Aortobifemoral Graft Research Articles

Endograft Thrombosis as an Indication for Open Conversion after Endovascular Aneurysm Repair in a Multicenter Experience over 25 Years

To describe the outcomes of aortic endograft thrombosis (AET) as an indication for open conversion (OC) after endovascular aortic aneurysm repair (EVAR) in a multicenter experience. This study retrospectively analyzed cases of OC for AET following EVAR across 12 Italian Vascular Surgery centers from 1997 to September 2022. The end points were as follows: 30-day mortality and major postoperative complications. Follow-up data included survival and aortic-related complications. Sixteen patients (mean age: 68.6±8.5years) were included. The median elapsed time between EVAR and OC was 26.46months (interquartile range: 13.8-45.9). Proximal aortic cross-clamping site was supraceliac in 8 out of 16 (50%) patients, and complete removal of the stentgraft was achieved in 75% of cases (12/16 patients). Reconstructions were aorto-bi-iliac grafts in 8 cases (50%), 7 aortobifemoral bypass grafts (43.8%), and 1 aortoaortic tube graft (6.3%). All patients were symptomatic at presentation (68.7% unilateral acute limb ischemia, 25% bilateral acute limb ischemia, 1 patient had chronic severe claudication). Thirty-day mortality was 12.5% (2/16 patients). The overall morbidity rate was 43.8% (7 of 16 patients). No specific risk factors for early mortality were found. The overall estimated survival rate was 80.4% at 1year, 62.5% at 2years, and 41.7% at 3years. OC for AET is typically reserved for complex cases that are not amenable to endovascular solutions. The frequent need for suprarenal clamping and complete endograft removal seems to be associated with high short-term mortality.

Outcomes of Surgical Revascularization in Trans-Atlantic Society Consensus (TASC II) Type C & D Aortoiliac Occlusive Disease

Introduction: Aortoiliac occlusive disease is a disabling illness. This study was conducted on the patients of Trans-Atlantic Society Consensus (TASC II) type C & D aortoiliac occlusive disease. Open surgical revascularization in the form of aortofemoral and aorto-bifemoral bypass grafting was done and the demography of patients of AIOD, the efficacy and outcomes of open surgical bypass in the patients of TASC II, type C & D aortoiliac occlusive disease was studied. Methods: in this study, total of 52 patients were revascularized and were observed for various parameters thoroughly throughout the course of diagnosis, preoperative, intra-operative and postoperative phase and until 6 months of follow-up. The demographics, clinical characteristics of the patients, co-morbid conditions, type of aorto-iliac occlusive disease (AIOD), the surgical procedure conducted and the outcomes of surgery in terms of limb salvageability, healing of ulcer, relief of claudication and graft patency were observed. Results: 50 (96.16%) out of 52 patients were males, with a mean age of presentation 55.01 + 8.58 years. 47 (90.38%) were smokers, 43 (82.69%) had hypertension, 17 (32.69%) had diabetes, 11 (21.15%) had CAD, 12 (23.07%) had COPD, 22 (42.30%) had type C and 30 (57.69%) patients had type D disease. Aorto-bifemoral bypass grafting was done in 42 (80.76%) . Mean duration of ICU stay was 1.9 days, 6 (11.53%) patients expired postoperatively. The graft patency and limb salvageability were 100% and 96.15% respectively during 1st, 3rd and 6th months of follow-up with complete healing of ulcers in 21 (91.30%) patients by the end of 6 months. Conclusion: Surgical revascularization is an important, high yielding, life changing intervention which serves as a boon for the patients with extensive or advanced aortoiliac disease. The surgery has excellent outcomes in terms of graft patency as well as limb salvageability.

Open revascularization for chronic mesenteric ischemia in the endovascular era: a quaternary-center experience and management algorithm.

