Eur J Vasc Endovasc Surg 11, 225-229 (1996)

Surgical Management of Brachioaxillary-subclavian Occlusion

V. S. Sottiurai, R. Lyon, C. Ross, M. Cooper and 3. Gonzales

Department of Surgery, Section of Vascular Surgery, Louisiana State University School of Medicine, 1542 Tulane Avenue, Louisiana 70112-2822, U.S.A.

Objective: The possibility of using Ring PTFE graft as venous bypass to preserve arteriovenous graft function and reduce upper extremity swelling. Methods: Twenty-two patients with stenosis/occlusion of the brachial-axillary- segment in haemodialysis patients (n = I9) and patients with penetration injury (n = 3) who were not candidates for balloon angioplasty were treated with ring PTFE venous bypass in renal patients and jugular to axillary vein transposition for trauma patients and followed for 10-87 months (mean 31) using venography, Doppler analysis and Duplex scanning. Results: There was no death or neurologic deficit resulting from the venous bypass. Resolution of swelling occurred in 8-48 h. 19/22 (86%) of the bypasses and 3/3 transpositions remained patent after a mean follow-up of 31 months (10-87) months. The attrition was due to AV graft occlusion (n = 2) and infection requiring graft removal (n = 1). Conclusions: Ring PTFE graft is an acceptable venous bypass for brachial-axillary-subclavian stenosis/occlusion to reduce swelling and preserve the function of AV grafts in patients with lesions not amendable with balloon angioplasty or thrombolytic therapy. Jugular-axillary transposition is inappropriate for renal patients.

Key Words: Brachioaxillary-subclavian vein occlusion; Venous hypertension; Arteriovenous graft; Chronic renal failure.

Introduction Table 1. Distribution of venous obstruction Brachiosubclavianvein Since the introduction of percutaneous dialysis cathe- Axillosubclavianvein thrombosis ter placement in the subclavian or internal jugular Subclavian vein thrombosis Brachiocephalicvein thrombosis vein for temporary dialysis, the incidence of innomi- Brachiosubclavian-int.jugular vein stenosis nate, subclavian, axillary or brachial vein stenosis or Subclavian-int.jugular vein stenosis occlusion has increased significantly.1-5 Although the aetiology responsible for these complications is not well defined, the sequelae of venous hypertension, swelling, cutaneous exudation and threatened throm- bosis of the arteriovenous graft (AVG) in the upper anatomic bypasses for treatment of upper extremity extremity are well recognised. This communication massive swelling (n--22), skin exudation (n = 8), blis- discusses (1) the extra-anatomic venous bypass to ter formation (n = 4), and breast enlargement (n = 7) alleviate venous hypertension (2) method of arter- due to occlusion of brachiosubclavian vein (n = 5), iovenous graft preservation (3) selection of the bypass axillosubclavian vein (n = 8), subclavian vein (n--2), conduit. (n = 1), stenosis of brachiosub- clavian-internal jugular (n = 3), and subclavian- internal jugular veins (n = 3) (Table 1). Except for the Materials and Methods three to axillary vein transposi- tion performed in patients with penetration injury, 19 Twenty-two patients (13 male, 9 female) with the of the 22 limbs belong to chronic renal failure patients mean age of 58 years (42-71) underwent extra- who were dependent on the AVGs for haemodialysis (Table 2). In 13/19 (63%) the patients had no addi- Please address all correspondence to: V.S. Sottiurai, M.D., Ph.D., tional available sites in the upper extremity for Department of Surger34 Section of Vascular Surgery, Louisiana State University School of Medicine,1542 Tulane Avenue, New Orleans, additional AVG. In 3/19 (16%) the patients have had Louisiana 70112-2822 Telephone (504) 568-4576 only one site in both upper extremities available for

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Table 2. Distribution of patients Results Trauma related subclavian and vein thrombosis 3 (13.6%) Dialysis catheter induced axillary-subclavian-jugular There was no death or neurologic deficit resulting vein thrombosis 19 (86.4%) from the venous bypass procedures. Transient vocal cord dysfunction attributed to traumatic intubation was noted in one patient following jugular-jugular bypass. AVG and 3/19 (16%) patients had one site remaining Resolution of the upper extremity swelling gen- in each upper extremity. erally occurred in a 8-48 h. Jobst compression sleeve to All patients were screened for chronic coagulopathy control swelling for 3-7 weeks was needed in two (antithrombin III, protein C and S, fibrinogen, plasmi- patients with brachial to contralateral internal jugular nogen). Antithrombin III deficiency was found in 4/21 bypass and in axillary-jugular bypass. patients (19%). They were treated with long-term low A total of 19/22 (86.3%) bypass grafts remained dose Coumadin (2.5-5 mg/day). Contrast venog- patent without arm swelling after a 10-87 month raphy, Duplex scan and Doppler ultrasonography were performed before and after the operations. Each (a) AVG was evaluated in the clinic at 3 months interval for haematoma, aneurysm, pseudoaneurysm, infec- tion and increased venous pressure during dialysis. Doppler analysis, Duplex scan and venogram were used selectively to supplement physical examination whenever potential complications were suspected.

