Axillofemoral Bypass Technique

Exposure of axillary artery

Make a transverse infraclavicular incision approximately two fingerbreadths below the clavicle. The pectoralis muscle is exposed and fibers are split superiorly and inferiorly. At this point, divide the pectoralis minor insertion to allow further exposure. The axillary fat pad, which contains the vein, artery, and brachial plexus, will be accessible. The axillary vein lies anterior to the artery and must be mobilized inferiorly to afford access to the artery. Isolate a 3- to 4-cm length of artery, which requires that some branching vessels be ligated or controlled.

Exposure of femoral artery

Obtain either unilateral or bilateral exposures of the femoral arteries, depending on the revascularization needs. Use longitudinal or oblique groin incisions for the femoral exposure. Carry the incision along the femoral pulse at the level of the common femoral artery (inguinal ligament). Dissect subcutaneous tissues, and enter the femoral sheath. The artery lies lateral to the femoral vein. Dissect the common femoral, superficial femoral, and deep femoral (profunda femoris) arteries, and control with vessel loops. Control and preserve circumflex branches.

Tunneling of graft

Perform subcutaneous tunneling before systemic heparinization. Use a graft tunneling device (eg, Gore Tunneler) to create a midaxillary tunnel, lateral to the nipple and above the abdominal fascia, from the axillary incision to the femoral incision. If necessary, create a femoral-to-femoral tunnel superior to the pubic bone for a bifemoral reconstruction. Pass the PTFE or Dacron graft(s) through the tunnel(s) with the use of the device and ensure that there are no twists or kinks. (See the image below.)

Axillary anastomosis

Administer intravenous heparin prior to vascular control for the creation of the anastomosis.

Perform the proximal axillary anastomosis first. Because the axillary and subclavian arteries are considerably more fragile than the femoral arteries are, take care to avoid aggressive handling of these vessels. Use angled clamps (ductus, angled DeBakey, or mini profunda) to obtain proximal and distal control of the axillary artery. Perform a longitudinal arteriotomy, and fashion a hood on the PTFE/Dacron graft. Then create an end-to-side running anastomosis. Assess graft inflow and distal axillary arterial outflow as the arm is abducted to ensure that there is no tension on the anastomosis.

Femoral anastomosis

There are many configurations for creating the distal femoral anastomosis; the choice depends on the needs of the patient. If a bifemoral configuration is required, construct the distal femorofemoral anastomosis first, and land on the distal axillary graft on the ipsilateral segment of the femorofemoral graft. Otherwise, the contralateral femoral limb may come directly off the ipsilateral axillofemoral graft in an end-to-side fashion. Premade axillobifemoral grafts are also available from several manufacturers.

Once the femoral vessels are controlled, create a longitudinal arteriotomy. Create the distal femoral anastomosis in an end-to-side fashion to an appropriate branch of the common femoral artery (most often, the common femoral artery itself). If there is significant disease of the superficial femoral artery, the anastomosis may have to be performed in such a way as to incorporate the deep femoral artery. In general, spatulation of the anastomosis to the deep femoral artery is recommended. Concomitant endarterectomy of the femoral artery may be necessary if significant disease exists on the distal target vessel.

Perioperative hemodynamic monitoring is essential to good outcomes. In view of the prosthetic burden, surgical wounds should be monitored diligently for early signs of infection and managed promptly. Prophylactic antibiotics should be administered before any future surgical interventions (eg, dental procedures) that may disseminate bacteria.

Potential complications of axillofemoral bypass include the following:

• Brachial plexus injury
• Axillary pullout syndrome (disruption of the axillary anastomosis)
• Graft thrombosis
• Graft infection ^[15]
• Early graft thrombosis and delayed pseudoaneurysm of the graft (may be a sign of underlying graft infection)

Shortening or lengthening of the graft has been reported as a late postoperative complication but is rare. ^[16]