Endovascular Surgery: An Integral Component of Treatment for Infected Aortobifemoral Bypass Grafts

Abstract

Endovascular reconstruction may be used alone or in combination with standard vascular techniques in dealing with infected grafts. This case report concerns a 53-year-old man who presented with sepsis 3 years after undergoing aortobifemoral bypass. The bypass was performed after two failed angioplasties. The proximal anastomosis was performed in an end-to-side fashion. One year prior to presenting with sepsis, the patient developed acute myelogenous leukemia and underwent chemotherapy with subsequent remission. Eight months later, the patient developed low-grade fever and chills and was treated for pulmonary infection. Persistent mild symptoms prompted a Gallium scan that raised the possibility of an infected aortic graft. Subsequent computed tomography (CT) scan, magnetic resonance imaging (MRI), and Indium scan were normal. Admission was prompted when he presented with biopsy-documented septic emboli to the right leg. Repeat CT scan suggested aortic graft infection localized to the proximal graft segment. Operative repair included a right common femoral endarterectomy, a right iliac balloon angioplasty, insertion of a right iliac Wallstent, and a right-to-left femoral-femoral polytetrafluoroethylene (PTFE) bypass. The well-incorporated femoral graft limbs were detached and the groins closed. Abdominal exploration identified a jejunal-aortic graft erosion with a localized abscess. The infected graft was removed and the aortotomy repaired with a patch fashioned from an endarterectomized portion of the occluded left external iliac artery. Small bowel resection with primary anastomosis and omental flap completed the operation. Four days postoperatively, the Wallstent required further expansion with an open balloon angioplasty to establish palpable pedal pulses. The patient recovered uneventfully and received a total of 6 weeks of broad-spectrum intravenous antibiotics. This case illustrates the use of adjunctive endovascular techniques in handling difficult vascular graft infections and stresses their importance as an integral component of the vascular surgeon's armamentarium.