Covered Stent Graft for Relining of Occluded Femoro-popliteal Bypass

Abstract

Introduction: Chronic long femoro-popliteal occlusions remain a significant challenge. In case of failure of endovascular procedures bypass surgery remains an important tool for revascularization in these patients. If both endovascular and open revascularization have failed the risk of major amputation is high. Methods: A 69-year old man with an extensive medical history including cardiac arrest, myocardial infarction, CABG and stroke presented with gangrene of his left forefoot. His vascular history included an occluded left sided above-the-knee prosthetic bypass with stents across the distal anastomosis and popliteal artery, an occluded left sided below-the-knee venous bypass and multiple left groin procedures for thrombectomies and correction of a false aneurysm of the proximal anastomosis of the above-the-knee bypass. Ultrasound guided retrograde puncture of the right common femoral artery was performed. A crossover sheath was placed and the occluded bypass was engaged. Unfortunately it proved impossible to cannulate either the occluded above- or below-the-knee bypasses. An attempt to recanalize the native femoral artery also failed due to the impossibility for reentry into the true lumen. Then a retrograde puncture of the popliteal stent was performed, a guidewire was advanced and the occluded above-the-knee bypass was cannulated in a retrograde way. After picking up the wire in the common femoral artery we then proceeded in an antegrade way and predilated the occluded bypass and occluded part of the popliteal artery. The occluded bypass was then relined with two 25 cm length covered stent grafts. At the end of the procedure the second and third toe of the left foot were amputated. He was discharged 2 days later. Results: During follow-up the wound of the amputation healed and he required no additional amputations. At 6 month follow-up the surveillance duplex ultrasound revealed a 80% distal edge stenosis which was treated succesfully with angioplasty. Conclusion: This is a case report of succesfull percutaneous relining of an occluded femoropopliteal bypass using covered stent grafts in a very high-risk patient with a history of multiple vascular procedures and an inaccessible ipsilateral groin. Disclosure: Nothing to disclose