A rare complication after axillofemoral bypass operation: disruption of the proximal anastomosis: single case after 12 years’ experience in extra-anatomic bypass surgery

Introduction

The extra-anatomic bypass term has been used for the grafts that pass through a pathway significantly different from that of the natural vessels they bypass. In 1952, Freeman and Leeds ¹ described the use of a superficial femoral artery to carry blood from one femoral artery to another. Formerly, the use of extra-anatomic bypass grafts was restricted to patients in which there were complications of aortoiliac reconstruction. Later reports of improved long-term results in axillofemoral bypass grafts, brought it as an alternative for aortofemoral bypass in high-risk patients. ²

There are well known complications following axillofemoral bypass operation such as upper extremity embolism, graft infection, seroma formation and disruption of the proximal anastomosis. In previous studies, disruption of the proximal anastomosis is usually observed in the early postoperative period, especially due to technical errors in anastomosis, mechanical distress and infections.^3–5 Here, we report a case with disruption of the proximal anastomosis after axillofemoral bypass operation.

Case report

A 46-year-old male patient admitted to our clinic with complaints of claudication in both extremities and an ischemic wound on left foot. He had history of diabetes mellitus, hypertension, coronary bypass operation and renal transplantation due to chronic renal failure. Physical examination revealed that femoral artery, popliteal artery and distal pedal pulses were non-palpable and left ankle-bracial index (ABI) was zero on left leg. On right leg, femoral artery pulse was palpable, popliteal artery and distal pedal pulses were non-palpable and right ABI was 0.5. There was critical limb ischemia and an ischemic wound on left foot. Left lumbar insicion was performed for renal transplantation. Magnetic resonance angiography imaging was preferred in this patient. This showed left external iliac and left common femoral arteries occlusion with reconstitution of the left profunda femorus and above knee popliteal arteries (Figure 1). There was a transplanted kidney to left common iliac artery. OPEN IN VIEWER

We performed a left axillofemoral bypass and left femoropopliteal bypass operation under general anesthesia by using an 8 mm full ringed polytetrafluoroethylene graft. There was no significant clinical problem in the early postoperative period follow up. On the seventh postoperative day, patient complained a sudden pain and swelling on left subclavian incision after a hyperabduction of the left arm. Patient was taken into operation theatre just after this complaint for suspicion of disruption of the proximal anastomosis. There was bleeding through the anastomosis line and detachment of the sutures. Anastomosis was repaired by continuous sutures with 5/0 polyprolylene. Patient was discharged at the 15th postoperative day and followed up at 30 day and third month without any problem.

Discussion

Daar and Finch ⁶ reported first disruption of the proximal anastomosis in axillofemoral bypass operation in 1978. Extra-anatomic bypass surgery is an alternative method in patients with high risk for aortofemoral approach (aortoenteric fistula, infected graft, existence of previous operations of abdomen, pelvic radiotherapy) and in existence of comorbid factors such as chronic obstructive pulmonary disease, high cardiac risk patients and morbid obesity. ⁷ Our patient had a history of kidney transplantation and transplanted renal artery was anastomosed to left common iliac artery, so we decided an axillofemoral bypass rather than an anatomic bypass.

External compression and graft thrombosis, graft infection, disruption of the proximal anastomosis, brachial plexus injury, axillary artery thrombosis and arterial steal syndrome are well known complications of axillofemoral bypass surgery.^8,9 These events appear with complaints of axillary pain and hematoma.^10–13 In our case, there was sudden pain and hematoma following postoperative proximal anastomosis disruption. For bleeding after dissociation of anastomosis, we could use transbracheal occlusion balloon. We took the patient into operation room quickly, we used local compression.

Several reports indicate an incidence of disruption of the proximal anastomosis after axillofemoral bypass around 5%. ³ In our clinic, we performed 2246 elective peripheric vascular operations between 1999 and 2011. Among them 41 patients had axillofemoral bypass operation. We observed this complication in only one patient (2.4%) in 12 years.

Disruption of the proximal anastomosis is usually due to hyperabduction of the arm or lateral flexion of thoracolumbar vertebrae. ⁴ Anastomosis disruption happens usually within a few weeks after operation and is due to high tension forces on the anastomotic sutures. ⁴ Insufficient fibrous tissue formation around anastomosis area may be a factor in late disruptions. ⁴ In our patient, disruption occurred following hyperabduction of the left arm at seventh postoperative day.

White et al. reported that axillary artery to femoral artery distance may increase up to 15% by abduction and lateral flexion. They suggested to leave the graft a few centimeters longer and positioning the graft medial to pectoralis minor muscle in order to avoid this complication. ¹⁰ Constructing the proximal anastomosis medial tothe pectoralis minor nuscle decreases dissociation of this anastomosis in the positions of lateral flexion and hyperabduction. We pulled up the graft to axillary region in order to avoid recurrence of this complication (Figure 2). OPEN IN VIEWER

In conclusion, choosing the appropriate axillary artery during operation, avoiding tension at proximal anastomosis line, informing the patients about mechanical distress and taking precautions regarding hyperabduction will add to long-term success rate of the axillofemoral bypass operation and reduce development of such a complication.