Vol. 32, No. 2, June 2016
pISSN 2288-7970 • eISSN 2288-7989

Left Subclavian Artery Occlusion: Femoro-Axillary
Artery Retrograde Bypass
Masaya Nakashima1, Hideaki Kobayashi1, and Masayoshi Kobayashi2
12Department of Vascular Surgery, Tokoname Municipal Hospital, Aichi,
Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Aichi, JapanThe treatment tactics for subclavian artery occlusion include the more commonlyused endovascular therapy rather than surgical intervention. We present a case of a61-year-old woman with dialysis-dependent chronic renal failure who experienced
left finger necrosis in the left upper extremity. To salvage the limb, we performed
femoro-axillary (fem-ax) artery bypass using an autologous saphenous vein
graft. However, 10 months later, she experienced coldness in the left forearm.
Angiography revealed chronic total occlusion of the venous bypass. Despite
emergent thrombectomy, redo fem-ax artery bypass operation was performed
using a prosthetic graft. Upper limb salvage can be achieved by fem-ax artery
retrograde bypass.
Key Words: Subclavian artery occlusion, Artery bypass, Upper limb salvage

Received February 12, 2016
Revised April 4, 2016
Accepted April 7, 2016

Corresponding author: Masaya Nakashima
Department of Vascular Surgery,
Tokoname Municipal Hospital, 3-3-3
Asukadai, Tokoname, Aichi 479-8510,
Japan
Tel: 81-569-35-3170
Fax: 81-569-34-8526
E-mail: tkdr-3697@tac-net.ne.jp
Conflict of interest: None.

Copyright © 2016, The Korean Society for Vascular Surgery
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Vasc Spec Int 2016;32(2):62-64 • http://dx.doi.org/10.5758/vsi.2016.32.2.62

INTRODUCTION
Subclavian artery (SCA) occlusion is not so rare. Although
SCA occlusion results in insufficient blood flow, it is mostly
observed without any symptoms. The therapeutic treat­ments include angioplasty and stent insertion into the SCA
to treat stenosis and occlusion. However if these interven­tions are not feasible, surgical options must be considered.
We performed femoro-axillary (fem-ax) retrograde arterial
bypass to prevent left finger necrosis. This report discusses
the relationship between endovascular therapy and surgicalprocedure for upper limb ischemia resulting from left SCAocclusion.

CASE
A 61-year-old woman with dialysis-dependent renal
failure experienced coldness in her left upper extremitywith left finger pain. Two years earlier, she underwent
aortic valve reconstruction and coronary artery bypass
62

graft (CABG) with a right great saphenous vein (GSV) graft.
Native vascular access (arteriovenous fistula) had been
constructed on the left forearm.
Angiography revealed total left SCA occlusion and morethan 75% stenosis of the left common iliac artery (CIA) (Fig.
1). Ankle brachial index (ABI) was 0.86 on the right and 0.68
on the left. Doppler ultrasound of the carotid artery showed
severe calcification and increased intramedial thickness
in the bulb region. She was diagnosed as having left SCA
occlusion and arteriosclerosis obliterans.
First endovascular treatment was utilized to revascularize
the left upper extremity. Endovascular methods to target
the lesion of the left SCA were attempted, but the catheterand guide wire could not pass through the orifice of theSCA occlusive lesion (30 mm length of SCA). Unfortunately
1 month later, septic shock caused by Methicillin-resistant
Staphylococcus aureus infection of the GSV necessitatedamputation of the right leg, above the right knee, toremove the necrotic tissue and source of infection.
Following amputation, angiography showed 75% stenosis
www.vsijournal.org

Case ReportOriginalArticle

Vascular Specialist International

Femoro-Axillary Artery Retrograde Bypass

Fig. 2. Left index, middle finger necrosis.

Fig. 1. Preoperative aortic angiography shows the left sub­clavian artery occlusion.
of the left CIA, and thus a self-expandable nitinol stent
was inserted into the left CIA. Although post-stenting ABIchanged from 0.68 to 0.81 in the left lower extremity, theleft finger necrosis gradually worsened (Fig. 2). Considering
the possibility of arteriovenous graft hemodialysis shuntreconstruction for the contralateral right upper extremity,and the presence of ipsilateral carotid arterial calcificationand sclerosis, we selected the fem-ax artery retrograde
bypass operation. Under general anesthesia, we successfully
performed a left femoral to left axillary artery bypass. To
accomplish successful bypass, we utilized the left GSV
free-graft through a covered 6 mm ringed expanded
polytetrafluoroethylene (ePTFE). (Fig. 3A). Ten months later,
coldness recurred in the left arm and angiography revealed
chronic total occlusion of the GSV bypass. This was causedby thrombotic occlusion of the GSV graft. Thrombectomy
did not cause reperfusion of the artery. To salvage theleft upper limb, fem-ax bypass was performed using a
prosthetic graft. In order to bypass the right femoral
artery to the left axillary artery bypass, we used an 8 mm
polytetrafluoroethylene graft (Gelsoft, knitted; Terumo,Tokyo, Japan). Postoperative blood pressure was 158/72
and 146/62 mmHg, respectively in the right and left arms.
After the second bypass surgery, ABI was 0.91 on left lower
extremity. Postoperatively, finger necrosis was completelycured. Follow-up angiography revealed sufficient arterial
flow through the prosthetic graft (Fig. 3B).
Salvage of the upper limb affected by SCA occlusion was
successful through the use of a fem-ax artery retrograde
bypass. As the patient’s course was favorable, she remained
free of any symptoms 3 years after the last operation.

