Axillobrachial artery bypass grafting with in situ cephalic vein for axillary artery occlusion: A case report

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1 CASE REPORTS Axillobrachial artery bypass grafting with in situ cephalic vein for axillary artery occlusion: A case report Evan S. Cohen,/VII), Robert B. Holtzman, MD, and George W. Johnson, Jr., MD, Houston, Texas The cephalic vein has been reported to be a suitable vascular conduit for arterial reconstructive surgery, but its use remains controversial. When used for lower extremity revascnlarization, its use has been complicated by elongation and dilation. Its use for upper extremity revasoalarization has only been rarely reported. This article represents the first published use of the cephalic vein with the in situ technique for upper extremity occlusive disease. This technique may avoid some of the complications noted when used in the reverse fashion. (J VAse SURG 1989;10:683-7.) Upper extremity arterial occlusive disease is a rare disorder when compared to occlusive disease involv- From the Department of Vascular Surgery, Houston Veterans Administration Hospital, Baylor College of Medicine. Reprint requests: Evan S. Cohen, MD, Depat~nent of Surgery, University of Alabama at Birmingham, Birmingham, AL /37/15980 ing the abdominal aorta, iliac artery, and femoral artery. Symptomatic arterial occlusive disease of the. upper extremity is usually treated with autogenous vein because of its superior results in long-term follow-up over synthetic grafts. The reversed saphenous vein has been advocated as the graft of choice in these cases. ~ This article describes the use Fig. 1. Preoperative arch aortogram shows the origin of the left subclavian artery free of occlusive disease. 683

2 684 Cohen,Holtzman, andjohnson Fig. 2. Preoperative left subclavian angiogram demonstrates complete obstruction of the distal left axillary artery. Diffuse atherosclerotic disease is also noted in the middle of the left axillary artery. Fig. 3. Preoperative left axillary angiogram demonstrates complete obstruction of the distal axillary artery and reconstitution of the brachial artery by means of collaterals. Journal of VASCULAR SURGERY

3 Volume 10 Number 6 December 1989 Axillobrachial artery bypass grafting with in situ cephalic vein 685 of the cephalic vein in situ for treatment of symptomatic axillary artery occlusive disease. CASE REPORT A 5S-year-old retired fireman came to the Houston Veterans Administration Hospital vascular surgical service with a &month history of progressive weakness of his left forearm and hand. He complained of intermittent numbness and cramping of his left forearm and hand that was associated with strenuous work and was relieved with rest. He also claimed that his left hand felt cooler than his right hand. He denied any history of trauma to his left arm or sudden onset of symptoms to suggest embolus as a cause for his symptoms. His past medical history was significant for two-vessel coronary artery disease documented by cardiac catheterization. In addition, he underwent aortobifemoral bypass grafting for symptomatic aortoiliac occlusive disease and nephrectomy for treatment of renal vascaalar hypertension in the past. On physical examination he had normal pulses in his right upper extremity and a pulse in the left subclavian artery palpated above the clavicle. No pulses were found in the left axillary, brachial, radial, and ulnar arteries. Bilateral cervical bnaits were present. Doppler pressure of the right brachial artery was 160 mm Hg, whereas that of the left brachial artery was 100 mm Hg. Aortic arch and left subdavian angiography revealed occlusion of the distal axillary artery with reconstimtion of the brachial artery by means of collaterals (Figs. 1 through 4). In addition, irregular plaques were noted proximal to the area of occlusion (Fig. 2). The decision to use the cephalic vein in this patient was made because of his relatively young age and extensive associated atherosclerotic occlusive disease. Preservation of his saphenous vein for coronary artery bypass grafting or lower extremity revasoalarization at a later date seemed appropriate. Operative technique.the patient was placed on the operating room table in the supine position with the left arm included in the operative field. An infraclavicular incision was made and the cephalic vein was identified. The cephalic vein was dissected proximally to its junction with the axillary vein by splitting the muscle fibers of the pectoralis major muscle. The axillary artery was identified adjacent to the axillary vein. Through a separate incision, the cephalic vein was exposed over its course down to the antecubital fossa, leaving it in situ. The brachial artery was identiffed proximal to the antecubital fossa (Fig. 5). After dividing the cephalic vein from the axillary vein, it was anastomosed to the proximal axillary artery with a running 6-0 Prolene suture (Ethicon, Inc., Sowerville, N.J.) (Fig. 5, insert). Le Maitre (Vascutech, Andover, Mass.) valvulotomes were passed from the distal Cephalic vein toward the cephalic vein-axillary artery anastomosis to render the valves incompetent \ Fig. 4. Illustration of preoperative angiographic finding indicates extent of occlusion and its anatomic relationship to the clavicle and left arm. (Fig. 6). The distal anastomosis was performed with a running 7-0 Prolene suture (Fig. 6, insert). An intraoperative angiogram was obtained to examine the distal anastomosis and identify any arteriovenous fistulas, which were then ligated. The patient's postoperative course was unremarkable, and he was discharged 7 days after surgery with a palpable pulse in the left brachial and ulnar arteries. Doppler pressures before discharge revealed a right brachial pressure of 130 mm Hg and a left brachial pressure of 124 mm Hg. A postoperative angiogram is shown in Fig. 7. Follow-up at 7 months revealed the patient to be free of symptoms and to have a palpable ulnar pulse in the left wrist. DISCUSSION Although the cephalic vein for arterial reconstruction has been shown to be a suitable vascular conduit by Kakkar 2 in 1969, its use remains controversial.

