Distal Graft Anastomosis Research Articles

Abstract 11589: Late Complications After Interrupted Aortic Arch Repair

Description of Case: A 38-year-old man with known type B interrupted aortic arch (IAA), bicuspid aortic valve, and a complex surgical history (including IAA repair with an ascending-descending aortic conduit, later conduit graft revision, and left pulmonary artery [LPA] stent) presented after many years of loss to follow-up and was found to have hypertensive urgency. Echocardiogram showed turbulent flow in the proximal descending aorta concerning for arch obstruction. Computed tomography angiography (CTA) (Fig. 1 A–C) showed: narrowed proximal graft anastomosis, dilation of the aortic root and ascending aorta, a large pseudoaneurysm arising from the distal graft anastomosis, and LPA stenosis due to compression from the descending aorta. Following improved hypertension, the patient underwent placement of a left carotid-subclavian bypass graft followed by thoracic endovascular aortic repair (TEVAR) with an endograft positioned across the distal aortic jump graft suture line. CTA one month postoperatively (Fig. 1 D–F) confirmed exclusion of the pseudoaneurysm. Discussion: Type B IAA is considered the most common subtype of IAA among cases diagnosed in infancy, though recent data regarding IAA epidemiology are scarce. IAA is associated with other congenital abnormalities, such as ventricular septal defect (VSD), LV outflow tract abnormalities, and 22q11 deletion syndrome. Additional surgical aortic arch procedures in these patients are not uncommon, perhaps especially among patients who required reintervention for LV outflow tract obstruction. While most studies examining long-term outcomes after IAA repair have not commented specifically on late risk of aneurysm or pseudoaneurysm, such findings have been described in the literature. Additionally, use of polytetrafluoroethylene material in arch repair and arch repair by a method other than direct anastomosis—such as were seen in our patient—have been observed to be risk factors for late reintervention.

Surgical bypass to the left subclavian artery: an extra-anatomical transpleural approach

A distal anastomosis in zone 3 is technically demanding during the frozen elephant trunk procedure. Proximalization of the distal anastomosis to zone 2 with subsequent revascularization of the left subclavian artery is an attractive alternative. This video tutorial describes the technique of an extra-anatomical bypass from the aortic prosthesis to the infraclavicular left subclavian (axillary) artery in arch replacement with the distal aortic graft anastomosis in zone 2.

A Rare Location of Pseudoaneurysm in Subaortic Ring after Bentall Operation

Bentall operation is considered a gold standard of surgery in the treatment of ascending aortic aneurysm. This operation with en-bloc resection of ascending aorta and aortic valve requires aortic valve with two coronary bottoms re-replacements in a prepared composite graft. The four important locations for the pseudoaneurysm include proximal and distal composite graft anastomosis and two coronary bottom sites. However, many complications have been reported with this technique but the most serious complication associated with this operation is defined as pseudoaneurysm. We report an exceedingly rare case of subaortic ring pseudoaneurysm in retro composite graft position enclosed by infected surgical that was used to control bleeding in this location. Dehiscence occurred between the aortic ring and the underlying left ventricular muscle. The aortic ring was separated from the underlying muscle by the high tensile strength of sewing ring sutures. The pseudoaneurysm compressing the left atrium without communicating with any cardiac chamber and presenting with high fever (39°C), chills, a few months after Bentall operation. The patient underwent redo operation and repair of the dehiscence's site. The 6-month follow-up revealed no recurrence of a pseudoaneurysm. The uniqueness of this case report is related to the site of pseudoaneurysm between the aortic ring and underlying left ventricular muscle that have not been reported in the medical literature so far.

Dexmedetomidine as an Anaesthetic Adjunct in Patients Undergoing Elective Off-Pump Coronary Artery Bypass Graft Surgery

