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Upper extremity thromboembolism after axillary-axillary bypass grafting
VASCULAR CASE REPORTS -
Upper extremity thromboembolism after axillary~axilihwybypass grafting R. B. McLaffetty, L. M. Taylor, Jr, G. L. Moneta, R. A. Yeager, J. M. Edwards and J. M. Porter The Division of Vascular Surge& Department of Surgery. Oregon Health Sciences University; Portland. Oregon, USA ‘MO patients experienced upper extremity thromboembolism after axillary-axillary bypass grafting (AxAG) for symptomatic subclavian artery stenosis. The first patient, a 67-year-old male. presented with left upper extremity thromboembolism 3 years after AxAG with 8 mm externally support PTFE. An arteriogram revealed a patent AxAG, thrombus in the proximal left subclavian arterial stump just distal to its occlusion, and multiple digital artery emboli. The patient was treated with warfarin for 8 months, with resolution of symptoms. The second patient, a 57-year-old male, occluded his AxAG (8mm knitted Dacron) with minimal return of symptoms. Non-operative treatment was elected and 4 years later the patient presented with right upper extremity (donor side) thromboembolism. Arteriography revealed occlusion of the AxAG, radial artery, and digital arteries of the index, long and ring fingers. Thrombolytic therapy of the right arm was undertaken with minimal improvement. Subsequent detachment of the AxAG and placement of an interposition reversed saphenous vein graft was performed. Both patients continue to be asymptomatic during follow-up of 4.7 and 2.0 years, respectively Keywords: extremity --
axillary, bypass, thrombus. embolism, upper
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Axillary-axillary bypass grafting (AxAG) for symptomatic subclavian steal and/or arm ischaemia is one of several extraanatomical bypass routes used for subclavian-axillary revascularization during the past 30 years14. Differences in durability
Correspondence to: Dr J. M. Porter, Professor of Surgery, Oregon Health Sciences University, Division of Vascular Surgery, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098, USA
CARDIOVASCULAR SURGERY FEBRUARY 1996 VOL 4 NO 1
and relative risk have resulted in ongoing controversy as to which method of revascularization is optima15~~H. Only a modest number of AxACJ series have been reported, including only 260 patients’. To our knowledge, there have been no published reports describing upper extremity thromboembolism after AxAG, although this complication has been reported afrer thrombosis of axillary-femoral bypass grafts (AxFG)‘“. Herein we report two patients who developed upper extremity thromhormholism after AxAG.
Case report 1 A 62-year-old man was admitted to the hospital m December of 1984 with a 6 month history of pain of the left hand and forearm associated with minimal activity. Past medical history was significant for coronary artery disease, hypertension, chronic obstructive pulmonary disease, obesity, alcohol abuse and a 50 pack per year smoking habit. Physical examination revealed a blood pressure of 70mmHg in the left arm and 132192 in the right, and diminished arm pulses. Arteriography showed proximal occlusion of the left subclavian artery and ?90% stenosis in the right internal carotid artery. it was unclear at the time of arteriography whether the left vertebral artery had reversal of flow. Non-operative treatment was elected. Three months later, the patient was readmitted with the chief complaint of one episode of severe dizziness and nausea lasting for approximately 10min unassociated with arm exercise or pam. No abnormal neurologic findings were noted. Uncomplicated right carotid endarterectomy was performed. Ten months later he presented with continuous paresthesias and severe pain in the left hand and forearm associated with minimal activitv. He also reported several episodes of light-headedncss associated with moderate left upper extremity activity. An arteriogram revealed both carotid arteries to be patent with mild atherosclerosis, left subclavian occlusion and retrograde flow in the left vertebral artery. Left carotid-subclavian bypass was performed using a 6 mm Dacron graft without complication. The left upper extremity arm-to-arm index was raised from 0.53 to 0.83 with relief of arm symptoms. Ten months later, the patient was readmitted after 8 months of worsening left upper extremity ischaemic symptoms. An arteriogram revealed an occluded carotid-subclav& bypsrss, Right to left AxAG using 8 mm externally &pported M’FE was performed, which raised the arm-to-arm index to O.&O. Four years later he presented with a 1 week history of pain in the left arm. Physical examination revealed equal arm blood pressures and a normal left radial p&e, but splimer Baemorrhages were noted on several fingers. An arteriogram revealed multiple left palmar and digital artery emboh, a patent AxAG, and thrombus in the left subclavian stump proximal to the AxAG anastomosis. He was anticoagulated with warfarin for 8 months, and has had no further embolic episodes of emboli to the left hand during a follow-up of 4.7 years. The AxAG continues patent.
