Axillary-bifemoral and axillary-unifemoral artery grafts have similar perioperative outcomes and patency.

OBJECTIVE: It has been suggested that more bypass outflow targets for bypass grafts improve patency and outcomes. Our objective was to examine this in a multicenter contemporary series of axillary to femoral artery grafts. METHODS: The Vascular Quality Initiative database was queried for all axillary-unifemoral (AxUF) and axillary-bifemoral (AxBF) bypass grafts performed between 2010 and 2017 for claudication, rest pain, and tissue loss. Patients with acute limb ischemia were excluded. Patients' demographics and comorbidities as well as operative details and outcomes were recorded. Univariable, multivariable, and Kaplan-Meier analyses were used to assess long-term outcomes. RESULTS: There were 412 (32.9%) AxUF grafts and 839 (67.1%) AxBF grafts identified. Overall, the mean age of the patients was 68.3 years, 51.1% were male, and 84.7% were white. Compared with AxBF grafts, AxUF grafts were more often performed for urgent cases; in patients who were younger, male, nonambulatory, and diabetic; and in those with preoperative anticoagulation, critical limb ischemia, prior bypass, aneurysm repair, peripheral vascular intervention, and major amputation (P < .05 for all). There were no significant differences between AxUF and AxBF grafts in perioperative wound complications (4.2% vs 2.9%; P = .23), cardiac complications (7.3% vs 10.4%; P = .08), pulmonary complications (4.1% vs 6%, P = .18), early stenosis/occlusion (0.2% vs 0.8%; P = .22), perioperative mortality (2.9% vs 3.2%; P = .77), and length of stay (6.4 ± 5.6 days vs 6.7 ± 8 days; P = .29). The mean estimated blood loss (268.1 mL vs 348.6 mL; P < .001) and mean operative time (201 minutes vs 224.1 minutes; P < .001) were significantly lower for AxUF grafts. Kaplan-Meier analysis showed that AxUF and AxBF grafts had similar freedom from graft occlusion (62.6% vs 71.8%; P = .074), major adverse limb event-free survival (57.1% vs 66.6%; P = .052), and survival (86% vs 86%; P = .897) at 1 year. Major amputation-free survival was lower for AxUF grafts (63.7% vs 73%; P = .028). Multivariable analysis also showed that the type of graft configuration did not independently predict occlusion/death (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.77-1.46; P = .72), amputation/death (HR, 1.12; 95% CI, 0.83-1.51; P = .45), major adverse limb event/death (HR, 0.97; 95% CI, 0.73-1.3; P = .85), or mortality (HR, 0.91; 95% CI, 0.65-1.26; P = .55). Three-year survival after placement of AxUF and AxBF grafts was similar (75.1% vs 78.2%; P = .414). CONCLUSIONS: AxUF and AxBF grafts have similar perioperative and 1-year outcomes. Graft patency was not significantly different between an AxBF graft and an AxUF graft at 1 year. Overall, patients treated with these reconstructions have many comorbidities and low long-term survival.

Shoulder-related donor site morbidity after delayed breast reconstruction with pedicled flaps from the back: An open label randomized controlled clinical trial.

BACKGROUND: This randomized controlled trial (RCT) investigates differences in shoulder-related morbidity after delayed breast reconstruction by either a latissimus dorsi (LD) flap or a thoracodorsal artery perforater (TAP) flap. MATERIAL AND METHODS: In accordance with the CONSORT guidelines, we included women for unilateral delayed breast reconstruction. Patients were randomized to reconstruction by either of the two flaps. Shoulder-function was assessed at baseline and at 3, 6 and 12 months after surgery. The primary endpoint was patient-reported shoulder-related pain. A further objective assessment by the Constant Shoulder Score (CSS) was included as secondary endpoints. RESULTS: A total of 50 women were enrolled over a two-year period and allocated to reconstruction, with 25 patients in each group. Patient-reported shoulder-related pain was significantly lower in the TAP group at 12 months after surgery when adjusting for pain at baseline: OR = 0.05 95%CI(0.005-0.51), p-value = 0.011. The estimated effect on the total CSS at 12 months, when applying the TAP flap instead of the LD flap and adjusting for the baseline score, was 6.2 points with 95%CI(0.5-12.0), p-value 0.033. The TAP flap seems to have a statistically significant positive effect on pain and activity in daily life (ADL), while there were no significant effect on range of motion and strength after one year. CONCLUSION: Patient reconstructed by the TAP flap are less likely to experience shoulder-related pain and have a better shoulder-function one year after the reconstruction. Harvest of the LD flap carries a higher risk of shoulder-function impairment, chronic pain and reduced ADL.