Chronic mesenteric ischemia (CMI) is a debilitating disease with a heavy burden on quality of life. Stenting of the superior mesenteric artery (SMA) is the first option for treatment, but there is a lack of consensus defining precise indications for open revascularization (OR). To describe a series of 4 patients with CMI treated with OR and to present an algorithm for the management of this condition. Three patients presented with typical intestinal angina and weight loss. One patient was subjected to prophylactic revascularization during open abdominal aortic aneurysm repair. Surgical techniques included: 1) Bypass from the infrarenal aorta to the SMA; 2) Bypass from an aorto-bifemoral polyester graft to the SMA; 3) Bypass from the right iliac artery to the SMA; 4) Bypass from the right graft limb of an aorto-biiliac polyester graft to the median colic artery at Riolan's arcade. PTFE was used in all surgeries. All grafts were placed in a retrograde configuration, tunneled under the left renal vein, making a smooth C-loop. A treatment algorithm was constructed based on the institution's experience and a review of recent literature. All patients demonstrated resolution of symptoms and recovery of body weight. All grafts are patent after mean follow-up of two years. Open revascularization using the C-loop configuration is a valuable technique for CMI and may be considered in selected cases. The algorithm constructed may help decision planning in other quaternary centers.

Neointimal dissection – a rare complication to endovascular treatment in grafts and stent grafts

BackgroundNeointima formation and hyperplasia in vascular grafts may lead to graft complications threatening the patency of the vascular reconstruction. A rare complication to endovascular treatment of grafts and stent grafts is dissection inside the graft.Case reportWe present here a case of a 69-year-old female with acute occlusion of the limb of an aorto-bifemoral graft for the third time, 16 years after the primary operation. As at the first two occasions, catheter-based intra-arterial thrombolysis was performed, but with residual stenosis inside the graft. During stent placement, dissection of the neointima or fibrin sheet occluded the inflow to the stent. The complication was resolved with placement of kissing stents.ConclusionsIt is important to recognize iatrogenic neointima dissection inside graft and stent grafts, as continued thrombolysis will not solve this, but increase the risk of hemorrhagic complications.

Digestive hemorrhage and fever as a result of a double secondary aortoenteric fistula following the repair of a juxtarenal abdominal aortic aneurysm and an infection of the aortobifemoral bypass graft: a case report.

During aortoc reconstructive surgery, the patient may present with a variety of unusual complaints, including fever and GI bleeding. These symptoms are indicative of problems, including the development of an aortoentric fistula, particularly when there is a double secondary fistula. The patient was admitted to the hospital due to hematemesis, melena, and high-grade fever after undergoing synthetic grafting aortobifemoral bypass (anatomical reconstruction) and partial resection of the juxtarenal abdominal aortic aneurysm. Pus discharge and a double aortoenteric fistula in unusual sites such as the second-third portion of the duodenum and caecum are visible in upper GI endoscopy and computed tomography angiography. The patient underwent a two-stage open surgery, the first stage involving aortic limb graft exclusion and extra anatomical reconstruction, and the second stage involving graft removal, fistula management, and bowel repair. Then the patient spent a few days in the surgical intensive care unit before being discharged. Primary and secondary AEF are the two categories of AEF. In patients who underwent aortic reconstruction surgery, the frequency of secondary AEF ranges from 0.36 to 1.6%. Due to the 8:1 injury ratio in the secondery AEF, men suffer more injuries than women.There are two types of fistula depending on whether or not the suture line is involved. The first form is graft enteric erosion, which excludes the suture line, while the second type is entric graft fistula, where the suture line is included. Most common site fistula is third and fourth part of duodenum and least common site is fistula formation in large bowel. An uncommon complication is double secondary AEF following aortic reconstruction surgery. Since one of the most significant presentations an AEF patient can present with is major GI bleeding and sepsis, A delay in seeking immediate medical treatment could result in the patient's death. It should be emphasized that one of the mechanisms for AEF formation and a frequent cause of sepsis in patients is recurrent aortic graft infection following aortic reconstruction surgery.

