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Infected Aorto-bifemoral Graft
48
History andPhysical Examination
A 64-year-old female came to the emergency
room of the hospital with purplish discoloration
of the right big toe. She had history of hypertension, nicotine abuse (60 pack years), and ArnoldChiari malformation of the brain. All pulses of
the right lower extremity femoral, popliteal, post
tibial, and dorsalis pedis were absent, and left
femoral pulse was diminished, and no pulses
were palpable below that level. Ankle brachial
index on the right side was 0.48 and on the left
side was 0.75. She underwent abdominal aortography which showed right common iliac artery
occlusion and left external iliac artery stenosis
with good lling of both femoral arteries and
arteries below that level.
Procedure
She underwent aorto-bifemoral graft in April
2000. Proximal anastomosis was performed end
to side. She was discharged following 10 days
stay in the hospital with palpable dorsalis pedis
on both sides. At follow-up (June 2000), patient
had palpable dorsalis pedis pulses in both sides
with ankle-brachial index of 1.0 on both sides.
She presented in September 2000 with pulsatile
mass in the groin (Fig. 48.1) and generalized
weakness. CTA of the abdomen and pelvis
showed perigraft uid (mixed echogenicity)
(Fig. 48.2). Aspiration of the groin mass
revealed thin greyish uid which grew
Staphylococcus epidermidis (Fig. 48.3). She
was started on IV vancomycin and underwent
re-exploration of abdomen and groin with
removal of un- incorporated aorto-bifemoral
graft and reconstruction by aortofemoral spiral
vein graft (right) harvested from right greater
saphenous vein in October 2000. Spiral vein
graft was 25 cm long and 8 mm in diameter
(Fig.48.4). Endarterectomy of left external iliac
artery was performed into vein patch graft. Left
femoral artery had vein patch placed taken from
left accessory saphenous vein. Postoperative
MRA showed patent right aortofemoral spiral
vein graft but occluded external iliac artery
(Fig. 48.5). Postoperative course was complicated by respiratory failure and need for ventilatory support for 3 days. She developed surgical
site infection at the site of harvesting of the
greater saphenous vein and was healed by local
wound care (debridement and dressings) and
antibiotics. She was followed till 2005 with patent bypass graft with primary healing of abdominal and groin incisions and secondary healing
of the right leg incision following management
of surgical site infection at the site of harvesting
of the greater saphenous vein. She was ambulating satisfactorily and her ischemic symptoms
had resolved. Doppler arterial study performed
in 2005 showed ankle brachial index of 1.00
(right) and 0.68 (left).
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_48
203
204
Fig. 48.1 Mass in the left groin following aorto-
bifemoral graft
Fig. 48.2 CTA showing perigraft accumulation of uid
Discussion
Prosthetic graft infection following open aortic
aneurysm reconstruction (open AAA), and
aorto- bifemoral graft reconstruction though
uncommon is a devastating complication. This
complication is associated with very morbidity
and mortality associated with signicant incidence of limb loss. In high-risk patients, a low-
48 Infected Aorto-bifemoral Graft
Fig. 48.3 Aspirated uid from the left groin
grade staph infection (staph epidermidis) can be
treated conservatively with aspiration of the
uid, long-term antibiotics, and improving the
nutritional status of the patient [1]. However, in
patients with sepsis or with anastomotic aneurysms secondary to sepsis, prosthetic graft has to
be removed, and arterial reconstruction needs to
be performed unless patient has developed signicant collateral circulation (in patients with
aortoiliac occlusive disease) in the event following removal of the graft the lower extremities are
viable so that the arterial reconstruction should
be postponed. Secondary reconstruction following removal of the prosthetic aortic graft falls in
two categories: (1) extra-anatomic reconstruction with axillobifemoral graft or bilateral axillofemoral grafts, and in these patients the distal
anastomosis often must be performed in the
proximal supercial femoral arteries; or (2) inline reconstruction with either cryopreserved
graft or rifampin-soaked grafts with omental
pedicle wrapping of the graft. Axillofemoral
grafts are prone to thrombosis, and patient may
need multiple operations for viability of lower
extremities [2]. Claggett etal. have reported the
use of deep venous system (femoral and popliteal veins) after the removal of infected aortoiliac and femoral graft with 10% hospital mortality
and 10% incidence amputations (BK/AK) [3].
However, deep veins require fairly extensive dissection for harvesting and because of their thin
walls are difcult to handle with propensity for
graft dilatation. In addition, there is always a
LEFT
Discussion
205
a
Fig. 48.4 (a–c) Construction of spiral vein graft
bc
RIGHT
Fig. 48.5 Postoperative MRA showing patent aorto-right femoral spiral vein graft and occlusion of the left external
iliac artery
206
48 Infected Aorto-bifemoral Graft
possibility of development of signicant venous
edema in patients where deep veins are removed
[3]. Spiral vein grafts are a suitable alternative in
select cases because of their ease of handling
and supercial dissection necessary for removal
of the greater saphenous vein. Because of the
long suture line necessary for construction of
spiral vein graft, there is potential for new intimal hyperplasia resulting in stenosis of the graft
[4]. If patient has pseudomonas infection, autogenous venous reconstruction should not be performed as venous disruption remains a signicant
problem. Pseudomonas typically releases bacterial proteases resulting in anastomotic
disruption.
References
1. Lawrence PF. Conservative treatment of aortic graft
infection. Semin Vasc Surg. 2011;24(4):199–204.
2. Nypaver T.Primary and secondary aortoenteric stulas in endovascular and open vascular reconstruction.
In: Hans SS, Shephard AD, Weaver MR, Bove PG,
Long GW, editors. Endovascular and open vascular
reconstruction: a practical approach. Boca Raton:
CRC Press; 2018. p.257–62.
3. Claggett GP, Bowers BL, Lobez-Vigo MA, Rossi
MB.Creation of a neo-aorto-iliac system from lower
extremity deep and supercial veins. Ann Surg.
1993;218:239–48.
4. Hans SS. Spiral vein grafts as vascular conduits in
irradiated and contaminated tissue beds: a report of
ve cases and midterm follow up. Jr Am Coll Surg.
2002;195(5):732–6.
Aorto-femoral Graft: A30-Year
Follow-Up
49
History andPhysical Examination
A 40-year-old male presented with disabling
bilateral hip and thigh claudication on walking 50
yards in June of 1989. Medical comorbidities
included hypertension, hyperlipidemia, nicotine
abuse (50 pack years), and coronary artery disease requiring coronary artery bypass graft.
Bilateral femoral pulses were absent, and no
pulses were palpable below that level. Ankle brachial index on the right side was 0.56 and 0.54 on
the left. Abdominal aortogram and runoff study
revealed infrarenal aortic occlusion at the level of
inferior mesenteric artery with reconstitution of
common femoral arteries and retrograde lling of
both hypogastric arteries.
Procedure
On July 17, 1989, patient underwent aortobifemoral graft reconstruction under general
anesthesia. Aortic diameter was small as was the
diameter of femoral arteries. A 14 × 7mm knitted
Dacron graft with proximal anastomosis end to
end was reconstructed. His postoperative course
was uneventful; he was discharged on the sixth
postoperative day. Follow-up evaluation revealed
normal pulses in the feet with an ankle brachial
index of 1.0 on the right and 1.0 on the left.
In 1995, patient had recurrent symptoms of
bilateral thigh, hip, and calf claudication. Due to
diminishing of distal pulses and decrease in ankle
brachial index (right 0.82, left 0.79), patient
underwent abdominal aortography and study of
the lower extremities which showed severe stenosis at both femoral anastomoses. Revision of both
femoral anastomoses was performed under spinal
anesthesia on April 17, 1995, with Dacron patch
angioplasty with extension of the patch to the
rst 2–3cm of both supercial femoral arteries.
He had satisfactory outcome with ankle brachial
index of 1.0 on both sides with primary healing
of both groin incisions.
On November 1, 2008, patient underwent
lumbar spine surgery through anterior approach.
He developed numbness in the left foot few days
later with absent left groin graft pulse. Ankle brachial index on the left was 0.4 and 0.96 on the
right. CT angiography showed occlusion of the
left limb of the aorto-bifemoral graft. Patient
underwent thrombectomy of the left limb of the
graft through the left femoral anastomosis with
PTFE patch angioplasty with palpable pulses in
both feet with normal ankle brachial indices on
both sides.
On June 24, 2019, patient underwent follow-
up evaluation and was found to have a loud right
femoral bruit. Right posterior tibial and dorsalis
pedis pulses were no longer palpable. Ankle brachial index on the right side was 0.76 and 1.05 on
the left. Duplex imaging revealed peak systolic
velocity 495 cm/sec at the right femoral graft
anastomosis. CT angiography of the abdominal
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_49
207
208
Fig. 49.1 CTA showing patent aorto-bifemoral graft with right graft limb stenting (calcic plaque)
49 Aorto-femoral Graft: A30-Year Follow-Up
Fig. 49.2 Operative pictures showing resection of stenotic right femoral limbs and interposition of a new 8mm Dacron
graft into proximal supercial femoral artery and reimplantation of deep femoral artery into the graft
aorta and runoff study showed patent aortobifemoral graft with severe calcic stenosis
(80%) of the right aorto-femoral limb anastomo-
(Fig. 49.2). Following revision of the femoral
limb, patient had satisfactory postoperative
course with palpable pulses in both feet.
sis and with extension proximally (Fig. 49.1).
Patient underwent resection of the right femoral
limb (distal 4 cm) and interposition of a new
Discussion
8 mm Dacron limb anastomosed to the previously placed graft and distally to the proximal
supercial femoral artery. Both anastomoses
were end to end. The deep femoral artery was
reimplanted into the newly placed 8 mm limb
Aortoiliac occlusive disease in young adults (age
less than 50) is associated with poor prognosis
with virulent nature of atherosclerotic disease
process. Such patients have small diameter aorta,
References
209
femoral, and infrainguinal arteries. Reed et al.
reported 5-year patency of aorto-femoral bypass
grafting of 66±81% in patients less than 50years
of age [1]. Late graft failure after aorto-femoral
reconstruction is common in young adults as
reported by Valentine et al. [2]. This patient
stopped nicotine abuse after his aortic reconstruction in 1989 and joined an exercise program,
and he has done well in spite of secondary intervention. Assessment of status of the graft with
noninvasive testing (ankle brachial index and
duplex imaging) can be helpful in detection of
treatable stenotic lesions by either percutaneous
intervention or surgical reconstruction (patch
graft) so that primary assisted and secondary
patency can be improved.
Iatrogenic arterial injuries have been reported
following spine and orthopedic operations. In
this patient, following a lumbar spine surgery via
anterior approach, patient developed thrombosis
of the left limb most likely due to extrinsic pressure of the retractors in association with stenosis
of the left femoral anastomosis [3]. In patients
undergoing orthopedic and spine surgery in the
presence of severe vascular disease with prior
reconstruction, a close cooperation infection with
orthopedic (spine surgeon and vascular surgeon)
should be considered to avoid acute arterial
events, and if they are unavoidable, they can be
addressed in timely manner.
References
1. Reed AB, Conte MS, Donaldson M, Mannick JA,
etal. The impact of age and aortic size on the results
of aorto-bifemoral bypass grafting. J Vasc Surg.
2003;37(6):1219–25.
2. Valentine RJ, Hansen ME, Myers SI, Chervu A, etal.
The inuence of sex and aortic size in late patency
after aortofemoral graft revascularization in young
adults. J Vasc Surg. 1995;21:296–306.
3. Hans SS, Shepard AD, Reddy P, Rama K, et al.
Iatrogenic arterial injuries of spine and orthopedic operations. J Vasc Surg. 2011;53(2):
407–13.
Aorto-Bifemoral Grafting for Infrarenal Aortic Occlusion
50
Physical Examination andHistory
A 68-year-old female was seen in the clinic with
symptoms of bilateral hip, thigh and calf claudication on walking 50 feet in August 2019. She
also complained of paresthesia in both feet with
ischemic rest pain and night pain. Medical
comorbidities included hypertension and nicotine abuse (60 pack years). Bilateral femoral,
popliteal, posterior tibial, and dorsalis pedis
pulses were absent. Duplex imaging showed
biphasic wave forms in both external iliac, common femoral, and supercial femoral arteries.
Monophasic wave forms were obtained in popliteal, posterior tibial, and dorsalis pedis arteries
on both sides. Toe brachial index on the right side
was 0.26 and 0.25 on the left. CT aortography of
the abdominal aorta and runoff study showed
infrarenal aortic occlusion, 1cm below the origin
of renal arteries with reconstitution of mid common iliac arteries and small diameter external
iliac arteries. Bilateral femoral, popliteal, and
tibial arteries were patent but small in caliber
(Fig.50.1).
Procedure
On September 5, 2019, patient underwent aortobifemoral grafting with a 14 × 7 mm knitted
Dacron graft. Proximal anastomosis was per-
formed end to end and distal femoral anastomosis were end to side as long spatulated
anastomoses to proximal supercial femoral
arteries. Postoperative course was uneventful,
and patient was discharged on the seventh postoperative day with palpable posterior tibial and
dorsalis pedis pulses in both lower extremities.
Postoperative CTA showed patent aortobifemoral graft with preserved ow to both renal
arteries (Fig. 50.2). Postoperative noninvasive
arterial Doppler study showed ankle brachial
index of 1.00 on both sides (October 21, 2019).
Discussion
Progression of aorto-iliac atherosclerosis occlusive disease eventually results in aortic occlusion.
Some patients may have associated small abdominal aortic aneurysm which may present as
chronic thrombosis. Typically, chronic occlusion
of the abdominal aorta occurs at the (A) juxtarenal level, (B) inferior mesenteric artery, or (C) at
the bifurcation of the abdominal aorta into common iliac arteries. In most patients, severe claudication is the presenting symptom. There have
been few case reports or small case series with
short-term follow-up about the role of endovascular therapy in patients with aortic occlusion.
However, most surgeons recommend direct aortic reconstruction (aorto-bifemoral graft) in
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_50
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212
50 Aorto-Bifemoral Grafting for Infrarenal Aortic Occlusion
Fig. 50.1 CTA showing aortic occlusion just below the renal arteries
good-risk patients. Extra-anatomic reconstruction (axillofemoral graft) may be considered in
patients with critical limb ischemia who are not
candidates for aorto-bifemoral bypass graft procedure. Few technical points regarding aortic
reconstruction need to be mentioned. Dissection
of the pararenal aorta should be carefully performed with passing a silastic loop around the
left renal vein and mobilizing it. In most patients,
division of the left renal vein is not necessary. If
the division becomes occasionally necessary,
adrenal and gonadal veins should be preserved.
However, if one can construct proximal anastomosis without division of the left renal vein,
gonadal and adrenal vein can be divided to assist
in the cephalad mobilization of the left renal vein.
Both renal arteries and suprarenal aorta are
exposed and mobilized for a short distance, and
preferably a silastic vessel loop should be passed
near the origin of renal arteries. In order to mobilize the suprarenal aorta, adrenal arteries need to
be carefully sutured ligated with a 5-0 cardiovascular polypropylene suture, and both crus of the
diaphragm need to be divided. West etal. reported
Reference
Fig. 50.2 Postoperative CTA showing patent aorto-
bifemoral graft and preserved ow to both renal arteries
213
the results of aortorenal endarterectomy with
suprarenal clamping in 26 out of 33 patients with
juxtarenal aortic occlusion. There were 20
patients with infrarenal aortic occlusion in their
series [1]. They did not observe any signicant
impairment of renal function with suprarenal
clamping. We have treated 38 patients with aortic
occlusion (26 juxtarenal, 8 at the level of inferior
mesenteric artery, and 4 at aortic bifurcation)
with no mortality.
Reference
1. West CA, Johnson LW, Doucet L, Caldito G, etal.
A contemporary experience of open aortic reconstruction in patients with chronic atherosclerotic
occlusion of the abdominal aorta. J Vasc Surg.
2010;52:1164–72.