Mary Lin1, Charles Drucker2, Junyan Gu2, Khanjan Nagarsheth2, Shahab Toursavadkohi2. 1. Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD. Electronic address: mary.lin@som.umaryland.edu. 2. Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD.
Abstract
BACKGROUND: Endovascular stent and prosthetic graft placement are commonplace techniques for correction of subclavian artery (SCA) lesions. However, when initial surgical repair of the SCA becomes complicated by subsequent infection or thrombosis of the repair site, stents and prosthetic grafts are no longer suitable for secondary repair due to the risk of recurrent failure and limited longevity. Autogenous tissue is more resistant to infection and has improved long-term patency, and thus may be a better option for secondary reconstruction in these complex clinical scenarios. The most commonly used autogenous conduit for SCA reconstruction is the great saphenous vein; however, the significant size mismatch makes this unsuitable in many circumstances. The autogenous femoral vein is a promising alternative conduit for SCA repair. Here we present 3 successful cases of its use as a salvage technique following iatrogenic complications of prior surgical repair. METHODS: From 2015 to 2019, 3 patients underwent harvest of the femoral vein for use in SCA repair, with 2 carotid-axillary bypasses and 1 carotid-subclavian bypass. Indications included a mycotic pseudoaneurysm secondary to an infected SCA stent, an SCA avulsion secondary to an infected carotid-subclavian bypass graft, and an occluded SCA stent in a young patient. Postoperative graft patency was monitored via clinical resolution of symptoms and maintenance of perfusion, intact pulses, and arterial duplex or computed tomography (CT) scan. RESULTS: All these patients had a good outcome following their procedures. Each had intact radial pulses immediately postoperatively and maintained normal perfusion to the upper extremity for the duration of follow-up, with bypass patency confirmed via CT scan or arterial duplex. The SCA repair also allowed for salvage of the upper extremity and symptomatic relief in all patients. None of the patients developed deep vein thrombosis in the donor extremity, and neither of the infected patients developed recurrent infection of the repair site. CONCLUSIONS: The success of these cases demonstrates that the autogenous femoral vein is an effective and safe option for SCA reconstruction. It is particularly useful for secondary salvage when prior surgical repair via standard techniques is complicated by infection or thrombosis, and when target vessel size precludes the use of the great saphenous vein. This is an excellent choice of conduit that vascular surgeons should consider for use in complex SCA repairs.
BACKGROUND: Endovascular stent and prosthetic graft placement are commonplace techniques for correction of subclavian artery (SCA) lesions. However, when initial surgical repair of the SCA becomes complicated by subsequent infection or thrombosis of the repair site, stents and prosthetic grafts are no longer suitable for secondary repair due to the risk of recurrent failure and limited longevity. Autogenous tissue is more resistant to infection and has improved long-term patency, and thus may be a better option for secondary reconstruction in these complex clinical scenarios. The most commonly used autogenous conduit for SCA reconstruction is the great saphenous vein; however, the significant size mismatch makes this unsuitable in many circumstances. The autogenous femoral vein is a promising alternative conduit for SCA repair. Here we present 3 successful cases of its use as a salvage technique following iatrogenic complications of prior surgical repair. METHODS: From 2015 to 2019, 3 patients underwent harvest of the femoral vein for use in SCA repair, with 2 carotid-axillary bypasses and 1 carotid-subclavian bypass. Indications included a mycotic pseudoaneurysm secondary to an infected SCA stent, an SCA avulsion secondary to an infected carotid-subclavian bypass graft, and an occluded SCA stent in a young patient. Postoperative graft patency was monitored via clinical resolution of symptoms and maintenance of perfusion, intact pulses, and arterial duplex or computed tomography (CT) scan. RESULTS: All these patients had a good outcome following their procedures. Each had intact radial pulses immediately postoperatively and maintained normal perfusion to the upper extremity for the duration of follow-up, with bypass patency confirmed via CT scan or arterial duplex. The SCA repair also allowed for salvage of the upper extremity and symptomatic relief in all patients. None of the patients developed deep vein thrombosis in the donor extremity, and neither of the infected patients developed recurrent infection of the repair site. CONCLUSIONS: The success of these cases demonstrates that the autogenous femoral vein is an effective and safe option for SCA reconstruction. It is particularly useful for secondary salvage when prior surgical repair via standard techniques is complicated by infection or thrombosis, and when target vessel size precludes the use of the great saphenous vein. This is an excellent choice of conduit that vascular surgeons should consider for use in complex SCA repairs.