http://dx.doi.org/10.5758/vsi.2016.32.2.62

AB

Fig. 3. Postoperative angiography. (A) In the first stage,left femoro-axillary artery bypass using a great saphenous
vein graft covered with expanded polytetrafluoroethylene(ePTFE). (B) In the final stage, right femoro-axillary artery
bypass with ePTFE graft.

DISCUSSIONSCA occlusion causes insufficient blood f low withvarious symptoms such as vertigo, arm weakness or numb­ness. We often encounter non-cardiac symptoms occur
prior to other systematic problems such as the bloodpressure differences of more than 20 mmHg between eacharm. Endovascular treatment is the first therapeutic option
for SCA occlusive lesions, and generally provides positiveresults [1-3]. For patients requiring revascularization forleft upper limb ischemia, intervention with contemporary
endovascular devices for SCA occlusion is used. In thiscase, many underlying diseases prevented surgical recon­
struction. However this treatment strategy should be63

Nakashima et al.

tailored based on the patient by considering several factors
including but not limited to age, daily activity and primary
illness. This is important as recent reports have describedthat 6% to 12% of cases develop restenosis after SCA
percutaneous angioplasty and stenting [1-4]. Although
long-term consequences are unknown, recent studies havedescribed stent grafts with the development of higher
quality stents and enhanced operator techniques.
Curative measures often require surgical interventions;aorto-axillary, carotid-axillary, and bilateral SCA or bilateralaxillary crossover arterial bypass. Axillary-femoral artery
bypass has been usually selected in the treatment of highrisk patients with abdominal and iliac artery obstruction
since it was first reported by Blaisdell and Hall in 1963 [5].
Extra-anatomical bypass is essential for various patientswith infectious aorta, prosthetic arterial graft, and dissec­
tion or aorto-enteric fistulae. However, satisfactory peri­
pheral perfusion and freedom from restenosis/occlusion
are difficult to achieve after bypass. We chose an extra-anatomical bypass, despite the risk of a calcified carotid
artery lesion, with expectations of a good long-term
bypass graft patency. The patient also had the possibilityof a secondary vascular access reconstruction in the con­tralateral upper limb because of regular hemodialysis
dysfunction, and we also considered the risk of coronary
steal syndrome post CABG [6,7]. The surgical procedure
and approach should depend on the primary illness andanatomical location of the occlusion. Considering postoperative bypass patency, we first selected an autologous
reverse GSV bypass graft, tapered with a PTFE graft.
However, the small vessel size of the GSV could not allow
sufficient blood flow for upper limb salvage, thus, weperformed surgical revascularization with a prosthetic graft.
Fem-ax retrograde arterial bypass may be a valuable tosalvage left finger necrosis when endovascular treatment
is not available. Additionally, for successful arterial bypass
reconstruction, it is essential to consider both bypass routeand graft type.

REFERENCES
1) Tsuura M, Terada T, Tanaka Y, Yoshi­mura R, Okada H, Nanto M, et al.
Endovascular reconstruction for stenotic
or occlusive lesions of subclavian andvertebral arter y. J Jpn Coll Angiol
2010;50:737-743.
2) Sixt S, Rastan A, Schwarzwälder U,
Bürgelin K, Noory E, Schwarz T, et al.
Results after balloon angioplasty or
stenting of atherosclerotic subclavian
artery obstruction. Catheter Cardio­
vasc Interv 2009;73:395-403.

643) Sadato A, Satow T, Ishii A, Ohta T,
Hashimoto N. Endovascular recanali­
zation of subclavian artery occlusions.
Neurol Med Chir (Tokyo) 2004;44:447453, discussion 454-455.
4) Schillinger M, Haumer M, Schillinger S,
Ahmadi R, Minar E. Risk stratification
for subclavian artery angioplasty: isthere an increased rate of restenosis
after stent implantation? J Endovasc
Ther 2001;8:550-557.
5) Blaisdell FW, Hall AD. Axillary-femoral

arter y bypass for lower extremit yischemia. Surgery 1963;54:563-568.
6) Sadek MM, Ravindran A, Marcuzzi
DW, Chisholm RJ.Complete occlusionof the proximal subclavian artery postCABG: presentation and treatment.
Can J Cardiol 2008;24:591-592.
7) Rogers JH, Calhoun RF 2nd. Diagnosis
and management of subclavian arterystenosis prior to coronar y arter y
bypass grafting in the current era. J
Card Surg 2007;22:20-25.

www.vsijournal.org