.)
Cecil Lewis of Australia was the first to use a n u p p e r e x t r e m i t y artery to restore circulation to the legs. ~ In 1959 h e sewed a n y l o n prosthesis f r o m the subclavian artery to an aortic h o m o g r a f t to repair a r u p t u r e d a b d o m i n a l aortic a n e u r y s m . Three years later Blaisdell a n d HaW p e r f o r m e d the first axillofemoral bypass in a patient w i t h a recently t h r o m b o s e d aortic prosthesis w h o suffered cardiac arrest during i n d u c t i o n of a n e s t h e sia for t h r o m b e c t o m y . The patient was resuscitated and u n d e r w e n t the e x t r a - a n a t o m i c bypass p r o c e d u r e to avoid a n o t h e r l a p a r o t o m y . During the e n s u i n g three decades, m a n y articles have b e e n published d e m o n s t r a t i n g the value of this p r o c e d u r e in persons w i t h aortoiliac occlusive disease w h o are too ill to u n d e r g o direct reconstruction. Along w i t h the w e a l t h of experience gained f r o m the use of axillofemoral bypass have c o m e the usual graft-related complications. These include thrombosis, h e m a t o m a f o r m a t i o n , a n d infection. A m o r e u n u s u a l complication is disruption of the axillary a n a s t o m o s i s w i t h f o r m a t i o n of a false a n e u r y s m . This results f r o m excessive stretching of the graft, w h i c h is caused by pulling of the suture line t h r o u g h either the prosthesis or the axillary artery. W e report a case in w h i c h the b o d y of a n axillofemoral graft fractured just distal to the axillary a n a s t o m o s i s resulting in c o m p l e t e disruption of the graft. The s u t u r e line a n d a complete ring of prosthesis w e r e left intact o n the axillary artery. From the Division of Vascular Surgery, North Shore University Hospital Manhasset, N.Y. Reprint requests: Steven G. Friedman, MD, Division of Vascular Surgery, North Shore University Hospital, 300 Community Dr., ManhasseL iVY 11030.
490
CASE R E P O R T A 73-year-old man with a history of a myocardial infarction and severe pulmonary disease was evaluated for severe rest pain in the right foot. The patient had undergone a right iliofemoral bypass 7 years earlier, which had subsequently thrombosed. An arteriogram also revealed occlusion of the external iliac, common, and superficial femoral arteries. The arch vessels were normal. The patient underwent an axillary-profunda bypass with a 6 mm thin-walled ringed potytetrafluroethylene (PTFE) graft (W.L Gore & Associates, Inc., Flagstaff, Ariz.). He was positioned with his arms at his sides. Although the graft had removable rings, none was removed for the axillary anastomosis because the end of the graft was used. The outer wrap of the graft remained completely intact and the anastomosis was constructed to the first part of the axillary artery. It emanated from the artery in a gentle C configuration and approached the femoral vessels with a slight curve to ensure that it would not be too short. Following completion of this anastomosis, an atraumatic vascular clamp was placed distal to the fracture site. The patient did well until the second morning after surgery when he slipped in an attempt to move himself toward the head of the bed while he was propped up on his elbows. Within minutes a 10 cm hematoma of the right chest wall developed. Vital signs remained stable and the axillary wound was reexplored in the operating room. Following evacuation of the hematoma, proximal and distal control of the axillary artery was obtained. The PTFE graft had tom completely along a slight angle that began approximately 0.75 cm from the suture line (Fig. 1 ). The remaining ring of graft was debrided from the axillary artery along with the intact suture line, The distal graft was also debrided and an interposition graft of the same material was inserted. The patient did well postoperatively and was discharged 3 days after the second operation. The graft
Vol. 10, No. 5 1996
Case reports 491
'~
~~, PTFEGraft
~ Axilaryartery Fig. 1. Fracture of an axillofemoral graft distal to the axillary anastomosis.
remains patent 6 months later and the patient is slowly recovering from brachial plexus neuropathy. The lot from which this prosthesis was taken met all of the prerelease specifications including those for longitudinal strength, suture retention, and resistance to aneurysmal dilatation.