Use of Omniflow® II Biosynthetic Graft for the Treatment of Vascular Graft and Endograft Infections

Vascular graft/endograft infection is a rare but life-threatening complication of cardiovascular surgery and remains a surgical challenge. Several different graft materials are available for the treatment of vascular graft/endograft infection, each having its own advantages and disadvantages. Biosynthetic vascular grafts have shown low reinfection rates and could be a potential second best after autologous veins in the treatment of vascular graft/endograft infection. Therefore, the aim of our study was to evaluate the efficacy and morbidity of Omniflow® II for the treatment of vascular graft/endograft infection. A multicenter retrospective cohort study was performed to evaluate the use of Omniflow® II in the abdominal and peripheral region to treat vascular graft/endograft infection between January 2014 and December 2021. Primary outcome was recurrent vascular graft infection. Secondary outcomes included primary patency, primary assisted patency, secondary patency, all-cause mortality, and major amputation. Fifty-two patients were included with a median follow-up duration of 26.5 (10.8-54.8) months. Nine (17%) grafts were implanted in intracavitary position and 43 (83%) in peripheral position. Most grafts were used as femoral interposition (n=12, 23%), femoro-femoral crossover (n=10, 19%), femoro-popliteal (n=8, 15%), and aorto-bifemoral (n=8, 15%) graft. Fifteen (29%) grafts were implanted extra-anatomically and 37 (71%) in situ. Eight patients (15%) presented with reinfection during follow-up, most of these patients received an aorto-bifemoral graft (n=3, 38%). Intracavitary vascular grafting had a 33% (n=3) reinfection rate and peripheral grafting 12% (n=5; p=0.025). The estimated primary patencies at 1, 2, and 3 years were 75%, 72%, and 72% for peripherally located grafts and 58% (at all timepoints) for intracavitary grafts (p=0.815). Secondary patencies at 1, 2, and 3 years were 77% (at all timepoints) for peripherally located prostheses and 75% (at all timepoints) for intracavitary prostheses (p=0.731). A significantly higher mortality during follow-up was observed in patients who received a intracavitary graft compared to patients with a peripheral graft (p=0.003). This study highlights the efficacy and safety of the Omniflow® II biosynthetic prosthesis for the treatment of vascular graft/endograft infection, in absence of suitable venous material, with acceptable reinfection, patency, and freedom of amputation prevalences, especially in replacing peripheral vascular graft/endograft infection. However, a control group with either venous reconstruction or another alternative graft is needed to make firmer conclusions.

Bilateral rectus femoris myocutaneous flaps to salvage exposed axillo-bifemoral graft of bilateral groins

Exposed prosthetic grafts are a challenge to vascular specialists. Groin dissections in vascular surgery can lead to local tissue breakdown, especially in patients who have multiple comorbidities and poor nutritional status. In this report, we describe a patient with exposed prosthetic bypass conduits in the groin region which was successfully covered with bilateral myocutaneous flaps. A 75-year-old Sri Lankan male with diabetes, hypertension and Parkinson's disease presented with bilateral non-healing wound and rest pain for 3 months. Since his premorbid status precluded the aortic cross-clamping and aorto-bifemoral graft, a decision was made to perform a right axillo-bifemoral bypass using a prosthetic graft. Re-operation was required for graft thrombectomy on the same day of surgery. His post-operative period was complicated with lymph leak and surgical site infection of bilateral groin wounds which ultimately led to exposed prosthetic graft which was fortunately patent. After optimizing his nutritional status and comorbidities, he underwent bilateral rectus femoris myocutaneous flaps to cover the soft-tissue defect over the exposed prosthetic grafts. His initial post-operative period was unremarkable except for a small area of skin breakdown. Myocutaneous flaps are preferred as they are more resilient to breakdown compared to facio-cutaneous flaps, especially in a patient with compromised blood supply. The type of loco-regional flap should be carefully selected in an individualized manner depending on the regional vascularity. The rectus femoris flap is a suitable option in terms of ease of surgical technique and durability. Comorbidities and local factors should be optimized prior to definitive reconstruction to maximize the chances for optimal wound healing.

