Axillary pullout syndrome: an unusual complication of axillary femoral bypass grafting

Article Information

Aqeel Alameer1*, Mohammed Janquli2 Abdelaziz Marzoug1, Dean Williams3, Christopher Murrills3

Affiliation:

1Department of Radiology, Ninewells hospital, Dundee, UK

2Department of Radiology, University Hospital Waterford, Waterford, Ireland

3Department of Vascular surgery, Ninewells hospital, Dundee, UK

*Corresponding author:

Aqeel Alameer, Department of Radiology, Ninewells hospital, Dundee, UK.

Received: December 11, 2022; Accepted: December 20, 2022; Published: December 27, 2022

Citation:

Aqeel Alameer, Mohammed Janquli, Abdelaziz Marzoug, Dean Williams Christopher Murrills. Axillary Pullout Syndrome: an Unusual Complication of Axillary Femoral Bypass Grafting. Journal of Radiology and Clinical Imaging 5 (2022): 91-92.

Share at Facebook

Abstract

A male patient in his eighties presented two weeks following axillary profunda femoris bypass grafting with chest pain, left upper arm swelling and haemodynamic instability. Imaging revealed axillary anastomotic dehiscence with haemorrhage and pseudoaneurysm formation consistent with a diagnosis of axillary pullout syndrome. Emergency management consisted of a combined endovascular and open surgical approach including emergency stenting of the left axillary artery pseudoaneurysm and open surgical closure of the brachial artery puncture site.

Keywords

axillary anastomotic dehiscence; axillary pullout syndrome; anastomotic failure; axillary femoral bypass; axillary stenting

axillary anastomotic dehiscence articles; axillary pullout syndrome articles; anastomotic failure articles; axillary femoral bypass articles; axillary stenting articles.

