Exertional Disruption of Axillofemoral Graft Anastomosis: ‘The Axillary Pullout Syndrome’

Five cases of exertional disruption of the axillary anastomosis occurred at intervals of 13 to 30 days after axillofemoral polytef (polytetrafluoroethylene [PTFE]) graft insertion. Graft evulsion was preceded by effort and heralded by axillary pain, an expanding hematoma, and a pseudoaneurysm formation. Proximal control of the subclavian artery by a supraclavicular approach or balloon allowed safe wound exploration. Successful reconstruction required lengthening of the graft or replacement. Secondary disruption occurred with simple repair. Although temporary postoperative brachial plexus neuropathy was common, no significant hand ischemia was noted. Twenty-two reports of axillary anastomotic disruption were made to the Food and Drug Administration, Washington, DC, during a 2-year period, and one manufacturer of polytef grafts provided data on 10 reports received throughout 7 years. Surface anatomy measurements in 20 control patients demonstrated that arm abduction and lateral flexion of the body increased the distance between the axillary and femoral arteries by a mean of 15.5%. Similar measurements taken from the proximal axillary artery showed a mean length increase of less than 10%. This complication may be avoided by inserting the polytef graft with several centimeters of excess length and positioning the axillary anastomosis medial to the pectoralis minor muscle.