Hybrid Revascularization of Infrarenal Aortic Occlusion due to Thrombophilia: A Case Report

Background: Infrarenal abdominal aortic occlusive disease has traditionally been treated with aortic endarterectomy, aortobifemoral bypass grafting, or both; however, it has also been associated with up to a 3.3% to 4.6% perioperative mortality rate and an 8.3% to 13.1% major early complication rate. European Guidelines on Peripheral Artery Diseases published in 2017 support a hybrid approach. Thrombophilia is a commonly overlooked cause of peripheral arterial disease (PAD) in younger patients. Thrombophilia is reported to lead to an increased incidence of graft failure and multiple revascularization procedures. This presented a rare case highlighting the surgical approach to complex aortoiliac occlusion due to thrombophilia with subsequent lower limb ischemia and the multi-disciplinary input needed in this vulnerable patient cohort. Case presentation: Herein, we present a case of an acute distal aortic occlusion and failed revascularization with a history of thrombophilia and previous left leg below-knee-amputation (BKA) due to acute limb ischemia. He had a background of recently withholding warfarin for a ureteric stent insertion for renal calculus. The diagnosis of our case depended on CT and angiography, where they confirmed an occluded infrarenal aorta with bilaterally occluded common and external iliac arteries. Our case underwent hybrid revascularisation under bivalirudin cover. An open thrombectomy of the right common femoral artery (CFA) and PFA was performed. A left brachial artery cutdown was performed, and a catheter was placed in the suprarenal abdominal aorta. The right iliac artery occlusion was crossed from the left brachial access with a Command 0.018 wire supported by a Van Schie II catheter with a through-and-through wire able to be retrieved from the open right CFA. The proximal IMA was stented with a 6 x 80mm Absolute Pro-self-expanding stent, deployed in a kissing-stent fashion with a 10 x 100mm Absolute Pro stent in the distal aorta. Overlapping self-expanding stents were deployed from the distal aorta to the right external iliac. Six weeks after the procedures, computed tomography/angiography confirmed the excellent radiologic results. Conclusion: This rare case highlights the catastrophic outcomes that can happen when anticoagulation is withheld in thrombophilic patients. It exhibits the Role of a hybrid open and endovascular approach in complex occlusive aortoiliac disease and the critical importance of early multi-disciplinary involvement in critically unwell patients.

P11.14: The Use of Ex Vivo Normothermic Perfusion to ‘Pause’ Cold Ischaemic Time to Allow for Third Recipient to Be Selected And Undergo Kidney Transplant

Introduction: On arrival to the hospital on receipt of a transplant offer, recipients can be found to be unfit precluding transplantation. In this instance, the graft is offered back to NHS Blood and Transplant. Grafts often, however, remain locally to reduce cold ischaemic time inherent in further relocation. When another suitable recipient is not found, and cold ischaemic time (CIT) increases to undesirable levels, grafts can unfortunately be deemed unusable. Case Presentation: Herein we describe a case in which ex vivo normothermic perfusion (EVNP) facilitated the admittance of a third potential recipient for a 66yo DCDkidney. The first two allocated recipients who were deemed unfit: the first recipient was found to have an infected lower limb ulcer; the second patient was found to have raised inflammatory markers in the context of an aorto-bifemoral graft. At the time a third recipient (55yo, pre-dialysis) was selected the CIT on the graft was 19 hours. The patient was admitted to the ward and EVNP was used to ‘pause’/limit CIT in order for the patient to be prepared, assessed and consented for transplantation. Outcome: EVNP assessment score = 1 (one hour perfusion duration), with excellent perfusion demonstrated and good urine output (>100ml); total CIT was 23 hours at in situ reperfusion. The patient was successfully transplanted and the graft achieved primary function with a creatinine of 166µmol at time of discharge. At 5 months the creatinine is 151µmol and eGFR 32mls/min/m2. Discussion: Without EVNP this graft would have likely been discarded. Cold ischaemic time was effectively paused by the perfusion technology allowing the graft to be assessed and utilised, and ultimately prevented graft discard. EVNP offers a technique to improve organ utilisation.