111
Vascular case reports
Casereport 2 A 52.year-old man presented in December of 1982 with tingling and coolness in the left hand and severe dizziness of 3 h duration. The patient’s past medical history was significant for history of deep venous thrombosis in both legs in the distant past, obesity, insulin dependent diabetes mellitus, and a 30 pack per year smoking habit. Physical examination revealed a systolic blood pressure of 150mmHg in the right arm and 80mmHg in the left. The Doppler signal was monophasic in the radial artery and absent in the ulnar artery. Arteriography revealed occlusion of the left subclavian artery I.3cm from its origin with retrograde flow in the vertebral artery. A left carotid-subclavian bypass was performed using 8 mm Dacron without complication. Seven days after discharge the patient returned to the hospital with dizziness, nausea and a cool left hand. Physical examination was consistent with acute bypass occlusion. An arteriogram revealed a thrombosed carotid-subclavian bypass with intraluminal thrombus trailing up into the common carotid artery. Thrombectomy was performed and a new 8mm Dacron interposition graft placed. Five days later the graft rethrombosed with similar symptoms. A right to left AxAG was performed using 8 mm Dacron with a thrombectomy of the left brachial artery. The patient recovered well and was discharged fully anticoagulated on warfarin. Five years later, while still on warfarin, the patient presented with acute onset of mild left-hand coolness. Duplex ultrasound revealed a thrombosed AxAG. Non-operative treatment was elected and warfarin was continued for another 3 months. Four years later the patient presented with a history of two months of cyanosis of the right first, second and third fingers. Digital to brachial ratios were 0.12, 0 and 0.41 in the index, long and ring fingers, respectively. Left and right arm systolic blood pressures were 155 mmHg and 75 mmHg, respectively. The right brachial pulse was normal and the radial pulse was slightly diminished. Arteriogram revealed AxAG occlusion, right radial artery occlusion at the origin, and common and proper digital artery occlusion in the first to third fingers. The junction of the AxAG and donor axillary artery showed only mild angulation.
Figure 1 junction
112
Loose embolic material is shown at the occluded graft-artery
The patient received intra-arterial therapy wsith urokinase overnight without benefit. The patient was taken to the operating room and underwent detachment of the thrombosed AxAG from the donor side axillary artery, .4xAG and distal vessel embolectomy, and excision of the donor arterial segment and placement of a segmental vein interposition graft in the axillary artery. Figure 1 shows a cross-section of the axillary arter-graft junction with loose embolic material in the lumen. The patient required amputation of the distal phalanges of the second and third fingers because of ischaemic necrosis. The arm continued to do well through 2 years of follow-up.