DISCUSSION In 1978 Daar and Finch 3 claimed to have encountered the first case of disruption of the axillary anastomosis of an axillofemoral bypass. The complication occurred in a 66-year-old w o m a n 3 weeks after graft placement. The patient had attempted to pull herself over the edge of the bed while prone. Sullivan et al. 4 reported two cases of graft disruption in which the sutures were also pulled through the axillary artery. A 53-year-old w o m a n experienced this complication 6 weeks after undergoing graft placement while she was raising and stretching her arm toward a high shelf. The second patient was a 66-year-old m a n who had also undergone axillofemoral bypass 6 weeks prior to disruption of the proximal anastomosis. The patient had pulled himself out of bed with an overhead trapeze when a pulsatile mass appeared beneath the clavicle. The authors speculated that a scissoring effect of the pectoralis minor muscle on the graft passing through its fibers may have been responsible for this disruption. In 1991 W e h m a n n and Rongaus 5 described disruption of an axillofemoral graft caused by the sutures tearing out of the graft. The complication occurred 6 months after the original operation. Brophy et al. 6 also described a case in which the sutures tore through a PTFE graft and re-
mained intact on the axillary artery. An interposition graft was used to repair the disruption and the patient did well postoperatively except for transient brachial plexus neuropathy. Most recently Taylor et al. 7 reported 10 cases of acute disruption of axillary anastomoses culled from a series of 202 axillofemoral bypasses. In four cases the sutures pulled out of the artery, in two cases they pulled out of the graft, and in one case the graft was partially torn and the sutures pulled out of it. The cause of disruption was u n k n o w n in two cases. Disruption of the axillary anastomosis of an axillofemoral bypass results from tearing of the sutures out of the artery, tearing of the sutures through the graft, fracture of the graft itself, or a combination of these events. Possible causes include inadequate bites w h e n the graft or artery is being sutured, misplacement of the graft with relation to the axillary artery and the pectoralis muscles, and a defect in the graft material. The latter may be inherent or iatrogenic (i.e., caused by clamping or disrupting of the external wrap of the graft). The present case and one of those reported by Taylor et al. differ from all of the other cases of axfllary anastomotic disruption in that the graft fractured completely, suggesting a defect in the material. In the case reported by Brophy et al. a small portion of the graft tore from the body of the prosthesis, also suggesting a defect in the material. The manufacturer (W.L. Gore & Associates, Inc.) confirmed that both grafts met all prerelease specifications. Although most cases of axillary anastomotic disruption are easily managed by obtaining proximal and distal control of the artery, care should be
492
CaseReports
t a k e n to avoid injury to the brachial plexus. The large h e m a t o m a that obscures the axillary artery, brachial plexus, a n d p r o x i m a l graft, a n d the h a s t e w i t h w h i c h arterial control is a t t e m p t e d , m a k e s the nerve susceptible to injury. In our case as well as that of B r o p h y et al., brachial plexus injuries resulted f r o m r e o p e r a t i o n a n d were n o t recognized until after surgery. The p r o x i m a l a n a s t o m o s i s of a n axillofemoral bypass s h o u l d be c o n s t r u c t e d at the first or seco n d p o r t i o n of the axillary artery. This allows full r a n g e of a r m m o t i o n w i t h o u t placing u n d u e tension o n the graft. If the a n a s t o m o s i s is situated too far laterally, e x t r e m e a b d u c t i o n or e x t e n s i o n of the a r m m a y result in a n a s t o m o t i c dehiscence. Only rings designed to be r e m o v e d should be t a k e n off of the graft, a n d this s h o u l d only be n e c e s s a r y at o n e of the a n a s t o m o s e s . The graft s h o u l d be c l a m p e d w i t h a t r a u m a t i c vascular clamps. Sutures s h o u l d be placed 1 to 2 m m f r o m the edge of the artery a n d the graft. The graft should e m a n a t e f r o m the axillary artery in a semicircular fashion, f o r m i n g a gentle C r a t h e r t h a n a straight line to the distal a n a s t o m o s i s . Similarly, it s h o u l d a p p r o a c h the f e m o r a l vessels in a gentle curve r a t h e r t h a n a straight line. This ensures that the graft will n o t be too short or tight. It should b e g i n medial to the pectoralis