Background: The aim of the present study was to study the hemodynamic profile of dexmedetomidine during induction and distal anastomosis of coronary arteries in patients undergoing OPCAB in comparison to the institutional practice of using midazolam. Methods: In Group I, (n=25) patients were anaesthetised using fentanyl, pancuronium bromide, Isoflurane and midazolam. Group II (n=25) patients received a loading dose of dexmedetomidine infusion (1µg/Kg) over 10 minutes followed by an infusion of dexmedetomidine at the rate of 0.6 µg/Kg/hour, along with fentanyl, Pancuronium bromide and isoflurane. Heart rate (HR) mean arterial pressure (MAP), pulmonary artery (PA) catheter derived data and BIS were recorded at baseline, at 1 and 3 minutes after induction, at 1, 3 and 5 minutes after intubation, and at 5 and 30 minutes after protamine administration. MAP and HR were recorded every 10 min during the operation, except during distal anastomosis of the coronary arteries when it was recorded every 5 minutes after application of the Octopus tissue stabilising system. Results: The intubation response by way of increase in HR was much less in group II and stabilized by 5 min after intubation. The accompanying hypotension at 1 minute after induction was more in group II, but it was clinically acceptable (81.68±21.74 mm Hg). During distal graft anastomoses HR was in the range of 68 beats/min to 85 beats/min in group II vs. 85 beats/min to 100 beats/min in Group I. The MAP was lower in this group during the distal anastomosis, but it was within clinically acceptable range (> 65 mm Hg). Conclusion: Dexmedetomidine is a viable option as an anaesthetic adjunct in a loading dose of 1µg/Kg followed by an infusion of 0.6 µg/Kg. Future studies will be necessary to show if this provides any outcome benefits.

Modification of an Old Technique to Correct Kinking of Tubular Graft Interposed to Reconstruct Ascending Aorta

Cardiac surgeons are occasionally faced with ascending aorta graft kinking following ascending aorta replacement. Although it may be difficult to precisely assess the correct length of the graft during aortic clamping, while performing proximal and distal graft anastomoses on an empty heart, the major reason for graft kinking is its excessive length. Haemolytic anaemia, graft thrombosis or even heart failure have been reported as a consequence of unrecognised and uncorrected kinking of the ascending aortic graft. This paper describes a modification and improvement of an old aortic graft non-clamping technique to solve the problem of kinked tubular graft without resuming cardiopulmonary bypass.

Peroperative epicardial ultrasonography of distal coronary artery bypass graft anastomoses using a stabilizing device. A feasibility study

BackgroundWidespread use of intraoperative epicardial ultrasonography (ECUS) for quality assessment of coronary artery bypass graft anastomoses during coronary artery bypass grafting (CABG) has not occurred - presumably due to technological and practical challenges including the need to maintain stable and optimal acoustic contact between the ultrasound probe and the target without the risk of distorting the anastomosis. We investigated the feasibility of using a stabilizing device during ultrasound imaging of distal coronary bypass graft anastomoses in patients undergoing on-pump CABG. Imaging was performed in both the longitudinal and transverse planes.MethodsSingle-centre, observational prospective feasibility study among 51 patients undergoing elective, isolated on-pump CABG. Ultrasonography of peripheral coronary bypass anastomoses was performed using a stabilizing device upon which the ultrasound transducer was connected. Transit-time flow measurement (TTFM) was also performed. Descriptive statistical tests were used.ResultsLongitudinal and transverse images from the heel, middle and toe were obtained from 134 of 155 coronary anastomoses (86.5%). After the learning curve (15 patients), all six projections were obtained from 100 of 108 anastomoses scanned (93%). Failure to obtain images were typical due to a sequential curved graft with anastomoses that could not be contained in the straight cavity of the stabilizing device, echo artefacts from a Titanium clip located in the roof of the anastomoses, and challenges in interpreting the images during the learning curve. No complications were associated with the ECUS procedure. The combined ECUS and TTFM resulted in immediate revision of five peripheral anastomoses.ConclusionsPeroperative use of a stabilizing device during ultrasonography of coronary artery bypass anastomoses in on-pump surgery facilitates imaging and provides surgeons with non-deformed longitudinal and transverse images of all parts of the anastomoses in all coronary territories. Peroperative ECUS in addition to flow measurements has the potential to increase the likelihood of detecting technical errors in constructed anastomoses.Trial registrationThe study was registered on September 29, 2016, ClinicalTrials.gov ID: NCT02919124.