Discussion In 1971 Myers et al. described the first AxAG, used to ‘resupply blood to the branches of the brachiocephalic tree’ in a severely ill patient ‘t . The operation continues to be an accepted alternative for extrathoracic revascularization of subclavian and innominate artery occlusive disease in high risk patients. Reports of complications associated with AxAG are sparse, probably reflecting in significant part the small number of reported patients. A recent review of 260 cases of AxAG over a I5 year period reported a 3.5% incidence of perioperative brachial plexus neuropathy, most of which were transient’. Interestingly, complications unique toxFG such as pseudoaneurysm formation, anastomotic disruption and steal phenomena occurring distal to the donor axillary artery were not reported in this large review. Twenty-two patients have been reported as having upper extremity thromboembolism after thrombosis of their AxFG”. Unique to our report of upper extremity thromboemholism after AxAG in case report 1 is a thrombus originating from the subclavian stump distal to occlusion in a patient with AxAG patency. The other patient with an occluded AxAG in place developed upper extremity thromboembolism in the donor arm 4 years later. Both delayed and concomitant upper extremity thromboembolism have been reported after thrombosis of an AxFG12,13 but not after AxAG occlusion. In our recent reported series of AxFG (184 procedures in 164 patients) i4 , five instances of thromboembolism occurred in four patients (2.5%). Three of the four patients had delayed upper extremity thromboembolism after known occlusion of the AxFG. The presence of a ‘blind pouch’ in the occluded end of the graft is the presumed source of loose embolic debris which may move down the arm. This is usually visible on the anterior-posterior arteriographic view of an occluded AxFG, but is more difficult to see on an occluded AxAG because the pouch is typically superimposed on the axillary artery. The presence of a small blind pouch with loose atherosclerotic debris was confirmed at operation in case report 2. A crosssection of the blind pouch at the graft-artery junction is shown in Figure 1. Treatment of this potentially limb-threatening complication is dependent upon prompt diagnosis. A high index of suspicion should exist towards any patient presenting with upper extremity ischaemia and an ipsilateral patent or occluded AxAG. Arteriography should be obtained to confirm the diagnosis and localize the embolus. In the case of AxAG occlusion, surgical correction typically consists of graft disconnection, embolectomy and repair of the axillary artery either by vein patch or vein interposition grafting.
CARDIOVASCULAR SURGERY FEBRUARY 1996 VOL 4 NO 1
Acknowledgements This study was supported in part by Grant RR00334 from the General Clinical Research Centers Branch, Division of Research Resources, National Institutes of Health, Bethesda, MD.
References 1. Crawford ES, Stowe CL, Powers RW, Jr. Occlusion of the mnominate. common carotid and subclavian arteries: long term results of surgical treatment. Sufgery 1983; 94: 781-91. 2. Thompson BW, Read RC, Cambell GS. Operative correction of proximal blocks of the subclavian and innominate arteries. / Cardiovasc Surg 1980; 21: 125-30. Evans WE, Williams TE, Mayes Jl? Aortobrachiocephabc reconstructions. Am J Surg 1988; 6: 421-7. Crtado FJ. Extrathoracic management of aortic arch syndrome. BY / Surg 1982; 69(Suppl): 4.5-51. Lamis PA, Stanton PE, Jr, Hyland L. The axillo-axillary bypass graft. Arch Surg IY76; 111: 13.53-6. Schanzer I-I, Chung-Lay h, Kotok M, Haimov M, Jacobson JH. Evaluation of axillo-axillary artery bypass for the treatment of suhclavian of innominate artery occlusive disease. J Cardiouasc surg 19x7; 28: 258-61. 7/. AhuRahma .tF, Robinson A, Khan MZ, Khan JH, Boland JP. Rr,tchiocrphnlic revascularization: a comparison between car-
CARDIOVASCULAR SURGERY FEBRUARY 1996 VOL 4 NO 1
otid-subclavian bypass and axilloaxdlar Y ,rrterb i~y(>as<.j:,rgerv 1992: 112: 84-91. 8. Mingoli A, Feldhaus RJ. Farina C, ichult~ RiI. <;,tvallaro A. Comparative results of carotid-subclavian b.:paas and axilloaxillary bypass in patients with symptomam -&Iav~ar~ steal. EMI ] Vast Surg 1992; 6: 26-30. 9. Lowell RC, Mills JL. Critical evaluation of .turiioaxliidr~ after); bypass for surgical management of symptoma:rc suhciavtan anri innominate artery occlusive disease. ! ~n~i~)r.~r~ c/Sri’ l”9 3; 1: 530-S. JO. McLafferty RB, Porter JM. Upper extremitv lhconlil~,trnl)triisni secondary to axiilary-femoral bvpass :hroin!~~ -5i;. ~:‘r!:p’c’f,~,~~~ I I. 12. 1.3.