Annals of Vascular Surgery
m i n o r t e n d o n a n d course posterior to the muscle. B e y o n d this m u s c l e the graft emerges s u b c u t a n e ously a n d c o n t i n u e s in this w a y to the groin. Because it occurs so rarely, we do not believe that this c o m p l i c a t i o n or those n o t e d previously indicate that t h i n - w a l l e d PTFE is unsuitable for use in this position. A d h e r e n c e to the a b o v e - m e n tioned steps should ensure that this remains a rare complication. REFERENCES 1. LewisCD. A subclavian artery as the means of blood-supplyto the lower half of the body. Br d Surg 1961;48:574-575. 2. Blaisdell FW, Hall AD. Axillary-femoralartery bypass for lower extremity ischemia. Surgery 1963;54:563-568. 3. Daar AS, Finch DRA. Graft avulsion: An unreported complication of axillofemoral bypass grafts. Br d Surg 1978;65:442447. 4. Sullivan LP, Davidson PG, D'Anna J Jr, et al. Disruption of the axillaD" anastomosis of axillobifemoral grafts: Two case reports. J Vasc Surg 1989;10:190-192. 5. Wehmann TW, Rongaus VA. Axillary disruption of axfllobifemoral graft, d Am Osteopath Assoc 1991;91:813-815. 6. BrophyCM, Quist we, Kwolek C, et al. Disruption of proximal axillobifemoral bypass graft anastomosis, J Vasc Surg 1992; 15:218-220. 7. Taylor LM Jr, Park TC, Edwards JM, et al. Acute disruption of polytetrafluoroethylene grafts adjacent to axillary anastomoses: A complication of axillofemoral grafting. J Vasc Surg 1994;20:520-528.
Since the introduction of axillofemoral bypass more than 30 years ago, there have been numerous reports demonstrating the value of this procedure in patients with aortoiliac occlusive disease who are too ill to undergo direct reconstruction. Along with the increasing use of axillofemoral bypass have come the usual graft-related complications including thrombosis, hematoma formation, and infection. A more unusual occurrence, however, is disruption of the axillary anastomosis with formation of a false aneurysm. We report herein a case in which the body of an axillofemoral graft fractured just distal to the axillary anastomosis resulting in complete disruption of the graft. (Ann Vasc Surg 1996;10:490-492.)
Cecil Lewis of Australia was the first to use a n u p p e r e x t r e m i t y artery to restore circulation to the legs. ~ In 1959 h e sewed a n y l o n prosthesis f r o m the subclavian artery to an aortic h o m o g r a f t to repair a r u p t u r e d a b d o m i n a l aortic a n e u r y s m . Three years later Blaisdell a n d HaW p e r f o r m e d the first axillofemoral bypass in a patient w i t h a recently t h r o m b o s e d aortic prosthesis w h o suffered cardiac arrest during i n d u c t i o n of a n e s t h e sia for t h r o m b e c t o m y . The patient was resuscitated and u n d e r w e n t the e x t r a - a n a t o m i c bypass p r o c e d u r e to avoid a n o t h e r l a p a r o t o m y . During the e n s u i n g three decades, m a n y articles have b e e n published d e m o n s t r a t i n g the value of this p r o c e d u r e in persons w i t h aortoiliac occlusive disease w h o are too ill to u n d e r g o direct reconstruction. Along w i t h the w e a l t h of experience gained f r o m the use of axillofemoral bypass have c o m e the usual graft-related complications. These include thrombosis, h e m a t o m a f o r m a t i o n , a n d infection. A m o r e u n u s u a l complication is disruption of the axillary a n a s t o m o s i s w i t h f o r m a t i o n of a false a n e u r y s m . This results f r o m excessive stretching of the graft, w h i c h is caused by pulling of the suture line t h r o u g h either the prosthesis or the axillary artery. W e report a case in w h i c h the b o d y of a n axillofemoral graft fractured just distal to the axillary a n a s t o m o s i s resulting in c o m p l e t e disruption of the graft. The s u t u r e line a n d a complete ring of prosthesis w e r e left intact o n the axillary artery. From the Division of Vascular Surgery, North Shore University Hospital Manhasset, N.Y. Reprint requests: Steven G. Friedman, MD, Division of Vascular Surgery, North Shore University Hospital, 300 Community Dr., ManhasseL iVY 11030.