Perfusion pressure does not affect neurologic outcome in axillary artery side graft cannulation in type a aortic dissection.

OBJECTIVE: Antegrade selective cerebral perfusion (ASCP) through the right axillary is a safe and effective method for cerebral protection in aortic surgery. In the present study, we evaluated whether or not pressure control in ASCP affected the neurologic outcome. METHOD: Sixty-two patients (17 female, 45 male) with a mean age of 53.9 +/- 9.4 years (range, 23-74 years) with a diagnosis of Type A aortic dissection were operated on by using the right axillary artery side graft cannulation technique. ASCP with pressure control was used in the first 37 (59.6%) patients (group 1), whereas ASCP with flow control was used in the consecutive 25 patients (39.4%) (group 2). The groups were compared according to postoperative neurologic outcomes. RESULTS: The hospital mortality rate was 9.7% with 6 patients. The mean ASCP flows of group 1 was 663 +/- 76 mL/min and 692 +/- 51 mL/min in group 2. This difference was not statistically significant (P = .120). The neurological dysfunction rates were 2.7% in group 1 with 1 patient and 8% in group 2 with 2 patients (P = .560). CONCLUSION: In this study, we could not find a statistically significant difference in patients treated with ASCP through the right axillary applicated with pressure control versus flow control.

Removal of axillofemoral graft.

Axillofemoral grafts which develop late occlusion often can be salvaged with a second operation, which frequently involves placement of a new graft. Velour Dacron grafts which have been in place for several years usually are bound tightly to adjacent tissues. We describe a simple method for removal of these grafts.

A comparison of the late patency rates of axillobilateral femoral and axillounilateral femoral grafts.

A total of 130 axillofemoral grafts were peformed in 120 patients from 1966 to present; 66 were axillobilateral femoral moral and 64 were axillounilateral femoral grafts. The average patient age was 66 years. The indications for operation were occlusive disease with rest pain or gangrene in 102 patients, severe claudication four, and bypass of a thoracic aneurysm in one. The one month operative mortality rate was 8 percent (ten patients). Four deaths occurred in elderly patients operated upon as emergencies with acute aortic occlusion. In the 126 elective cases, there were six postoperative deaths (4.7 percent). Twenty thrombectomies were performed in 15 axillobilateral femoral grafts of which 15 (75 percent) were successful. In the unilateral grafts there were 25 thrombectomies in 22 grafts, of which only eight (32 percent) were successful. The 5 year patency rate by the life-table method was 74 percent for axillobilateral femoral grafts and 37 percent for axillounilateral femoral grafts. This difference in patency rates is statistically significant (p < 0.01). Average flow measured by electromagnetic flow meter in six axillobilateral femoral grafts was 621 c.c. per minute and in 11 unilateral femoral grafts was 273 c.c. per minute. We attribute the higher patency rate in axillobilateral femoral grafts to this increased flow. These data indicate that axillobilateral femoral grafts may be performed with anticipation of a 5 year patency rate comparable to that with conventional aortoiliac reconstruction and that axillobilateral femoral grafts should be performed in preference to axillounilateral femoral grafts in poor-risk patients requiring extra-anatomic bypass for aortoiliac occlusive disease.

The axillo-axillary bypass graft: further experience.

The recent utilization of the axillo-axillary bypass graft for revascularization of proximal subclavian or innominate artery occlusions has proved to be a successful operation, technically simple with a low operative morbidity. We have reviewed the reported experience to date and have added our experience of nine additional cases. The procedure has produced excellent results in all patients, with no evidence of postoperative "steal" from the donor limb. Preoperative hemodynamic defects were corrected. Our experience has led us to the conclusion that this simpler and safer extrathoracic approach should be considered as the procedure of choice when arterial lesions allow for its selection and use.

New concepts in the use of axillofemoral bypass grafts.