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Upper extremity thromboembolism after axillary~axilihwybypass grafting R. B. McLaffetty, L. M. Taylor, Jr, G. L. Moneta, R. A. Yeager, J. M. Edwards and J. M. Porter The Division of Vascular Surge& Department of Surgery. Oregon Health Sciences University; Portland. Oregon, USA ‘MO patients experienced upper extremity thromboembolism after axillary-axillary bypass grafting (AxAG) for symptomatic subclavian artery stenosis. The first patient, a 67-year-old male. presented with left upper extremity thromboembolism 3 years after AxAG with 8 mm externally support PTFE. An arteriogram revealed a patent AxAG, thrombus in the proximal left subclavian arterial stump just distal to its occlusion, and multiple digital artery emboli. The patient was treated with warfarin for 8 months, with resolution of symptoms. The second patient, a 57-year-old male, occluded his AxAG (8mm knitted Dacron) with minimal return of symptoms. Non-operative treatment was elected and 4 years later the patient presented with right upper extremity (donor side) thromboembolism. Arteriography revealed occlusion of the AxAG, radial artery, and digital arteries of the index, long and ring fingers. Thrombolytic therapy of the right arm was undertaken with minimal improvement. Subsequent detachment of the AxAG and placement of an interposition reversed saphenous vein graft was performed. Both patients continue to be asymptomatic during follow-up of 4.7 and 2.0 years, respectively Keywords: extremity --
axillary, bypass, thrombus. embolism, upper
---_
Axillary-axillary bypass grafting (AxAG) for symptomatic subclavian steal and/or arm ischaemia is one of several extraanatomical bypass routes used for subclavian-axillary revascularization during the past 30 years14. Differences in durability
Correspondence to: Dr J. M. Porter, Professor of Surgery, Oregon Health Sciences University, Division of Vascular Surgery, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098, USA
CARDIOVASCULAR SURGERY FEBRUARY 1996 VOL 4 NO 1
and relative risk have resulted in ongoing controversy as to which method of revascularization is optima15~~H. Only a modest number of AxACJ series have been reported, including only 260 patients’. To our knowledge, there have been no published reports describing upper extremity thromboembolism after AxAG, although this complication has been reported afrer thrombosis of axillary-femoral bypass grafts (AxFG)‘“. Herein we report two patients who developed upper extremity thromhormholism after AxAG.
Case report 1 A 62-year-old man was admitted to the hospital m December of 1984 with a 6 month history of pain of the left hand and forearm associated with minimal activity. Past medical history was significant for coronary artery disease, hypertension, chronic obstructive pulmonary disease, obesity, alcohol abuse and a 50 pack per year smoking habit. Physical examination revealed a blood pressure of 70mmHg in the left arm and 132192 in the right, and diminished arm pulses. Arteriography showed proximal occlusion of the left subclavian artery and ?90% stenosis in the right internal carotid artery. it was unclear at the time of arteriography whether the left vertebral artery had reversal of flow. Non-operative treatment was elected. Three months later, the patient was readmitted with the chief complaint of one episode of severe dizziness and nausea lasting for approximately 10min unassociated with arm exercise or pam. No abnormal neurologic findings were noted. Uncomplicated right carotid endarterectomy was performed. Ten months later he presented with continuous paresthesias and severe pain in the left hand and forearm associated with minimal activitv. He also reported several episodes of light-headedncss associated with moderate left upper extremity activity. An arteriogram revealed both carotid arteries to be patent with mild atherosclerosis, left subclavian occlusion and retrograde flow in the left vertebral artery. Left carotid-subclavian bypass was performed using a 6 mm Dacron graft without complication. The left upper extremity arm-to-arm index was raised from 0.53 to 0.83 with relief of arm symptoms. Ten months later, the patient was readmitted after 8 months of worsening left upper extremity ischaemic symptoms. An arteriogram revealed an occluded carotid-subclav& bypsrss, Right to left AxAG using 8 mm externally &pported M’FE was performed, which raised the arm-to-arm index to O.&O. Four years later he presented with a 1 week history of pain in the left arm. Physical examination revealed equal arm blood pressures and a normal left radial p&e, but splimer Baemorrhages were noted on several fingers. An arteriogram revealed multiple left palmar and digital artery emboh, a patent AxAG, and thrombus in the left subclavian stump proximal to the AxAG anastomosis. He was anticoagulated with warfarin for 8 months, and has had no further embolic episodes of emboli to the left hand during a follow-up of 4.7 years. The AxAG continues patent.