axillary anastomotic dehiscence articles axillary anastomotic dehiscence Research articles axillary anastomotic dehiscence review articles axillary anastomotic dehiscence PubMed articles axillary anastomotic dehiscence PubMed Central articles axillary anastomotic dehiscence 2023 articles axillary anastomotic dehiscence 2024 articles axillary anastomotic dehiscence Scopus articles axillary anastomotic dehiscence impact factor journals axillary anastomotic dehiscence Scopus journals axillary anastomotic dehiscence PubMed journals axillary anastomotic dehiscence medical journals axillary anastomotic dehiscence free journals axillary anastomotic dehiscence best journals axillary anastomotic dehiscence top journals axillary anastomotic dehiscence free medical journals axillary anastomotic dehiscence famous journals axillary anastomotic dehiscence Google Scholar indexed journals axillary pullout syndrome articles axillary pullout syndrome Research articles axillary pullout syndrome review articles axillary pullout syndrome PubMed articles axillary pullout syndrome PubMed Central articles axillary pullout syndrome 2023 articles axillary pullout syndrome 2024 articles axillary pullout syndrome Scopus articles axillary pullout syndrome impact factor journals axillary pullout syndrome Scopus journals axillary pullout syndrome PubMed journals axillary pullout syndrome medical journals axillary pullout syndrome free journals axillary pullout syndrome best journals axillary pullout syndrome top journals axillary pullout syndrome free medical journals axillary pullout syndrome famous journals axillary pullout syndrome Google Scholar indexed journals anastomotic failure articles anastomotic failure Research articles anastomotic failure review articles anastomotic failure PubMed articles anastomotic failure PubMed Central articles anastomotic failure 2023 articles anastomotic failure 2024 articles anastomotic failure Scopus articles anastomotic failure impact factor journals anastomotic failure Scopus journals anastomotic failure PubMed journals anastomotic failure medical journals anastomotic failure free journals anastomotic failure best journals anastomotic failure top journals anastomotic failure free medical journals anastomotic failure famous journals anastomotic failure Google Scholar indexed journals axillary femoral bypass articles axillary femoral bypass Research articles axillary femoral bypass review articles axillary femoral bypass PubMed articles axillary femoral bypass PubMed Central articles axillary femoral bypass 2023 articles axillary femoral bypass 2024 articles axillary femoral bypass Scopus articles axillary femoral bypass impact factor journals axillary femoral bypass Scopus journals axillary femoral bypass PubMed journals axillary femoral bypass medical journals axillary femoral bypass free journals axillary femoral bypass best journals axillary femoral bypass top journals axillary femoral bypass free medical journals axillary femoral bypass famous journals axillary femoral bypass Google Scholar indexed journals axillary stenting articles axillary stenting Research articles axillary stenting review articles axillary stenting PubMed articles axillary stenting PubMed Central articles axillary stenting 2023 articles axillary stenting 2024 articles axillary stenting Scopus articles axillary stenting impact factor journals axillary stenting Scopus journals axillary stenting PubMed journals axillary stenting medical journals axillary stenting free journals axillary stenting best journals axillary stenting top journals axillary stenting free medical journals axillary stenting famous journals axillary stenting Google Scholar indexed journals  Imaging articles  Imaging Research articles  Imaging review articles  Imaging PubMed articles  Imaging PubMed Central articles  Imaging 2023 articles  Imaging 2024 articles  Imaging Scopus articles  Imaging impact factor journals  Imaging Scopus journals  Imaging PubMed journals  Imaging medical journals  Imaging free journals  Imaging best journals  Imaging top journals  Imaging free medical journals  Imaging famous journals  Imaging Google Scholar indexed journals CT  articles CT  Research articles CT  review articles CT  PubMed articles CT  PubMed Central articles CT  2023 articles CT  2024 articles CT  Scopus articles CT  impact factor journals CT  Scopus journals CT  PubMed journals CT  medical journals CT  free journals CT  best journals CT  top journals CT  free medical journals CT  famous journals CT  Google Scholar indexed journals pseudoaneurysm articles pseudoaneurysm Research articles pseudoaneurysm review articles pseudoaneurysm PubMed articles pseudoaneurysm PubMed Central articles pseudoaneurysm 2023 articles pseudoaneurysm 2024 articles pseudoaneurysm Scopus articles pseudoaneurysm impact factor journals pseudoaneurysm Scopus journals pseudoaneurysm PubMed journals pseudoaneurysm medical journals pseudoaneurysm free journals pseudoaneurysm best journals pseudoaneurysm top journals pseudoaneurysm free medical journals pseudoaneurysm famous journals pseudoaneurysm Google Scholar indexed journals radiology articles radiology Research articles radiology review articles radiology PubMed articles radiology PubMed Central articles radiology 2023 articles radiology 2024 articles radiology Scopus articles radiology impact factor journals radiology Scopus journals radiology PubMed journals radiology medical journals radiology free journals radiology best journals radiology top journals radiology free medical journals radiology famous journals radiology Google Scholar indexed journals vascular surgery articles vascular surgery Research articles vascular surgery review articles vascular surgery PubMed articles vascular surgery PubMed Central articles vascular surgery 2023 articles vascular surgery 2024 articles vascular surgery Scopus articles vascular surgery impact factor journals vascular surgery Scopus journals vascular surgery PubMed journals vascular surgery medical journals vascular surgery free journals vascular surgery best journals vascular surgery top journals vascular surgery free medical journals vascular surgery famous journals vascular surgery Google Scholar indexed journals

Article Details

Introduction

Axillary pullout syndrome is a rare complication of axillary femoral bypass grafting which can result in life threatening bleeding. This is thought to be a direct consequence of poor technique, excessive tension, and exertional arm movements (1,2). Endovascular control of arterial haemorrhage and subsequent surgical repair are key in the management of this syndrome.

Case Presentation

A diabetic male patient in his eighties with a left sided critical limb ischaemia underwent a left axillary-profunda femoral bypass with Miller cuff followed by a transtibial amputation due to extensive disease. He presented two weeks post procedure with new onset chest pain and a left sided arm swelling 3 cm below the site of the axillary anastomosis.