Sigmoid Perforation Caused by an Aortobifemoral Vascular Graft

An 83-year-old man underwent aortobifemoral bypass graft surgery for an abdominal aortic aneurysm. Ten days after his discharge he was readmitted with fever and signs of infection. A computed tomography scan revealed sigmoid diverticulosis, a perigraft collection containing gas bubbles near the aortic anastomosis and smaller localized collections near the iliac vessels. He was started on antibiotics but a day later he developed hematochezia. A sigmoidoscopy was performed, which revealed a prosthetic vascular graft penetrating “through and through” the sigmoid colon (Figures A–C) with active bleeding at 1 site of the perforation (Figure D, arrow). The patient underwent a partial left colectomy of the involved sigmoid with a primary anastomosis, and explantation and replacement of the aortobifemoral graft. Postoperatively, he was transferred to the intensive care unit but unfortunately died 10 days later because of septic complications.

A Retrospective Medical History Based on Cadaveric Dissection

The purpose of this case study was to form a well‐researched evaluation of the potential procedures and disease states of a donor from Western Michigan University during a cadaveric dissection program at Central Michigan University College of Medicine. The donor was an 83‐year‐old male with a primary cause of death of acute respiratory failure secondary to chronic obstructive pulmonary disease (COPD). Over 6 weeks, using a systematic dissection approach, we identified various surgical remnants and abnormalities within our donor’s body. Based on the surgical interventions and evidence of pathology, we formulated a retrospective diagnosis of the donor. We hypothesized the following procedures and disease states were present: bilateral percutaneous femoral‐popliteal bypass with a reverse saphenous vein anastomosis of the left leg, left carotid endarterectomy, and femorofemoral bypass with an aortobifemoral bypass graft, all of which were thought to be secondary to vascular disease, tobacco use, diabetes and hypertension, with the additional presence of knee arthroplasty and autosomal dominant polycystic kidney disease. At the end of the program, we compared our predictions to the donor's medical history, provided to us by Western Michigan University. Our methods included researching the surgical procedures as we discovered them and using these procedures to predict underlying disease states of our donor. Utilizing resources from PubMed and our program directors, we were able to narrow down the bilateral percutaneous femoral‐popliteal bypass, left carotid endarterectomy, and femorofemoral bypass with an aortobifemoral bypass graft. These vascular surgical interventions led us to believe our donor experienced symptoms of claudication due to underlying vascular disease including peripheral artery disease (PAD), aortoiliac occlusive disease (AIOD), and carotid artery disease (CAD). Common risk factors and causes for vascular disease include male sex, smoking, diabetes mellitus and hypertension; these are risk factors present in our donor that we later confirmed. Additionally, due to the age of our donor and the carotid endarterectomy, we predicted our donor likely experienced a cerebrovascular accident (CVA) during his lifetime. Our results, based on the provided medical history, revealed that we correctly predicted our donor's underlying vascular disease, our donor's risk factors of smoking, diabetes and hypertension, and our donor's surgical interventions including bilateral percutaneous femoral‐popliteal bypass, femorofemoral bypass with an aortobifemoral bypass graft, knee arthroplasty and left carotid endarterectomy. Additional procedures and disease states that we did not explicitly predict include spinal stenosis surgery, bilateral cataract extraction, coronary stent placement, deformity of the proximal femoral shaft, and myocardial infarction.

Idiopathic Aortic Thrombosis and Thromboembolism in Young Women

Introduction: Spontaneous aortic thrombosis causing distal embolization and acute limb ischemia is an ominous medical condition with a poor prognosis. Herein are reported the clinical courses of two women who presented with severe lower extremity ischemia caused by distal embolization of spontaneous aortic thrombus without obvious antecedent arterial disease. This unusual diagnosis should be expected in patients presenting with persistent lower extremity pain and numbness even in the absence of overt physical findings. Case 1: A 42 year-old woman with mild hyperlipidemia complained of left leg numbness and weakness. She was treated with analgesia but her symptoms worsened. Lower extremity ultrasound revealed a significant infra-inguinal perfusion defect; computed tomography revealed mural thrombus in a normal aorta along with extensive thrombotic occlusion of the left popliteal and tibial arteries. Attempts at endovascular recanalization were unsuccessful; the patient underwent successful left popliteal-to-plantar artery bypass with autologous vein. Case 2: A 57 year-old woman without medical history presented to a local Emergency Room with a five-day history of numbness in the right lower extremity. Computed tomographic angiography revealed complete infrarenal aortic occlusion in a 3 cm diameter area of mild aortic ectasia along with iliac and distal right infrainguinal thromboembolism. The patient was treated with aortobifemoral bypass grafting with right leg fasciotomy, which restored perfusion and function. Conclusion: Spontaneous aortic thrombosis causing distal embolization and acute limb ischemia is an ominous medical condition with a poor prognosis. Episodes of embolization may be intermittent and asymptomatic such that, when symptoms finally occur, the distal thrombus is often chronic and inaccessible. The diagnosis should be suspected in patients with unexplained lower extremity symptoms and pulse deficits; it can be readily established with computed tomography.