111
Vascular case reports
Casereport 2 A 52.year-old man presented in December of 1982 with tingling and coolness in the left hand and severe dizziness of 3 h duration. The patient’s past medical history was significant for history of deep venous thrombosis in both legs in the distant past, obesity, insulin dependent diabetes mellitus, and a 30 pack per year smoking habit. Physical examination revealed a systolic blood pressure of 150mmHg in the right arm and 80mmHg in the left. The Doppler signal was monophasic in the radial artery and absent in the ulnar artery. Arteriography revealed occlusion of the left subclavian artery I.3cm from its origin with retrograde flow in the vertebral artery. A left carotid-subclavian bypass was performed using 8 mm Dacron without complication. Seven days after discharge the patient returned to the hospital with dizziness, nausea and a cool left hand. Physical examination was consistent with acute bypass occlusion. An arteriogram revealed a thrombosed carotid-subclavian bypass with intraluminal thrombus trailing up into the common carotid artery. Thrombectomy was performed and a new 8mm Dacron interposition graft placed. Five days later the graft rethrombosed with similar symptoms. A right to left AxAG was performed using 8 mm Dacron with a thrombectomy of the left brachial artery. The patient recovered well and was discharged fully anticoagulated on warfarin. Five years later, while still on warfarin, the patient presented with acute onset of mild left-hand coolness. Duplex ultrasound revealed a thrombosed AxAG. Non-operative treatment was elected and warfarin was continued for another 3 months. Four years later the patient presented with a history of two months of cyanosis of the right first, second and third fingers. Digital to brachial ratios were 0.12, 0 and 0.41 in the index, long and ring fingers, respectively. Left and right arm systolic blood pressures were 155 mmHg and 75 mmHg, respectively. The right brachial pulse was normal and the radial pulse was slightly diminished. Arteriogram revealed AxAG occlusion, right radial artery occlusion at the origin, and common and proper digital artery occlusion in the first to third fingers. The junction of the AxAG and donor axillary artery showed only mild angulation.
Figure 1 junction
112
Loose embolic material is shown at the occluded graft-artery
The patient received intra-arterial therapy wsith urokinase overnight without benefit. The patient was taken to the operating room and underwent detachment of the thrombosed AxAG from the donor side axillary artery, .4xAG and distal vessel embolectomy, and excision of the donor arterial segment and placement of a segmental vein interposition graft in the axillary artery. Figure 1 shows a cross-section of the axillary arter-graft junction with loose embolic material in the lumen. The patient required amputation of the distal phalanges of the second and third fingers because of ischaemic necrosis. The arm continued to do well through 2 years of follow-up.