490
CASE R E P O R T A 73-year-old man with a history of a myocardial infarction and severe pulmonary disease was evaluated for severe rest pain in the right foot. The patient had undergone a right iliofemoral bypass 7 years earlier, which had subsequently thrombosed. An arteriogram also revealed occlusion of the external iliac, common, and superficial femoral arteries. The arch vessels were normal. The patient underwent an axillary-profunda bypass with a 6 mm thin-walled ringed potytetrafluroethylene (PTFE) graft (W.L Gore & Associates, Inc., Flagstaff, Ariz.). He was positioned with his arms at his sides. Although the graft had removable rings, none was removed for the axillary anastomosis because the end of the graft was used. The outer wrap of the graft remained completely intact and the anastomosis was constructed to the first part of the axillary artery. It emanated from the artery in a gentle C configuration and approached the femoral vessels with a slight curve to ensure that it would not be too short. Following completion of this anastomosis, an atraumatic vascular clamp was placed distal to the fracture site. The patient did well until the second morning after surgery when he slipped in an attempt to move himself toward the head of the bed while he was propped up on his elbows. Within minutes a 10 cm hematoma of the right chest wall developed. Vital signs remained stable and the axillary wound was reexplored in the operating room. Following evacuation of the hematoma, proximal and distal control of the axillary artery was obtained. The PTFE graft had tom completely along a slight angle that began approximately 0.75 cm from the suture line (Fig. 1 ). The remaining ring of graft was debrided from the axillary artery along with the intact suture line, The distal graft was also debrided and an interposition graft of the same material was inserted. The patient did well postoperatively and was discharged 3 days after the second operation. The graft
Vol. 10, No. 5 1996
Case reports 491
'~
~~, PTFEGraft
~ Axilaryartery Fig. 1. Fracture of an axillofemoral graft distal to the axillary anastomosis.
remains patent 6 months later and the patient is slowly recovering from brachial plexus neuropathy. The lot from which this prosthesis was taken met all of the prerelease specifications including those for longitudinal strength, suture retention, and resistance to aneurysmal dilatation.
DISCUSSION In 1978 Daar and Finch 3 claimed to have encountered the first case of disruption of the axillary anastomosis of an axillofemoral bypass. The complication occurred in a 66-year-old w o m a n 3 weeks after graft placement. The patient had attempted to pull herself over the edge of the bed while prone. Sullivan et al. 4 reported two cases of graft disruption in which the sutures were also pulled through the axillary artery. A 53-year-old w o m a n experienced this complication 6 weeks after undergoing graft placement while she was raising and stretching her arm toward a high shelf. The second patient was a 66-year-old m a n who had also undergone axillofemoral bypass 6 weeks prior to disruption of the proximal anastomosis. The patient had pulled himself out of bed with an overhead trapeze when a pulsatile mass appeared beneath the clavicle. The authors speculated that a scissoring effect of the pectoralis minor muscle on the graft passing through its fibers may have been responsible for this disruption. In 1991 W e h m a n n and Rongaus 5 described disruption of an axillofemoral graft caused by the sutures tearing out of the graft. The complication occurred 6 months after the original operation. Brophy et al. 6 also described a case in which the sutures tore through a PTFE graft and re-