4 / 686 Cohen, Holtzman, and Johnson lournal of VASCULAR SURGERY Fig. 5. Illustration of incisions and exposure and identification of the axillary artery and axillary vein, the cephalic vein, and the brachial artery. Insert demonstrates the transposition of the cephalic vein from the axillary vein to the axillary artery. \ Fig. 6. Illustration demonstrates the use of the Le Maitre val~alotomes to make the valves of the cephalic vein incompetent. Insert demonstrates the completion of the distal anastomosis.

5 Volume 10 Number 6 December 1989 Axillobrachial artery bypass grafting with in situ cephalic vein 687 by several authors, the cephalic vein is thin, difficult to work with, and prone to injury. 4'9 The in situ technique may prevent many of these problems. Long-term follow-up of arm veins has revealed their tendency to dilate and elongate when used in the reverse fashion and for lower extremity revascularization. 9 The future of the cephalic vein when left in situ for upper extremity revascularization remains to be seen. The saphenous vein has been reported to be the conduit of choice for upper extremity revascularization. In patients with generalized atherosclerosis, who will probably require additional vascular procedures, the in situ cephalic vein is a reasonable vascular conduit for upper extremity revascularization. We are gratefifl to Dr. Nestor Sandoval for his assistance with the illustrations and Ms. Olivera Vucinic for help in preparation of the manuscript. Fig. 7. Completion arteriography of the axillary artery to brachial artery bypass graft by means of the cephalic vein with the in sltu technique. Most series report on the use of upper arm vein for lower extremity revascularization only. 3"6 There are only scattered reports about the use of reversed cephalic vein for upper extremity revascularization. 79 This present case represents the first reported example of use of the cephalic vein in situ for upper extremity revascularization. As had been pointed out REFERENCES 1. Garrett HE, Lovelace MH, Moynihan JJ. Revascularization of the upper extremity. In: Ernst CB, Stanley JC, eds. Current therapy in vas~lar surgery. Philadelphia: BC Decker Inc, 1987: Kakkar VV. The cephalic vein as a peripheral vascular graft. Surg Gynecol Obstet 1969;128: Clayson KR, Edwards WH, Allen TR, Dale WA. Arm veins for peripheral arterial reconstruction. Arch Surg 1976;111: Campbell DR, Hoar CS, Gibbons GW. The use of arm veins in femoral-popfiteal bypass grafts. Ann Surg 1979;190: Harris RW, Andros G, Dolawa LB, et al. Successfial long-term limb salvage using cephalic vein bypass grafts. Ann Surg 1984;200: Stipa S. The cephalic and basilic veins in peripheral arterial reconstructive surgery. Ann Surg 1972;175: Gross WS, Flanigan DP, Kraft RO, Stanley JC. Chronic upper extremity arterial insufficiency-etiology, manifestations, and operative management. Arch Surg 1978;113: Welling RE, Cranley JJ, Krause RJ, Hafner CO. Obliterative arterial disease of the upper extremity. Arch Surg 1981; 1!6: Schulman ML, Badkey MR. Late results and angiography evaluation of arm veins or long bypass grafts. Surgery 1982; 92: