2040 Neurologic Improvement Following Revision of Vascular Graft Remnants in the Upper Extremity

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INTRODUCTION: Rates of extracorporeal membrane oxygenation (ECMO) have increased over the years, and arteriovenous fistulas provide vascular access commonly for hemodialysis patients. Upon removal of cannulas or grafts, is common practice to leave behind a graft remnant, or stump, to avoid damaging the parent blood vessel. METHODS: We review clinical signs and symptoms suggestive of nerve compression following primary graft removal and a multidisciplinary surgical strategy for treatment. Both cases provided consent for publication. RESULTS: A 69-year-old female with a history of Takotsubo cardiomyopathy was admitted to the hospital post-ECMO decannulation of the right axillary artery. The patient reported significant weakness and pain in the right upper extremity. On exam six months after surgery, the patient had no intrinsic hand movement and minimal grip strength with a complete wrist drop. A 49-year-old female with a history of end-stage renal disease on hemodialysis, diabetes mellitus type 1, and hypertrophic cardiomyopathy presented with left hand weakness and pain following upper arm arteriovenous graft partial removal due to concern for infection. On exam one year after graft removal, the patient had weakness primarily in median nerve innervated muscles with minimal grip strength. She had moderate weakness of hand intrinsic muscles. In both cases, removal of the remnant graft, patch arteriotomy, and nerve decompression resulted in significant neurologic improvement. CONCLUSIONS: Neural compression by residual vascular grafts after ECMO or hemodialysis procedures can result in neurological deficits that may significantly improve by removal of the remnant graft and subsequent nerve decompression. A multidisciplinary approach can be taken to surgical treatment for safe and effective reversal of neurologic symptoms.

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