Discussion In 1971 Myers et al. described the first AxAG, used to ‘resupply blood to the branches of the brachiocephalic tree’ in a severely ill patient ‘t . The operation continues to be an accepted alternative for extrathoracic revascularization of subclavian and innominate artery occlusive disease in high risk patients. Reports of complications associated with AxAG are sparse, probably reflecting in significant part the small number of reported patients. A recent review of 260 cases of AxAG over a I5 year period reported a 3.5% incidence of perioperative brachial plexus neuropathy, most of which were transient’. Interestingly, complications unique toxFG such as pseudoaneurysm formation, anastomotic disruption and steal phenomena occurring distal to the donor axillary artery were not reported in this large review. Twenty-two patients have been reported as having upper extremity thromboembolism after thrombosis of their AxFG”. Unique to our report of upper extremity thromboemholism after AxAG in case report 1 is a thrombus originating from the subclavian stump distal to occlusion in a patient with AxAG patency. The other patient with an occluded AxAG in place developed upper extremity thromboembolism in the donor arm 4 years later. Both delayed and concomitant upper extremity thromboembolism have been reported after thrombosis of an AxFG12,13 but not after AxAG occlusion. In our recent reported series of AxFG (184 procedures in 164 patients) i4 , five instances of thromboembolism occurred in four patients (2.5%). Three of the four patients had delayed upper extremity thromboembolism after known occlusion of the AxFG. The presence of a ‘blind pouch’ in the occluded end of the graft is the presumed source of loose embolic debris which may move down the arm. This is usually visible on the anterior-posterior arteriographic view of an occluded AxFG, but is more difficult to see on an occluded AxAG because the pouch is typically superimposed on the axillary artery. The presence of a small blind pouch with loose atherosclerotic debris was confirmed at operation in case report 2. A crosssection of the blind pouch at the graft-artery junction is shown in Figure 1. Treatment of this potentially limb-threatening complication is dependent upon prompt diagnosis. A high index of suspicion should exist towards any patient presenting with upper extremity ischaemia and an ipsilateral patent or occluded AxAG. Arteriography should be obtained to confirm the diagnosis and localize the embolus. In the case of AxAG occlusion, surgical correction typically consists of graft disconnection, embolectomy and repair of the axillary artery either by vein patch or vein interposition grafting.
CARDIOVASCULAR SURGERY FEBRUARY 1996 VOL 4 NO 1
Acknowledgements This study was supported in part by Grant RR00334 from the General Clinical Research Centers Branch, Division of Research Resources, National Institutes of Health, Bethesda, MD.
References 1. Crawford ES, Stowe CL, Powers RW, Jr. Occlusion of the mnominate. common carotid and subclavian arteries: long term results of surgical treatment. Sufgery 1983; 94: 781-91. 2. Thompson BW, Read RC, Cambell GS. Operative correction of proximal blocks of the subclavian and innominate arteries. / Cardiovasc Surg 1980; 21: 125-30. Evans WE, Williams TE, Mayes Jl? Aortobrachiocephabc reconstructions. Am J Surg 1988; 6: 421-7. Crtado FJ. Extrathoracic management of aortic arch syndrome. BY / Surg 1982; 69(Suppl): 4.5-51. Lamis PA, Stanton PE, Jr, Hyland L. The axillo-axillary bypass graft. Arch Surg IY76; 111: 13.53-6. Schanzer I-I, Chung-Lay h, Kotok M, Haimov M, Jacobson JH. Evaluation of axillo-axillary artery bypass for the treatment of suhclavian of innominate artery occlusive disease. J Cardiouasc surg 19x7; 28: 258-61. 7/. AhuRahma .tF, Robinson A, Khan MZ, Khan JH, Boland JP. Rr,tchiocrphnlic revascularization: a comparison between car-
CARDIOVASCULAR SURGERY FEBRUARY 1996 VOL 4 NO 1
otid-subclavian bypass and axilloaxdlar Y ,rrterb i~y(>as<.j:,rgerv 1992: 112: 84-91. 8. Mingoli A, Feldhaus RJ. Farina C, ichult~ RiI. <;,tvallaro A. Comparative results of carotid-subclavian b.:paas and axilloaxillary bypass in patients with symptomam -&Iav~ar~ steal. EMI ] Vast Surg 1992; 6: 26-30. 9. Lowell RC, Mills JL. Critical evaluation of .turiioaxliidr~ after); bypass for surgical management of symptoma:rc suhciavtan anri innominate artery occlusive disease. ! ~n~i~)r.~r~ c/Sri’ l”9 3; 1: 530-S. JO. McLafferty RB, Porter JM. Upper extremitv lhconlil~,trnl)triisni secondary to axiilary-femoral bvpass :hroin!~~ -5i;. ~:‘r!:p’c’f,~,~~~ I I. 12. 1.3.
14.
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