Gore-Tex Mesh as Cause for Distal Outflow Graft Obstruction in Ventricular Assist Device Patients

Purpose Re-do sternotomy following left ventricular assist device (LVAD) implant can occur due to cardiac transplantation or device complication. A polytetrafluoroethylene membrane (Gore-Tex) has been used to cover portions of the outflow graft to reduce adhesions. We describe 3 cases of late-presenting extrinsic compression of the distal outflow graft from a Gore-Tex membrane in both HVAD and HMII devices. Methods We conducted a retrospective analysis of all LVAD implants which included a Gore-Tex membrane at our institution between 1/2012-6/2018. We defined cases of extrinsic outflow graft obstruction (OGO) by clinical presentation, CT imaging, and intraoperative findings. Results During the study period, 158 LVADs with tubular Gore-Tex outflow graft coverage were implanted (93 HVAD, 59 HM2, 4 HM3). Three cases of extrinsic OGO (1 HVAD, 2 HM2) were identified, for a cumulative incidence of 1.9% (1.44 per 100 patient years). The average time to clinical presentation was 1157 ± 155 days. Each case presented with persistent low-flow alarms detected via remote monitoring in the absence of power spikes or clinical symptoms. Markers of hemolysis (LDH, plasma free hemoglobin) were normal, INR was therapeutic, and echocardiograms did not indicate volume depletion or right ventricular failure. In each case, CT imaging demonstrated critical narrowing of the distal outflow graft (N=2) or aortic anastomosis (N=1) (Fig A). Each patient underwent surgical exploration; upon incision of the overlying Gore-Tex membrane, a proteinaceous material was drained resulting in immediate improvement in flows and avoidance of pump exchange (Fig B). Conclusion We highlight 3 cases of a previously undescribed mechanism of OGO by extrinsic compression, resulting from accumulation of proteinaceous material underneath the Gore-Tex membrane. Each presented with gradual onset of low flows without additional symptoms, suggesting that a high level of clinical suspicion is necessary to ensure appropriate management.

Image Predictors of Treatment Outcome after Thoracic Aortic Dissection Repair.

Treatment of thoracic aortic dissection remains highly challenging and is rapidly evolving. Common classifications of thoracic aortic dissection include the Stanford classification (types A and B) and the DeBakey classification (types I to III), as well as a new supplementary classification geared toward endovascular decision making. By using various imaging techniques, the extent of the dissection, the location of the primary intimal tear, the shape of the aortic arch, and the zonal involvement of the aortic arch-factors that affect the treatment strategy-can easily be identified. Thoracic endovascular aortic repair (TEVAR) is generally performed in two groups of patients: (a) those with a surgically repaired type A dissection, and (b) those with a complicated type B dissection. Several imaging findings can help predict the course of remodeling of the dissected aorta after a repaired type A dissection and TEVAR. A spectrum of imaging findings exist with regard to favorable (positive) or failing (negative) remodeling. A schematic model with imaging support allows the classification of important causes of failing remodeling into proximal and distal groups, on the basis of the origin of the refilling of the false lumen and the underlying pathophysiology of pressurization. Refilling of the false lumen of the aorta after repair of a type A dissection is usually secondary to a persistent intimal tear at the aortic arch, a leak of the distal graft anastomosis, or refilling from the false lumen of a dissected aortic arch vessel. After TEVAR, false lumen refilling is most commonly due to an incomplete seal of the proximal landing related to the aortic tortuosity, an arch branch stump, a supra-arch chimney stent, or the TEVAR technique. Online supplemental material is available for this article. ©RSNA, 2018.

A Case of Anastomotic Stenosis of a Peripheral Arterial Bypass Graft Undetected in Indocyanine Green Angiography.

We report the case of a 75-year-old man who underwent right femoral-popliteal bypass surgery. Anastomotic stenosis was overlooked in indocyanine green (ICG) angiography due to opacification on the bypass graft. X-ray angiography revealed slit-shaped stenosis in the distal graft anastomosis that required revision. Although blood flow may be maintained despite of anastomotic stenosis, small decreases in blood flow cannot be detected in ICG angiography. We describe and discuss the pitfalls of qualitative graft assessment using ICG angiography, and compare ICG fluorescence luminance intensity between primary and revised grafts.

The "Auto-sliding Graft" Aortic Wrapping Technique.

We describe the "auto-sliding graft" technique, a different anastomotic option for reconstructive prosthetic procedures on the ascending aorta especially in patients at risk of circulatory arrest with mild aortic dilatation. This simple technique provides not only an important hemostatic reinforcement for the distal aortic graft anastomosis but also a protective effect on the native ascending aorta beyond the suture line.