Surgical techniques

Brachial or axillary vein to internal jugular vein bypass using 8-10mm ring Gore-Tex PTFE graft was the standard procedure. Internal jugular veins were dissected free between the bifurcated attachment of the sternocleidomastoid muscle to the clavicle (Fig. (b) 1A). Following the end-to-side anastomosis to the internal jugular vein, the PTFE graft was placed in a retroclavicular tunnel and the axillary or brachial anastomosis was constructed also in an end-to-side configuration (Fig. 1B). The internal jugular to axillary vein transposition was accomplished by mobilising the internal jugular vein for adequate length through an oblique incision placed along the anterior border of the sternocleido- mastoid muscle. The axillary vein was exposed through a supraclavicular incision placed along the clavicle. Transection of the internal jugular vein at the level of the mandible provided adequate length for transposition to the axillary vein. Postoperative venography was performed routinely prior to patients' discharge from the hospital (Figs. 2 and 3). Elastic bandage wrapping for 24 48 h follow- Fig. 1. (A) Intraoperative photograph of ring PTFE graft (G) in an ing the bypass has significantly reduced arm swelling. end-to-side anastomosis to the contralateral internal jugular vein One dose of intravenous prophylatic antibotic was (IJ). (B) Intraoperative photograph of ring PTFE graft (G) in an end- to-side anastomosis to the contralateral axillary vein (AV) for given preoperatively to minimise potential wound innominate vein occlusion. The graft was placed subcutaneously infection. across the neck (N).

Eur J Vasc Endovasc Surg Vol 11, February 1996 Brachial-axillary-subclavian Vein Thrombosis 227

(mean 31) follow-up (Table 3). Two jugular vein stenoses after brachiointernal jugular bypass were successfully revised using vein patch angioplasty at the jugular anastomosis. The jugular-jugular bypass for brachiocephalic vein occlusion was functional for 17 months until the AVG was thrombosed (Fig. 3). A total of 3/22 (13.7%) jugular to axillary transposi- tion had no postoperative adverse consequence. There was no cervical venous congestion or swelling. How- ever resolution of arm swelling was evident. Arterial-venous graft occlusion (2/22) and AVG infection (1/22) have accounted for the sole attrition of venous bypass failure in our study.

Discussion

Although arteriovenous fistula is preferred to pros- thetic or biologic arteriovenous access, AVG is con- sidered an acceptable substitute for patients who urgently need a vascular access for haemodialysis. The abuse of the convenience of jugular or subclavian catheter for temporary dialysis has contributed to the high incidence of stenosis plus occlusion of axillary, Fig. 2. Post brachiojugular bypass venogram. Arrows indicate the subclavian and jugular veins. 1-s This complication not course o5 the brachiojugular bypass. Internal jugular (IJ). only affects the function of the upper extremity but also threatens the patency of the AVG. The incidence of subclavian-axillary vein stenosis/occlusion has initially surpassed the similar complication encoun- tered in jugular veins due to the preference of placing the dialysis catheter in the subclavian vein. However, the incidence of jugular vein stenosis/occlusion is becoming more common with the increased frequency of internal jugular vein catheter placement. 6 There were several theories regarding the sub- clavian, axillar~ and jugular vein stenosis/occlu- sion. 6-9 Fibrotic reaction from repeated percutaneous cannulation, delayed catheter removal extrinsic hae- matoma compression, and reactive fibroplasia secon- dary to intraluminal catheter vibration generated by the cyclic cardiac contraction are among the proposed aetiologic factors. 6'1° Coagulopathy is a potential complication for graft thrombosis. However, it is uncommon in our series despite the high incidence of antithrombin III deficiency identified in 4/21 (19%) in our patients. Low-dose Coumadin (2.5-5.0 mg) daily has been found beneficial in selected patients without significantly altering the prothrombin time (12-15 s). Elevated sedimentation rates in lupus erythematosis are also known to cause AVG thrombosis and has accounted for one patient in our series. Whether Fig. 3. Internal jugular to internal jugular bypass with ring PTFE improvement of haematocrit from erythropoetin treat- graft. Open arrows indicate sites of anastomoses. ment, per se, has any effects on coagulability in

