Atraumatic Bi-femoral Axillary Bypass Graft Non-anastomotic Disruption With Pseudoaneurysm Formation Detected by Doppler Ultrasound

Abstract

Bi-femoral axillary bypass graft placement is a well-known and typically safe procedure. It is generally indicated for patients with advanced peripheral vascular disease, aortoiliac occlusive disease, or infectious artery disease. In rare cases, the graft can be fractured or dislodged after placement, though most often, this occurs almost exclusively at the anastomosis site, secondary to blunt trauma. Using ultrasonic imaging is a reliable method of detecting these fractures. We present a case of a bi-femoral axillary bypass graft fracture in a 68-year-old male with the development of a pseudoaneurysm in the right lateral abdominal wall. The patient reported spontaneous development of a "strange" sensation in his right lower abdomen and a "painful lump" upon waking. Physical examination showed a small right lower quadrant outpouching which was pulsatile on palpation. The initial workup included a bedside ultrasound which showed a fractured graft with the fluid collection and a Doppler signal. Vascular surgery was immediately consulted for evaluation, and the patient was taken to the operating room for emergent surgical repair. CT angiography confirmed a successful operation in which an 8 mm graft was placed to anastomose the original bypass graft fracture site. The patient remained stable postoperatively and was discharged without further complications. This report highlights the importance of using ultrasonography for the immediate identification of potential graft complications to prevent serious complications and expedite definitive management.

Keywords: atraumatic; graft complication; non-anastomotic; pseudoaneurysm; vascular graft.

Figure 1. Sagittal and sonographic image of the vessel with the graft fracture.

Figure 2. POCUS Doppler showing pulsatile flow in abdominal mass.

POCUS: point-of-care ultrasound

Figure 3. CT angiogram showing graft fracture with pseudoaneurysm and active extravasation.

The red outline indicates the boundaries of the pseudoaneurysm.