Optimisation of a Novel Spiral-Inducing Bypass Graft Using Computational Fluid Dynamics

Graft failure is currently a major concern for medical practitioners in treating Peripheral Vascular Disease (PVD) and Coronary Artery Disease (CAD). It is now widely accepted that unfavourable haemodynamic conditions play an essential role in the formation and development of intimal hyperplasia, which is the main cause of graft failure. This paper uses Computational Fluid Dynamics (CFD) to conduct a parametric study to enhance the design and performance of a novel prosthetic graft, which utilises internal ridge(s) to induce spiral flow. This design is primarily based on the identification of the blood flow as spiral in the whole arterial system and is believed to improve the graft longevity and patency rates at distal graft anastomoses. Four different design parameters were assessed in this work and the trailing edge orientation of the ridge was identified as the most important parameter to induce physiological swirling flow, while the height of the ridge also significantly contributed to the enhanced performance of this type of graft. Building on these conclusions, an enhanced configuration of spiral graft is proposed and compared against conventional and spiral grafts to reaffirm its potential benefits.

Non-contrast MR angiography at 1.5 Tesla for aortic monitoring in Marfan patients after aortic root surgery

BackgroundContrast-enhanced cardiovascular magnetic resonance angiography (CE-CMRA) is the established imaging modality for patients with Marfan syndrome requiring life-long annual aortic imaging before and after aortic root replacement. Contrast-free CMRA techniques avoiding side-effects of contrast media are highly desirable for serial imaging but have not been evaluated in the postoperative setup of Marfan patients. The purpose of this study was to assess the feasibility of non-contrast balanced steady-state free precession (bSSFP) magnetic resonance imaging for aortic monitoring of postoperative patients with Marfan syndrome.MethodsSixty-four adult Marfan patients after aortic root replacement were prospectively included. Fourteen patients (22%) had a residual aortic dissection after surgical treatment of type A dissection. bSSFP imaging and CE-CMRA were performed at 1.5 Tesla. Two radiologists evaluated the images regarding image quality (1 = poor, 4 = excellent), artifacts (1 = severe, 4 = none) and aortic pathologies. Readers measured the aortic diameters at defined levels in both techniques. Statistics included observer agreement for image scoring and diameter measurements and ROC analyses for comparison of the diagnostic performance of bSSFP and CE-CMRA.ResultsBoth readers observed no significant differences in image quality between bSSFP and CE-CMRA and found a median image quality score of 4 for both techniques (all p > .05). No significant differences were found regarding the frequency of image artifacts in both sequences (all p > .05). Sensitivity and specificity for detection of aortic dissections was 100% for both readers and techniques. Compared to bSSFP imaging, CE-CMRA resulted in higher diameters (mean bias, 0.9 mm; p < .05). The inter-observer biases of diameter measurements were not significantly different (all p > .05), except for the distal graft anastomosis (p = .001). Using both techniques, the readers correctly identified a graft suture dehiscence with aneurysm formation requiring surgery.ConclusionUnenhanced bSSFP CMR imaging allows for riskless aortic monitoring with high diagnostic accuracy in Marfan patients after aortic root surgery.

Numerical Assessment of Novel Helical/Spiral Grafts with Improved Hemodynamics for Distal Graft Anastomoses.

In the present work, numerical simulations were conducted for a typical end-to-side distal graft anastomosis to assess the effects of inducing secondary flow, which is believed to remove unfavourable flow environment. Simulations were carried out for four models, generated based on two main features of 'out-of-plane helicity' and 'spiral ridge' in the grafts as well as their combination. Following a qualitative comparison against in vitro data, various mean flow and hemodynamic parameters were compared and the results showed that helicity is significantly more effective in inducing swirling flow in comparison to a spiral ridge, while their combination could be even more effective. In addition, the induced swirling flow was generally found to be increasing the wall shear stress and reducing the flow stagnation and particle residence time within the anastomotic region and the host artery, which may be beneficial to the graft longevity and patency rates. Finally, a parametric study on the spiral ridge geometrical features was conducted, which showed that the ridge height and the number of spiral ridges have significant effects on inducing swirling flow, and revealed the potential of improving the efficiency of such designs.

Late reoperations after acute aortic dissection repair: Single-center experience.