A CT angiogram of the aorta revealed disintegration of the left axillary- profunda proximal anastomosis with inferior migration of the graft [Figure 1A]. There was a 7.3 x 8 cm pseudoaneurysm arising from the left axillary artery with a 6.8 cm opacifying component denoting active bleeding [Figure 1B].

Upper limb angiogram confirmed anastomotic disruption and a 5.9 x 7.2 cm pseudoaneurysm arising from the left proximal axillary artery 1 cm distal to the origin of the posterior circumflex humeral artery [Figure 2A]. A 6 mm x 5 cm covered self-expanding metal stent (GORE® VIABAHN®) deployed to exclude the pseudoaneurysm, and post-dilated with 6 x 40 mm balloon (Sterling™ Boston Scientific™) [Figure 2B]. The 7F sheath left in situ to permit surgical cut-down to close arteriotomy.

Due to poor tissue healing and loss of continuity of the axillary graft, the patient underwent a revision above knee amputation. Post operative course was uneventful and the patient is currently well.

fortune-biomass-feedstock

Figure 1A: CT angiogram showing disintegration of the proximal anastomosis of the left axillary-profunda bypass with inferior migration of the graft (arrow).

fortune-biomass-feedstock

Figure 1B: CT angiogram showing a sizeable pseudoaneurysm arising from the left axillary artery.

fortune-biomass-feedstock

Figure 2A: Upper limb angiogram confirms pseudoaneurysm arising from the proximal left axillary artery.

fortune-biomass-feedstock

Figure 2B: Upper limb angiogram demonstrating no contrast within the pseudoaneurysm after stent graft placement.

Discussion

Disruption of the proximal anastomosis of the axillary artery with bleeding and the formation of a pseudoaneurysm or what is known as ‘axillary pullout syndrome’ is an unusual yet life threatening complication of axillary-femoral bypass grafting. This complication is believed to occur due to excessive anastomotic tension and technical errors in positioning the anastomosis (1) Cases have been described to occur due to exertional arm movements (2).

In the present case, a pseudoaneurysm of the axillary artery developed following disintegration of the proximal anastomosis of  a  left  axillary-profunda  femoris  bypass.  A similar case has been reported in the literature and successfully treated with a hybrid method combining an endovascular approach to limit the haemorrhage followed  by an open exploration and repair of the graft with limb salvage and favourable outcome  for  the  patient  (3).  In  our case, endovascular stenting succeeded in limiting the bleeding, but endovascular closure was not possible as the vessel was deemed to be too small therefore a sheath was left to be used for surgical closure of the brachial artery access site. Unfortunately, the continuity of the bypass was lost  and poor tissue healing subsequently led to an above knee amputation. To our knowledge, this is one of a few cases in the literature using a combined graft and surgical approach for the treatment of this complication.

Our case highlights that while axillary-femoral bypass grafting is an attractive option especially for patients who  are frail and limited by co-morbidities; it can result in devastating complications such as axillary pullout syndrome and pseudoaneurysm formation. Clinical suspicion of this complication should be maintained, and appropriate imaging obtained especially in cases of soft tissue swelling near the anastomosis site. Multidisciplinary input from interventional radiology, vascular surgery and critical care is crucial for safe patient management.

Conflict of Interest:

The authors declare no conflict of interest.

References

  1. White GH, Donayre CE, Williams RA, et al. Exertional disruption of axillofemoral graft anastomosis. 'The axillary pullout syndrome'. Arch Surg 125 (1990): 625-627.
  2. Sullivan LP, Davidson PG, D'Anna JA Jr, et Disruption of the proximal anastomosis of axillobifemoral grafts: two case reports. J Vasc Surg 10 (1989): 190-192.
  3. Kugler NW, Lewis BD, Malinowski M. Axillary pullout syndrome: A novel approach to managing a devastating complication. Vascular 30 (6)

© 2016-2024, Copyrights Fortune Journals. All Rights Reserved