Surgical Repair of Axillary Graft Stump Syndrome: Report of Two Cases

Abstract

Late upper extremity embolic complications of occluded axillofemoral bypass graft (AxFG) or occluded axillo- axillary bypass graft (AxAG) are not frequently noted. A patient presented with acute right upper extremity thromboembolism 2 years after an AxFG occlusion. Computed tomography (CT) findings revealed kinking and occlusion of the axillary artery at the anastomosis. Another patient presented with acute left upper extremity thromboembolism 2 years and 6 years after an AxAG occlusion. CT indicated a thrombus progressing from the occluded graft to the axillary artery. Surgical repair of the axillary artery was performed in both patients without any complications.

Recurrent upper extremity acute limb ischemia secondary to retained axillary polytetrafluoroethylene cuff causing axillary stump syndrome

“… 4 , 5 , 6 , 7 , 9 , 10 In the few case reports describing the syndrome, management techniques of the axillary stump include both endovascular and open surgical options in combination with anticoagulation 4 , 5 , 6 , 7 , 8 , 9 , 10 ( Table ). Kanamitsu et al 10 suggested that treating an axillary stump is not always necessary, but once a thromboembolic event occurs, they recommend resection of the graft with arterial reconstruction. In their case, when initially treated with anticoagulation, as in the patient presented here, recurrent thromboembolism was reported.…”

“… 4 , 5 , 6 , 7 , 8 , 9 , 10 A blind stump and Y configuration of the bypass have been postulated as mechanisms for thromboembolic events in AxFSS. 4 , 5 , 6 , 7 , 9 , 10 In the few case reports describing the syndrome, management techniques of the axillary stump include both endovascular and open surgical options in combination with anticoagulation 4 , 5 , 6 , 7 , 8 , 9 , 10 ( Table ). Kanamitsu et al 10 suggested that treating an axillary stump is not always necessary, but once a thromboembolic event occurs, they recommend resection of the graft with arterial reconstruction.…”

“…In their case, when initially treated with anticoagulation, as in the patient presented here, recurrent thromboembolism was reported. 10 No other authors specified the use of anticoagulation in their reports. There is a paucity of data regarding the long-term durability of endovascular management of AxFSS as all cases were initially treated with open surgery.…”

“…Consistent with cases involving graft occlusion, anticoagulation after thromboembolectomy was insufficient to prevent recurrence of thromboembolism in the setting of a PTFE cuff. 10 We believe this cuff acted in a similar nature to the blind stump in an occluded axillary-femoral bypass graft. As such, once a thromboembolic event occurs, either endovascular exclusion or complete open surgical excision should be performed to prevent additional recurrences.…”

“… 1 , 2 A rare etiology is axillary-femoral stump syndrome (AxFSS) where thrombus embolizes to the upper extremity from an occluded axillary-femoral bypass. 4 , 5 , 6 , 7 , 8 , 9 , 10 We present the case of recurrent acute upper limb ischemia following explantation of an infected axillary-profunda bypass with a retained axillary cuff salvaged with covered stent exclusion of the cuff after repeated distal embolization. The patient agreed in writing to his images and case details being published.…”