After repair of acute type A aortic dissection, aortic complications can develop, and reoperations might be necessary. In our retrospective study, we wanted to assess early and late outcomes in this cohort of patients. From September 2005 to July 2012, 21 consecutive patients previously operated on for acute type A aortic dissection underwent 27 redo aortic surgical procedures. Indications for redo procedures were: enlargement of the false lumen in the residual aorta (18 events), severe aortic regurgitation with or without aortic root dilatation (8 events), suture dehiscence and pseudoaneurysm at the proximal or distal aortic graft anastomosis (5 events) or at the coronary button anastomosis in patients who previously underwent a Bentall procedure (1 patient). In all cases, total or partial cardiopulmonary bypass was used. Hypothermic cardiocirculatory arrest was needed in 22 (81%) procedures. Hospital mortality was 3.7% (1/27), reexploration for bleeding and paraplegia rates were 7.4% and 7.4%, respectively. Marfan patients received 3.2 procedures per patient vs. 1.5 in non-Marfan patients (p < 0.01). At a mean follow-up of 6.5 years, 2 aortic events occurred: 1 aortic death, and 1 additional aortic redo surgery. When procedures are carried out on elective basis, redo aortic surgery can be performed in all segments of the aorta with good early and late outcomes. Close lifelong clinical and radiological follow-up is mandatory. After repair of acute type A aortic dissection, Marfan patients are more prone to develop late complications, with a more rapid evolution.

Distal anastomotic patency of the Cardica C-PORT® xA system versus the hand-sewn technique: a prospective randomized controlled study in patients undergoing coronary artery bypass grafting†

The C-Port® Distal Anastomosis Systems (Cardica, Inc., Redwood City, CA, USA) demonstrated favourable results in feasibility trials. However, distal vein anastomoses created with the C-Port® or C-Port xA® system have never been compared with hand-sewn distal vein anastomoses. The objective of this study was to compare distal end-to-side anastomoses facilitated with the C-Port xA® System with the traditional hand-sewn method. This single-centre prospective randomized controlled study comprised 71 patients (device group n = 35, control group n = 36) who underwent primary elective coronary artery bypass grafting between June 2008 and April 2011. The primary study end-point was 12-month distal anastomotic patency, which was assessed with prospective ECG-gated 256-multislice computed tomographic coronary angiography using a step-and-shoot scanning protocol. For the primary end-point, a per-protocol analysis was used. In the device group, four (11%) anastomoses were converted to hand-sewn anastomoses, and additional stitches to achieve haemostasis were necessary in 22 (76%) patients. There was no hospital mortality in either group. During the 12-month follow-up, a single death occurred in the Device group and was unrelated to the device. Twenty-nine patients in the device group and 32 in the control group completed 12-month CT coronary angiography. The overall patency of 160 studied distal vein graft anastomoses was 93%. Comparison of the end-to-side target anastomosis showed 12-month patencies of 86 and 88% in the device group and the control group, respectively. According to these preliminary results and despite the limited number of patients, the use of the C-Port xA® System is safe enough to perform distal end-to-side vein graft anastomosis, with respect to 12-month end-to-side distal venous anastomotic patency. Although there are some technical challenges with this device, the incidence of complications is comparable to the traditional hand-sewn technique.

Left Carotid-to-Subclavian Artery Bypass Grafting for Recurrent Angina Caused by Coronary-Subclavian Steal Syndrome

A 60-year-old man visited the outpatient clinic due to one month of recurrent exertional chest pain. Eleven years earlier he had undergone off-pump coronary artery bypass grafting using bilateral internal thoracic artery (ITA) Y-composite grafts based on the left ITA. Preoperative coronary angiography showed patent distal graft anastomoses and visualized the left ITA retrogradely. The arch aortography revealed near-total occlusion of the left subclavian artery at the level of the ostium. The patient underwent left carotid-to-subclavian artery bypass grafting using a 6 mm vascular conduit. Postoperative computed tomographic angiography revealed a patent bypass conduit between the left common carotid artery and left subclavian artery. The patient was discharged on postoperative day 4 with no symptoms or signs of myocardial ischemia.

Non- invasive in vivo analysis of a murine aortic graft using high resolution ultrasound microimaging