Eur J Vasc Endovasc Surg Vol 11, February 1996 228 V.S. Sottiurai et aL

Table 3. Demographic data of upper extremity venous bypass

Procedures No. Sex Age Occlusion Follow-up AVG Swelling Complication

Brachioqugular 15 8M7F 48-71 Brach-subcl. 5 10-49 mon Functional (--) 1 graft infect, and Ax-Subcl. 8 ocd. Subclavian 2 I graft occl. after AV graft thrombosed Jugular-jugular 1 M 51 Brach-cephalic 17 mon Functional (--) Brach-contra. Jugular 3 2M 1F 56-71 Brach-subclav. 16-18 mon Functional (--) i bypass occlus. int. Jugular after AV graft thrombosed Jugular-axillary 3 2M 1F 42-68 axillo-subcl. 42,-87mon N/A (--) none, bypass patent. renal patients is not known and is worthy of further months by Criado et al. 21 These findings are in investigation. 1°-13 agreement with our experience and histologic findings Bypassing the occluded segment of the brachiosub- that fibroplasia in venous stenosis is resistant to clavian or innominate vein using ring Gore-Tex PTFE dilation and stenting. 22 graft in this study has produced surprisingly good The pertinent information that emerged from this and durable results in preserving AV graft patency, study are: (1) the success rate of ring PTFE graft, and reducing arm swelling, breast swelling, cutaneous (2) spiral saphenous vein or femoral vein for venous exudation, pain and restoring function to the bypass are no longer necessary. The elegant approach limb. 14-16 Also, no obvious adverse sequelae resulted of jugular to axillary vein transposition is more suited from these venous bypass procedures. On the basis of for non-renal patients. In renal patients the jugular this promising and encouraging data, the traditional vein should be preserved as potential site for future approach of AVG ligation to reduce swelling is no temporary or permanent catheter access. A pro- longer necessary and should be avoided particularly spective randomised study comparing the patency in patients who have limited sites available for future and durability of autogenous versus ring PTFE graft AVG. 3,17 will be the most ideal and more scientific study. Balloon dilation 5'1s and thrombolytic therapy 1°'18-2° However, the fact remains that ring PTFE access with have been reported with acceptable results but has a distal AVG has been proven effective in reducing high incidence of recurrence.21-22 Five renal patients arm swelling and AVG preservation. presented in these studies were candidates whose axillosubclavian vein (n = 3) and subclavian veins (n = 2) could not be resolved with thrombolytic ther- apy. The remaining 14/19 renal patients were not Acknowledgements amendable for balloon angioplasty due to the long The authors gratefully acknowledge the assistance of Shirley Lim segment of venous occlusion. Sue in the preparation of the manuscript. The study is supported in It is well aware that longer follow-up is needed to part by Romi Sottiurai Foundation Inc. more accurately define the durability and the true value of venous bypass in the preservation of the function of the upper extremity and the AVG. None- theless, the patency rate of 16/19 (84%) in a follow-up References of 10-87 months (mean 31) has produced encouraging 1 BARRETTN, SPENCERS, McIvoR J, BROWNEA. Subclavian stenosis: and creditable result in ring PTFE graft bypass for a major complication of subclavian dialysis catheters. Nephrol venous outflow obstruction of the upper extremity Dial Transplant 1988; 3: 423425. and AVG preservation. The high incidence of ring 2 SCHWAB SJ, QUARLES LD, MIDDLETON JP, COHAN RH, SAEED M, DENNIS VVV. Hemodialysis-associated subclavian vein stenosis. PTFE venous bypass graft patency in this study can in Kidney Int 1988; 33: 1156-1159. part be attributed to (1) ring PTFE graft is resistant to 3 HELDB, CHARYTANC. Subclavian vein stenosis as a complication compression and kink, (2) the distal AVG functioning of subclavian catheterization for hemodialysis. Arch Intern Med 1987; 147: 305-307. as a fistula enhances venous flow and improves 4 SABOT JP, WATERLOTY, MARCHAL M. Complications related to patency. subclavian catheters for hemodialysis. Report and review. Am J Balloon dilation in conjunction with 76.5% stenting Nephrol 1986; 6: 339-345. 5 STATLER KA, STEVENS GF, STERLING WA Jr. Late stenosis of the of axillary-subclavian stenosis/occlusion did not yield subclavian vein after hemodialysis catheter injury. Surgery 1986; promising results even in short term follow-up of 9-13 100: 924-927.

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