mained intact on the axillary artery. An interposition graft was used to repair the disruption and the patient did well postoperatively except for transient brachial plexus neuropathy. Most recently Taylor et al. 7 reported 10 cases of acute disruption of axillary anastomoses culled from a series of 202 axillofemoral bypasses. In four cases the sutures pulled out of the artery, in two cases they pulled out of the graft, and in one case the graft was partially torn and the sutures pulled out of it. The cause of disruption was u n k n o w n in two cases. Disruption of the axillary anastomosis of an axillofemoral bypass results from tearing of the sutures out of the artery, tearing of the sutures through the graft, fracture of the graft itself, or a combination of these events. Possible causes include inadequate bites w h e n the graft or artery is being sutured, misplacement of the graft with relation to the axillary artery and the pectoralis muscles, and a defect in the graft material. The latter may be inherent or iatrogenic (i.e., caused by clamping or disrupting of the external wrap of the graft). The present case and one of those reported by Taylor et al. differ from all of the other cases of axfllary anastomotic disruption in that the graft fractured completely, suggesting a defect in the material. In the case reported by Brophy et al. a small portion of the graft tore from the body of the prosthesis, also suggesting a defect in the material. The manufacturer (W.L. Gore & Associates, Inc.) confirmed that both grafts met all prerelease specifications. Although most cases of axillary anastomotic disruption are easily managed by obtaining proximal and distal control of the artery, care should be
492
CaseReports
t a k e n to avoid injury to the brachial plexus. The large h e m a t o m a that obscures the axillary artery, brachial plexus, a n d p r o x i m a l graft, a n d the h a s t e w i t h w h i c h arterial control is a t t e m p t e d , m a k e s the nerve susceptible to injury. In our case as well as that of B r o p h y et al., brachial plexus injuries resulted f r o m r e o p e r a t i o n a n d were n o t recognized until after surgery. The p r o x i m a l a n a s t o m o s i s of a n axillofemoral bypass s h o u l d be c o n s t r u c t e d at the first or seco n d p o r t i o n of the axillary artery. This allows full r a n g e of a r m m o t i o n w i t h o u t placing u n d u e tension o n the graft. If the a n a s t o m o s i s is situated too far laterally, e x t r e m e a b d u c t i o n or e x t e n s i o n of the a r m m a y result in a n a s t o m o t i c dehiscence. Only rings designed to be r e m o v e d should be t a k e n off of the graft, a n d this s h o u l d only be n e c e s s a r y at o n e of the a n a s t o m o s e s . The graft s h o u l d be c l a m p e d w i t h a t r a u m a t i c vascular clamps. Sutures s h o u l d be placed 1 to 2 m m f r o m the edge of the artery a n d the graft. The graft should e m a n a t e f r o m the axillary artery in a semicircular fashion, f o r m i n g a gentle C r a t h e r t h a n a straight line to the distal a n a s t o m o s i s . Similarly, it s h o u l d a p p r o a c h the f e m o r a l vessels in a gentle curve r a t h e r t h a n a straight line. This ensures that the graft will n o t be too short or tight. It should b e g i n medial to the pectoralis
Annals of Vascular Surgery
m i n o r t e n d o n a n d course posterior to the muscle. B e y o n d this m u s c l e the graft emerges s u b c u t a n e ously a n d c o n t i n u e s in this w a y to the groin. Because it occurs so rarely, we do not believe that this c o m p l i c a t i o n or those n o t e d previously indicate that t h i n - w a l l e d PTFE is unsuitable for use in this position. A d h e r e n c e to the a b o v e - m e n tioned steps should ensure that this remains a rare complication. REFERENCES 1. LewisCD. A subclavian artery as the means of blood-supplyto the lower half of the body. Br d Surg 1961;48:574-575. 2. Blaisdell FW, Hall AD. Axillary-femoralartery bypass for lower extremity ischemia. Surgery 1963;54:563-568. 3. Daar AS, Finch DRA. Graft avulsion: An unreported complication of axillofemoral bypass grafts. Br d Surg 1978;65:442447. 4. Sullivan LP, Davidson PG, D'Anna J Jr, et al. Disruption of the axillaD" anastomosis of axillobifemoral grafts: Two case reports. J Vasc Surg 1989;10:190-192. 5. Wehmann TW, Rongaus VA. Axillary disruption of axfllobifemoral graft, d Am Osteopath Assoc 1991;91:813-815. 6. BrophyCM, Quist we, Kwolek C, et al. Disruption of proximal axillobifemoral bypass graft anastomosis, J Vasc Surg 1992; 15:218-220. 7. Taylor LM Jr, Park TC, Edwards JM, et al. Acute disruption of polytetrafluoroethylene grafts adjacent to axillary anastomoses: A complication of axillofemoral grafting. J Vasc Surg 1994;20:520-528.