Over a four-year period, 52 patients underwent axillofemoral bypass operations. Indications for operation were divided into three groups: those that were performed emergently (aortoenteric fistula, graft infection, and leaking aortic aneurysm), those performed electively for aneurysm, and those for ischemia. Operative procedures were categorized as follows: axillofemoral bypass alone, axillofemorofemoral bypass with the proximal femorofemoral anastomosis being graft to graft, or axillofemorofemoral bypass with the femorofemoral anastomosis to either a transected proximal common femoral artery or superficial femoral artery distal to the axillofemoral anastomosis. Thirty-three percent of the unilateral axillofemoral grafts failed, while only 14% of the axillobifemoral grafts failed. There was a further difference between the two methods of femorofemoral grafting with 22% failure in the former group but no failures in the latter.

Axillary artery cannulation in acute ascending aortic dissections.

BACKGROUND: Standard cannulation of the femoral artery in preparation for repair of a dissection involving the ascending aorta carries a high risk of malperfusion. Arterial perfusion through the right axillary artery is more likely to perfuse the true lumen and should be advantageous in acute dissections involving the ascending aorta. METHODS: Thirteen patients underwent repair of acute ascending aortic dissections and were perfused through the right axillary artery. All had deep hypothermic circulatory arrest. RESULTS: There was one mild intraoperative cerebrovascular accident with complete recovery and one operative death secondary to low cardiac output. There were no intraoperative problems with perfusion through the axillary artery, and there were no postoperative problems or complications involving the axillary artery, axillary vein, or brachial plexus. CONCLUSIONS: Arterial perfusion through the right axillary artery is a safe and effective means of more reliably perfusing the true lumen. In this regard, it may be superior to femoral artery perfusion and could lead to improved outcomes with repair of acute deBakey type I and II aortic dissections.

Long-term follow-up of bypasses to the brachial artery across the shoulder joint.

BACKGROUND: Most atherosclerotic lesions in the subclavian artery are successfully treated with carotid to subclavian bypass. The need to bypass to the brachial artery (BA) is rare. We reviewed our experience with this bypass. METHODS: Over a 10-year period, we have performed 13 bypasses to the BA originating from an artery proximal to the shoulder joint. In this retrospective study, the demographic and clinical risk factors were evaluated. Long-term results were analyzed. RESULTS: Thirteen operations were performed in 10 patients, aged 47 to 80 years. The operations were carried out for acute severe ischemia in 1 limb, effort discomfort in 9, and rest pain in 3 limbs. Donor arteries were axillary (7), carotid (4), and subclavian (2). All bypasses were to the BA proximal to the elbow joints. Life-table analysis showed 100% patency in the first 3 years and 88% at 7 years. There were 2 deaths in follow-up. Average preoperative brachial to brachial index was 0.59 and postoperative index was 1.1. In patients with bilateral occlusions, mean preoperative brachial artery pressure was 62 mm Hg, which improved to 142 mm Hg postoperatively. There were no neurological complications and no 30-day mortality. CONCLUSIONS: Bypass across the shoulder joint to the BA using expanded polytetrafluoroethylene (ePTFE) or vein is a safe operation with excellent long-term patency. The carotid artery can be used as a donor vessel without complications. Hypertension and female gender appear to be risk factors for extensive disease in proximal upper extremity arteries.

Total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion.

OBJECTIVE: Right axillary artery (AxA) perfusion, which can prevent cerebral embolism caused by retrograde perfusion via the femoral artery (FA), was used for selective cerebral perfusion (SCP) as well as cardiopulmonary bypass (CPB) in aortic arch repair. We review the outcome of aortic arch surgery using SCP with right AxA perfusion to clarify its efficacy. METHOD: Between 1998 and 2002, 120 patients underwent aortic arch repair using SCP with right AxA perfusion. The mean age was 69+/-10 years. Aneurysms were atherosclerotic in 79, dissecting in 32, and others in nine patients. Twenty of them (16.7%) required emergency surgery. CPB was initiated with right AxA and FA perfusion, and following SCP was established using right AxA and left common carotid artery perfusion. RESULTS: With right AxA perfusion, hospital mortality was 5.8%. Multivariate analysis showed only ruptured aneurysm was an independent determinant for hospital mortality. Permanent neurological dysfunction developed in one patient (0.8%), while seven (5.8%) suffered from temporary one. In univariate analysis, SCP time, stenosis of the carotid arteries, past history of cerebrovascular events, and atherosclerotic aneurysm were not related to temporary neurological deficits CONCLUSION: Right AxA perfusion in conjunction with SCP is a safe and useful alternative for brain protection in total arch replacement.

