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Unsuspected inflow disease in candidates for axillofemoral bypass operations: a prospective study
K D Calligaro1, E Ascer, F J Veith
1Division of Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, N.Y.
Insights
Routine arteriography is recommended before axillofemoral bypass surgery. Inflow disease, often unsuspected, can cause graft failure, affecting 25% of patients and not always detected by pressure measurements.
Area of Science:
- Vascular Surgery
- Interventional Radiology
Background:
- Axillofemoral bypass surgery is a treatment for peripheral artery disease.
- Inflow vessel stenosis (axillary, subclavian, innominate arteries) is often presumed rare.
- Extensive atherosclerosis can lead to graft failure from undetected inflow disease.
Purpose of the Study:
- To prospectively determine the incidence of unsuspected inflow stenosis in patients undergoing axillofemoral bypass.
- To evaluate the efficacy of a new arteriographic technique for assessing inflow and outflow tracts.
- To compare arteriographic findings with upper extremity arterial pressure measurements.
Main Methods:
- Prospective study of 40 consecutive axillofemoral bypass candidates (28 primary, 12 secondary).
- Utilized a novel arteriographic technique via single translumbar puncture for visualization.
- Assessed inflow stenosis (>50% luminal diameter) and compared with upper extremity arterial pressures.
Main Results:
- Ten of 40 patients (25%) had significant inflow stenosis (unilateral in 8, bilateral in 2).
- Stenotic lesions occurred in subclavian, axillary, and innominate arteries, with 20% ipsilateral to the ischemic leg.
- Upper extremity pressures were poor indicators, detecting only 3 of 12 (25%) instances of stenosis.
Conclusions:
- Unsuspected inflow stenosis is common (25%) in patients undergoing axillofemoral bypass.
- Arteriography is crucial for identifying inflow disease that can compromise graft patency.
- Routine arteriographic assessment of inflow arteries is recommended prior to axillofemoral bypass surgery.
Abstract:
Routine arteriography of the axillary, subclavian, and innominate arteries before axillofemoral bypass surgery has not been advocated because of the presumed rarity of stenosis of these inflow vessels. However, we have noted in this patient population with extensive atherosclerosis that inflow disease can cause axillofemoral graft failure despite normal preoperative clinical and noninvasive parameters. We prospectively determined the incidence of unsuspected inflow stenosis with arteriography in 40 consecutive candidates for primary (28) or secondary (12) axillofemoral bypass surgery. A new arteriographic technique with a single translumbar puncture was developed to safely and clearly visualize the potential inflow and outflow tracts. Ten of the 40 patients (25%) exhibited inflow stenosis greater than 50% of luminal diameter (unilateral in eight patients and bilateral in two patients). Seven were on the left side (five subclavian, two axillary) and five were on the right side (three subclavian, one axillary, one innominate). In eight of the 40 patients (20%) the stenotic inflow lesion was ipsilateral to the ischemic leg and therefore proximal to the preferred inflow site of an axillofemoral bypass. Upper extremity arterial pressure measurements suggested potential inflow artery stenosis in only three of the 12 (25%) instances. These findings show that equal arterial pressures in the upper extremities do not ensure adequate inflow for an axillofemoral graft. Routine arteriographic assessment of inflow intacts is recommended before axillofemoral bypass surgery.