Abdominal Aorta Anastomotic False Aneurysm Leading to Double Focal Vertebral Body Erosion.

Anastomotic aortic false aneurysm with consequent erosion of vertebral bodies is a very rare event that needs prompt treatment. We report the case of a 71-year-old man with an aortobifemoral graft that was complicated by an uninfected proximal anastomotic pseudoaneurysm with double focal vertebral body erosion.

Should the Proximal Part of a Bifurcated Aortic Graft be Kept as Short as Possible? A Computational Study Elucidates on Aortic Graft Hemodynamics for Various Main Body Lengths

It is accepted that surgically placed bifurcated aortic grafts should be shaped as a short proximal main tube with two long distal limbs. We aim to investigate the hemodynamic effect of different main body lengths in bifurcated aortic grafts using 3D computer models. Five different idealized models are generated to represent an aorto-bifemoral graft. Distance from renal to femoral arteries is set at 25cm and distance between the femoral arteries is set at 14cm. Values of the main body length taken into account to build the idealized models are 3cm, 6cm, 9cm, 12cm and 15cm. Blood flow resistance, Time Average Wall Shear Stress (TAWSS), Oscillatory Shear Index (OSI) and Relative Residence Time (RRT) are estimated using the constructed 3D models. The total resistance decreased monotonically by as far as 40% as the main body length increased. Appropriate hemodynamic simulations show a maximum TAWSS decrease and a corresponding maximum OSI and RRT increase with elongated main body configurations, indicating a hemodynamic benefit of the "Short" main body configuration. Nevertheless, the differences in these later variables are small, affecting a limited portion of the geometries. A long main body of a bifurcated aortic graft results in significantly reduced total resistance in idealized models designed to represent an aorto-bifemoral surgical graft, while the differences observed in TAWSS, OSI and RRT between models are small.

Fatal Aortoduodenal Fistula Caused by a Ruptured Abdominal Aortic Aneurysm - a Case Report

ABSTRACT Introduction: Ruptured abdominal aortic aneurysm (AAA) has a high mortality, even when the patients reach the hospital in time and the intervention is expeditious. Case presentation: We present the case of a 66-year-old male patient, with a known history of AAA, presenting to the emergency room in a state of hypovolemic shock due to massive bleeding in the upper and lower gastrointestinal tract and acute abdominal pain, which presented an abrupt onset one hour before presentation. The computed tomography angiography identified an aortoduodenal fistula with a trajectory toward the D3 segment of the duodenum, as well as a common iliac artery occlusion and extensive atherosclerotic stigmas. The patient was rushed to the operation room where he was resuscitated with intravenous fluids, two units of packed red blood cells, and hemostatic agents. The bleeding was stopped by clamping the aorta above the aneurysm. The duodenum was sutured, and the aorta was reconstructed with an aortobifemoral graft. Unfortunately, even though intensive care procedures continued for a few hours after surgery, all therapeutic efforts failed and the patient had succumbed.