The axillocoronary bypass. Blood flow and short-term graft histology in a porcine model.

BACKGROUND: Bypass grafts arising from the axillary artery may be indicated for complications during minimally invasive direct coronary artery bypass grafting, for redo operations and for management of a severely atherosclerotic ascending aorta. As basic data research on this technique is scanty, we investigated intraoperative function and postoperative morphology of axillocoronary bypass grafts in a porcine model. METHODS: Thirteen German domestic pigs received an axillocoronary vein graft (Group I, n=7) or an aortocoronary vein graft (Group II, n=6) to the left anterior descending artery. In Group I the proximal anastomosis was performed to the left axillary artery, and after partial rib resection the graft was brought transpleurally to the target vessel. In both groups the coronary anastomosis was carried out on the beating heart without cardiopulmonary bypass. Graft flow was measured using transit time ultrasonic flow probes. RESULTS: Intraoperatively all grafts showed a typical diastolic flow profile. Stable graft flow was lower in axillocoronary bypass grafts: 47 (30-60 mL/min) in Group I and 65 (35-126 mL/min) in Group II (p=0.005). Flow given as percentage of cardiac output, however, did not differ between the two grafts: 0.9 (0.6-1.2%) in Group I and 1.2 (0.8-2.4%) in Group II (p=NS). At day 4 after surgery there was no clear histologic predilection site for microtrauma and early degenerative changes in the axillocoronary graft. CONCLUSIONS: Axillocoronary bypass flow compares well with flow in the aortocoronary graft. Microtrauma after implantation and early degenerative changes in the axillocoronary vein bypass are not particularly impacted by the thoracic entry site.

A successful management of concomitant renovascular hypertension and symptomatic subclavian steal syndrome due to Takayasu's arteritis using balloon angioplasty and axillo-axillary bypass grafting.

We present a case of Takayasu's arteritis with severe renovascular hypertension and symptomatic subclavian steal syndrome. A 60-year-old woman underwent successful percutaneous balloon renal angioplasty and axillo-axillary bypass grafting. The role of hybrid therapy, angioplasty and extra-anatomical bypass grafting for revascularization of symptomatic ischemia in this disease is reviewed. (Ann Thorac Cardiovasc Surg 2003: 9; 334-6)

Visualization of arterial grafts on a gastrointestinal bleeding scan.

A case of patent arterial grafts causing an abnormal Tc-99m sulfur colloid bleeding scan is presented. This finding has not been reported previously.

Axillary-femoral graft compression by prosthetic belt.

In severe peripheral vascular disease, a patient may need not only an amputation but an axillary-femoral bypass. In order to prevent the potential problem of axillary-femoral graft compression by a prosthetic belt, the importance of amputation length is stressed in this case report discussion.

Direct puncture of the prosthetic bypass graft in the treatment of critical limb ischemia patient undergoing prior axillo-femoral bypass.

A 76-year-old man presented with a non-healing ischemic ulceration of the left foot. He had undergone left axillo-femoral bypass surgery 4 years previously. Diagnostic angiography showed total occlusion from the left common iliac to the common femoral artery and the anterior and posterior tibial artery as well as severe stenosis of the superficial femoral and peroneal artery. Because there were no other access sites except for the axillo-femoral bypass graft, we performed endovascular therapy (EVT) by direct puncture of this bypass graft. Here, we have described the utility of direct puncture of axillo-femoral prosthetic bypass graft for EVT of the infrainguinal arteries.

Totally endoscopic quadruple coronary artery bypass grafting is feasible using robotic technology.

Multivessel robotic totally endoscopic coronary artery bypass grafting is currently under development. Quadruple totally endoscopic coronary artery bypass has so far not been reported. A 75-year-old patient with multivessel coronary artery disease underwent daVinci Si-assisted completely endoscopic placement of a left internal mammary artery bypass to the left anterior descending artery and construction of a right internal mammary artery Y-graft off the left internal mammary artery to the posterior descending artery. The left internal mammary artery was also connected to a diagonal branch as a sequential graft. The obtuse marginal branch was revascularized using an endoscopically harvested vein graft originating from the left axillary artery.