Society For Clinical Vascular Surgery

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Trans-Axillary Approach for Acoustic Pulse Thrombolysis in Acute Occlusions of Extra-Anatomic Peripheral Bypasses
Nicolas J. Mouawad, MD MPH MBA RPVI.
McLaren Bay Region / Michigan State University, Bay City, MI, USA.

Thrombolytic management for acute and subacute ischemia in peripheral vascular disease has catapulted to the front line and is generally performed through a transfemoral approach with crossover technique. Patients with occluded extra-anatomic bypasses pose a difficult access problem to maintain an endovascular approach. We describe a trans-axillosubclavian approach for thrombolytic management of extra-anatomic bypasses.
A retrospective review of patients presenting with Rutherford I/II ischemia was conducted at a single center community referral hospital over a three year period. Patients were partitioned into endovascular and open thrombectomy groups, and then subdivided into those with extra-anatomic bypasses. Data collected included patient demographics, vascular comorbidities, previous bypass and choice of conduit, and revascularization outcome.
Sixty-four patients presented with acute arterial limb ischemia over the study period. Fifty-seven patients underwent acoustic pulse thrombolysis via standard transfemoral crossover technique. Three patients were identified to have occluded femoral-femoral bypasses. The average age was 67 (60-75 years) and two-thirds were male. Left axillo-subclavian access was successful in 100% with no post-operative complications. Operative time was increased compared to standard transfemoral approach due to complexity engaging the extra-anatomic bypass. Lysis was achieved successfully by 26 hours in all patients. Adjunctive stenting was necessary in 1 patient for inflow augmentation. Percutaneous closure was obtained in all patients.
Percutaneous trans-axillosubclavian access can be used successfully for endovascular interventions and delivery of thrombolysis in complex vascular patients with occluded extra-anatomic bypasses. It is preferential to brachial access due to length discrepancy of standard catheters.

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