Staphylococcus Lugdunensis Vascular Aortic Graft infection: A report of first case

Staphylococcus lugdunensis has been reported to cause a wide variety of serious infections to include infective endocarditis, peritonitis and osteomyelitis. This report describes our patient who developed aorto bifemoral graft infection with Staphylococcus lugdunensis not previously described in the literature. Bangladesh Crit Care J September 2021; 9 (2): 116-117

S2250 Polymicrobial Bacteremia With Insidious Gastrointestinal Blood Loss: A Rare Clinical and Endoscopic Manifestation of Secondary Aortoenteric Fistula

Introduction: Secondary aortoenteric fistula (AEF) is a rare (0.3-1%) but life-threatening complication after aortic reconstructive surgery with graft. Case Description/Methods: A 68-year-old man with a significant past medical history of type 2 diabetes, COPD, coronary artery disease status post cardiac stent, and aortobifemoral bypass graft performed 10 years ago, was hospitalized with presentations of shortness of breath, chills but no fever, and progressive anemia for the past 14 months. ECG and trend of cardiac enzymes were negative. Chest CT imaging revealed no evidence of pulmonary embolism. He was hemodynamically stable. The pertinent initial labs showed a hemoglobin of 7.5 g/dl (6 months earlier 8.1 g/dl, 14 months earlier 11.9 g/dl) and elevated inflammatory markers (leukocytes 9.8/nL, CRP 85.3 mg/dL) with transient lactic acidosis. Blood cultures on admission showed positive of a variety of microorganisms (Streptococcus sanguis, Lactobacillus paracasei, Candida lusitaniae). Patient reported one episode of red blood per rectum and melena between 1 to 3 weeks before admission. An esophagogastroduodenoscopy (EGD) revealed a large excavated and diverticular-like lesion, without bleeding, in the third part of the duodenum (Figure 1). The initial blood cultures growth and the subsequent blood cultures growth of another microorganism (Enterobacter Cloacae) were considered to have a likely GI source. A PET-CT scan result showed hypermetabolism signal associated with the proximal end of the aortoiliac graft, concerning for infection of the graft itself (Figure 2). The EGD finding was consistent with a secondary aorto-enteric fistula formed by infected aortic graft eroding into duodenum and served as the source of recurrent polymicrobial bacteremia. The patient subsequently underwent explantation of the infected aortobifemoral bypass graft (old graft with fistula to the duodenum), reconstruction with cryopreserved aortoiliac allograft, and resection of small intestine with anastomosis closure of duodenotomy. The removed aortic graft cultures grew a variety of microorganism (Enterococcus faecalis, Enterobacter Cloacae, Candida lusitaniae). The patient was discharged 10 days after the operation and when examined 2 months later he was doing well. Discussion: Secondary AEF should be suspected in patients presenting with unclear source of bacteremia with or without GI bleeding and a history of aortic repair. Clinical suspicion is the most important factor contributing to the right diagnosis.Figure 1.: Esophagogastroduodenoscopy suggested the secondary aortoenteric fistula in the third part of duodenum.Figure 2.: A PET-CT scan showed increased hypermetabolism signal associated with the proximal end of the aortoiliac graft (white arrow), concerning for infection of the graft itself.

A giant anastomotic late pseudoaneurysm of aortobifemoral graft in the groin: Treatment and management of complications

A giant anastomotic late pseudoaneurysm of aortobifemoral graft in the groin: Treatment and management of complications

Infection of aortobifemoral bypass graft implanted 20 years ago proved by labeled leukocytes SPECT-CT

Infection of aortobifemoral bypass graft implanted 20 years ago proved by labeled leukocytes SPECT-CT

Exteriorized thrombosed axillo-bifemoral graft with empyema post coronary artery bypass grafting with axillo-femoral bypass

Following its introduction in 1963, axillofemoral bypass grafts have improved, with patency rates comparable to aortofemoral and aortobifemoral grafts. Graft infection and thrombosis may worsen axillofemoral bypasses, rendering subsequent management challenging in surgically high-risk patients.We present an unusual case of anexteriorized thrombosed axillofemoral graft infection in a 65 years’ male who recently underwent coronary artery bypass grafting with axillobifemoral grafting, presented in sepsis with empyema of chest and infected graft was exteriorised. He developed foul smelling discharge and fever. The patient was treated with antibiotics and infected graft was removed. The image highlights the social stigma and debilitating complications caused by these grafts in developing countries. Keywords: Exteriorized Axillobifemoral graft, Coronary artery bypass surgery.