Acute disruption of polytetrafluoroethylene grafts adjacent to axillary anastomoses: A complication of axillofemoral grafting

Purpose: Acute disruption at or adjacent to axillary anastomoses of axillofemoral grafts has been sporadically reported. We have recently reported the patency and limb salvage results of a large number of axillofemoral grafts. In this report we describe a series of axillary artery-graft disruptions that occurred in these patients. Methods: Beginning in 1983, axillofemoral bypass was performed by the authors using standardized operative technique and a single prosthetic graft material (8 mm externally supported polytetrafluoroethylene). Axillary anastomoses were placed on the first portion of the artery and were performed with the arm abducted and with the graft redundant. The records and operative reports of all patients with disruption were reviewed for findings and subsequent hospital course. Results: Two hundred two axillofemoral grafts were performed from 1983 to 1993. Ten patients (5%) had axillary disruption at intervals ranging from 1 to 46 days (mean 21 days) after operation. Ischemia was the indication for operation for seven of the patients and infected aortic prostheses for three. Infection did not occur in any of the axillary wounds and was not the cause of any of the disruptions. Four disruptions occurred with arm abduction/shoulder elevation movements; three awakened patients from sleep, and one occurred while the patient was sitting quietly. For the other two patients, preceding activity was unknown. Brachial plexus deficit was present in one patient. Four of the 10 disrupted grafts were also acutely occluded. Operative findings included sutures pulling out of the artery in four cases, tearing or sutures pulling out of the graft in four cases, and cause unknown in two cases. Treatment included arterial ligation in one patient, and restoration of circulation through revision of the axillofemoral grafts in the other nine patients. There were no operative deaths. One patient had a prolonged hospital course followed by nursing home placement and died 9 months later. The brachial plexus deficit did not resolve. There have been no repeat disruptions. Conclusions: We conclude that axillofemoral grafting includes the potential for disruption of the proximal anastomosis, which has occurred in 5% of our patients. Although multiple steps have been recommended to avoid this complication, occasional cases continue to occur despite observing all precautions.