As yet, murine aortic grafts have merely been monitored histopathologically. The aim of our study was to examine how these grafts can be monitored in vivo and non-invasively by using high-resolution ultrasound microimaging to evaluate function and morphology. A further aim was to prove if this in vivo monitoring can be correlated to immunohistological data that indicates graft integrity. Murine infrarenal aortic isografts were orthotopically transplanted into 14 female mice (C57BL/6-Background) whereas a group of sham-operated animals (n = 10) served as controls. To assess the graft morphology and hemodynamics, we examined the mice over a post-operative period of 8 weeks with a sophisticated ultrasound system (Vevo 770, Visual Sonics). The non-invasive graft monitoring was feasible in all transplanted mice. We could demonstrate a regular post-transplant graft function and morphology, such as anterior/posterior wall displacement and wall thickness. Mild alterations of anterior wall motion dynamics could only be observed at the site of distal graft anastomosis (8 weeks after grafting (transplant vs. sham mice: 0.02 mm ± 0.01 vs. 0.03 mm ± 0.01, p<0.05). However, the integrity of the entire graft wall could be confirmed by histopathological evaluation of the grafts. With regard to graft patency, function and morphology, high resolution ultrasound microimaging has proven to be a valuable tool for longitudinal, non-invasive, in vivo graft monitoring in this murine aortic transplantation model. Consequently, this experimental animal model provides an excellent basis for molecular and pharmacological studies using genetically engineered mice.

Successful treatment of delayed aortobifemoral graft thrombosis with manual aspiration thrombectomy

We present a 67-year-old man who had undergone aortobifemoral synthetic graft surgery one year earlier. The patient experienced thrombosis of the graft nine months after the operation, and thrombectomy of the graft was planned. However, the patient refused to undergo repeat surgery for thrombus removal and was referred to our center for possible endovascular treatment. We treated the patient with percutaneous aspiration thrombectomy. The thrombi were chronic in nature but could be removed with minimal residue in any part of the graft by using repeated aspiration thrombectomy with 7 F guiding catheters. Underlying stenosis of both distal graft anastomoses was treated with percutaneous balloon angioplasty, and a self-expanding stent was deployed on the right distal anastomosis. A small fragment of thrombus embolized to the right popliteal artery and was removed with aspiration thrombectomy through a second antegrade puncture on the right side. We believe this is the first report of aspiration thrombectomy for an aortobifemoral graft thrombosis. The method was successful despite the chronic nature of the thrombi. Manual aspiration thrombectomy with largebore guiding catheters can be used as an effective recanalization method for delayed aortobifemoral graft occlusion and could be regarded as a good alternative technique to surgical thrombectomy in selected patients.

Increased Graft Occlusion or String Sign in Composite Arterial Grafting for Mildly Stenosed Target Vessels

Composite grafting is a useful technique that avoids the need for aortic manipulation and enables a wide range of target vessels to be revascularized, effectively using the limited arterial grafts available. However, it has not been clarified whether composite grafting can achieve angiographic outcomes equivalent to those obtained with individual grafting for specific target vessels. We retrospectively reviewed 830 distal arterial graft anastomoses in 256 patients who underwent off-pump coronary artery bypass surgery and also underwent 1-year follow-up coronary angiograms. Four hundred and ten anastomoses using a composite grafting technique were compared with 420 anastomoses using individual grafting. In target vessels with mild stenosis, the incidence of graft occlusion or string sign was significantly higher in composite internal thoracic arteries (ITA) than in individual ITA grafts (composite 20.3% versus individual 7.3%; p = 0.018) and showed a higher tendency in composite radial arteries (RA) than in individual RA grafts (59.3% versus 36.4%, p = 0.09). In contrast, the incidence was similar between composite and individual ITA grafts (5.7% versus 3.3%, p = 0.278) and composite and individual RA grafts (11.5% versus 29.6%, p = 0.297) in target vessels with severe stenosis. The angiographic outcomes of composite grafts were closely related to the severity of stenosis of the target coronary artery. In target vessels with mild stenosis, composite grafting resulted in a higher incidence of graft occlusion or string sign than individual grafting did.

Primary Stenting Immediatly after Surgery in Occluded Anastomoses of Aortoaortic Tube Graft: A Case Report

The conventional elective open procedures for abdominal aortic aneurysm repair are reliable and yield durable results. The aortoaortic tube graft has the lowest morbidity incidence when compared with different techniques. Albeit infrequent, thrombosis can be present in the first 30 days. Its treatment consists in thrombectomy and anastomosis evaluation, but with an increase in morbidity, especially in patients with urgent reintervention. This is a case report of a patient with aortoaortic tube graft, who present critical left limb ischemia immediately after surgical procedure. Angiography showed complete occlusion of left common iliac artery, affecting the distal graft anastomosis. The occlusion was resolved with endovascular treatment, and a noncovered, self-expanding, nitinol stent was deployed (primary stenting) covering the distal bypass anastomosis, with no complications and complete lower limb perfusion recovery. One month later, the patient was still asymptomatic, with distal pulse palpable and ankle-brachial index 1.