Upper Extremity Thromboembolism Caused by Occlusion of Axillofernoral Grafts Robert 3. McLafferty, MD, Lloyd M. Taylor, Jr, MD, Gregory L. Moneta, MD, Richard A. Yeager, MD, James M. Edwards, MD, John M. Porter, MD, Portland, Oregon BACKGROUND: The axillofemoral bypass graft (AxFG) is increasingly accepted as treatment for lower extremity ischemia caused by aortoiliac oc- clusive disease in high-risk patients. The inci- dence of upper extremity (UE) thromboembolism caused by occlusion of an AxFG and the results of treatment form the basis for this report. METHODS: From 1984 to the present, all pa- tients undergoing axillofemoral bypass grafting were followed up in a vascular registry. A stan- dardized operative technique, using an exter- nally supported 8-mm polytetrafluoroethylene graft, was used in performing 202 AxFGs in 182 patients. UE thromhoembolism caused by occlusion of an AxFG was identified by retro- spective patient record review. RESULTS: Occlusion of an AxFG occurred in 20 patients. Fifteen patients (75%) underwent im- mediate revision of the occluded graft. Two pa- tients (10%) developed UE thromboembolism simultaneous with graft occlusion. One of these patients had immediate revision of the graft, and 1 had bra&al embolectomy only. This patient and 4 others (25%) had the occluded AxFG left in place. Four of these 5 patients (80%) devel- oped UE thromboembolism at 26 days, 2 years, 5 years, and 7 years, respectively, after occlu- sion. Overall, six UE thromboemholic complica- tions occurred iu 5 patients. CONCLUSIONS: UE thromboembolism represents a significant and specific complication of oc- cluded AxFGs in our series (2.7% of patients, 25% of occluded grafts). It may be prudent to prophylactically detach the axillary portion of the graft and repair the axillary artery in pa- tients who do not require immediate revision of an occluded AxFG. P rosthetic bypass grafting from the axillary artery to the femoral arterieswasfirst performed by Louw’ and by Hall and Blaisdel12 in 1962. Axillofemoral bypasshas be- come the treatment of choice for infected aortic prosthe- ses, aswell asaortoiliac occlusive disease in high-risk pa- From The Division of Vascular Surgery, Department of Surgery, Oregon Health Sciences University, Portland, Oregon. Requests for reprints should be addressed to Lloyd M. Taylor, Jr, MD, Professor of Surgery, Division of Vascular Surgery, 3181 S.W. Sam Jackson Park Road, Portland, OR 97201-3098. This study supported in part by Grant RRCO334. General Clinical Research Centers Branch, Division of Research Resources, National Institute of Health, Bethesda, Maryland. Presented at the Slst Annual Meeting of the North Pacific Surgical Association, Coeur d’Alene, Idaho, November 10-11, 1994. tients. Coincident with the use of external supporting rings for Dacron and polytetrafluoroethylene (PTFE) grafts, pa- tency resultsin recent years have improved markedly.3-8 Axillofemoral bypass grafting has been associated with a variety of complicationsspecific to the upper extremity (UE). Theseinclude brachial plexus injury’ and perianas- tomotic graft disruption. loOther complications include UE steal phenomenon inducedby ambulation and UE throm- boembolism associated with axillofemoral bypass throm- bosis.9 An extensive literature review by Bunt and Moore’ ’ in 1986 revealed UE complications which were graft re- lated in 1.6% of cases. Fifteen cases of symptomatic UE thromboembolism as- sociated with occlusion of axillofemoral bypass grafts (AxFG) have been reported.9*11-18 Eleven are single-case reports and 4 are identified in 2 early AxFG series.17*18 The incidence of symptomatic UE thromboembolism causedby occlusion of externally supported AxFGs has not been previously reported. Our experience with this complication in a large modem series of AxFG forms the basis of this report. METHODS From January 1, 1984 to November 1, 1994, all patients undergoing axillofemoral grafting were followed up prospectively in a vascular registry. The operationswere performedby vascularand senior generalsurgeryresidents under direct supervision of attending surgeonsin the Division of Vascular Surgery at Oregon Health Sciences University Hospital and Portland Veterans Administration Hospital. The patency and limb salvage resultsfor this se- ries have been previously reported.5 Standardoperative techniquewas used for axillofemoral bypass grafting. All grafts were externally supported8- mm diameterPTFE. The axillary andfemoral components were performed simultaneously by multiple surgical teamsto shorten operating time. An end-to-side anasto- mosis was performed anteriorly to the first portion of the axillary artery medial to the pectoralis minor. The AxFG wastunneledposterior to the pectoralismajor muscle,fol- lowing the courseof the axillary artery for 8 to 10 cm be- fore turning inferiorly, providing a moderate amount of graft redundancy. Patients who developed UE thromboembolism after oc- clusionof the AxFG were identified from the vascularreg- istry database.Patient records were retrospectively re- viewed with regard to presenting signs and symptoms, diagnostic work-up, treatment, and outcome. RESULTS Of the 182 patientswho had 202 AxFGs implanted dnr- ing the study period, 20 patients (11%) had occlusion (Figure 1). Six episodes of UE thromboembolism occurred 492 THE AMERICAN JOURNAL OF SURGERY” VOLUME 169 MAY 1995