Case Report

DepartmenCenter, San An

CorrespondSurgery, SanDr, San Anton

Ann Vasc Surghttp://dx.doi.or� 2014 Elsevi

Manuscript rec

2014; publishe

Endovascular Aortoiliac Reconstruction toAllow Excision of an InfectedAxillobifemoral Bypass

Thomas A. Heafner, Michael Clemens, Daniel Scott, Yiming Ching, Sean Hislop,

and Zachary M. Arthurs, San Antonio, Texas

Axillofemoral graft reconstructions were initially intended to restore lower extremity perfusion inhigh-risk patients with symptomatic aortoiliac atherosclerotic occlusive disease. However, thesereconstructions are now relegated to ‘‘bailout’’ procedures for infected grafts or high-risk criticallimb ischemia patients that fail endovascular therapy. Infection of an extra-anatomic bypass graftis a challenging complication as it occurs in poor operative candidates with limited revasculari-zation options and failure has a high rate of amputation and mortality. Described is a novelapproach using endovascular reconstruction to treat symptomatic Trans-Atlantic Inter-SocietyConsensus-II type D aortoiliac lesions allowing for complete excision of an infected axillobife-moral bypass.

Axillofemoral graft reconstructions were historically

intended to provide lowerextremity revascularization

in patients with aortoiliac disease who were at high

risk for an intra-abdominal aortic reconstruction.

They have been increasingly used as a means of

providing extra-anatomic lower extremity revascular-

ization after excision of infected intra-abdominal

vascular pathology.

Since initial technical descriptions, the complica-

tions of the axillary-to-femoral bypass graft have

beenwell documented. These include graft dissocia-

tion, graft thrombosis, and graft stenosis, all contrib-

uting to technique changes in graft placement.

However, the infected axillofemoral graft poses a

formidable challenge for surgeons. Few publications

exist documenting the morbidity, mortality, and

t of Vascular Surgery, San Antonio Military Medicaltonio, TX.

ence to: Thomas Heafner, MD, Department of VascularAntonio Military Medical Center, 3851 Roger Brookeio, TX 78234, USA; E-mail: heafnert@gmail.com

2014; -: 1–4g/10.1016/j.avsg.2014.03.009er Inc. All rights reserved.

eived: February 4, 2014; manuscript accepted: March 7,

d online: ---.

surgical challenges of treating this complication.

Described is a novel approach using an endovascular

reconstruction to treat symptomatic Trans-Atlantic

Inter-Society Consensus-II (TASC) type D aortoiliac

lesions allowing for complete excision of an infected

axillofemoral bypass.

CASE REPORT

Thirty days after an axillobifemoral bypass procedure for

claudication performed at an outside facility, a 70-year-

old male with multiple prior intra-abdominal operations

was bending over a sink, began bleeding from his right

flank and subsequently fell to the floor. He presented to

our emergency department tachycardic and hypotensive

with paramedics controlling the bleeding with external

compression. In addition, he had sensory loss at the level

of the mid-calf.

He was taken emergently to the operating roomwhere

the axillobifemoral graft was found to be constructed in a

lazy-Y configuration with inline flow from the right axil-

lary artery to the left common femoral artery (CFA) using

a 7-mm ringed polytetrafluorethylene (PTFE) graft and a

6-mm ringed PTFE jump graft to the right CFA (Fig. 1).

On exposure, the anastomosis at the level of the jump

graft was completely dehisced from the bypass graft,

friable, surrounded by biofilm, and without incorporation

1

Fig. 1. Axillobifemoral bypass in a lazy-Y configuration

with inline flow from the right axillary artery to the

left CFA using a 7-mm ringed PTFE graft and a 6-mm

ringed PTFE jump graft to the right CFA.

Fig. 2. Preoperative coronal image demonstrating a

3.5-cm infrarenal aneurysm with bilateral common iliac

occlusion.

2 Case Report Annals of Vascular Surgery

into the surrounding tissues, consistent with a graft infec-

tion. However, the infection appeared limited to this

segment with good tissue incorporation proximally and

distally. As the patient had poor collateralization to his

lower extremities evident by the development of Ruther-

ford IIa ischemia of his right leg, a damage control proce-

dure was performed. This consisted of graft debridement 4

cm proximal and distal; this segment was replaced with 6-

mmPTFE graft. Before reperfusion, distal thrombectomies

were performed, and a completion angiogram confirmed

restoration of flow to bilateral CFAs with brisk filling of

the profunda arteries. Postoperatively, the patient had res-

olution of his lower extremity ischemia and return of

biphasic signals to his bilateral lower extremities.

As preoperative planning for complete graft excision

was being made, he was maintained on intravenous

(I.V.) vancomycin and Zosyn. On review of his computed

tomography angiogram, the patient had a concomitant

3.5-cm infrarenal aortic aneurysmwith bilateral complete

iliac occlusions to the level of both femoral arteries with

significant circumferential calcification and intraluminal

thrombus (Fig. 2). In considering our revascularization

options, an open aortobifemoral procedurewould be chal-

lenging because of his prior intra-abdominal operations,

and a left-sided axillobifemoral bypass could introduce

cross-contamination through the abdominal subcutane-

ous tracts. With no evidence of infection in the groins,

an endovascular reconstruction was determined to have

the lowest risk of causing a superimposed infection. Given

these were long segment aortoiliac occlusions, covered

stents as opposed to uncovered were chosen because of

concerns about the ability to obtain an adequate intralu-

minal diameter, decrease the chance of thrombus emboli-

zation, and provide the longest durability. Surgery was

delayed for 10 days while waiting for culture results. Tis-

sue and graft cultures failed to identify an offending or-

ganism suggesting a likely Staphylococcus epidermidus

infection. Additionally, 2 sets of blood and urine cultures

were also negative.

Bilateral femoral artery cutdowns and a local debri-

dement of both groins were performed without any evi-

dence of infection. Using a combined left brachial and

bilateral femoral artery access, his aortoiliac occlusions

were crossed subintimally with wires. True-lumen was

confirmed at the level of the infrarenal aorta. First, an

Endologix (Irvine, CA) 28 � 70 � 16 � 30 mm unibody

prosthesis was deployed at the aortic bifurcation. An

Endologix 20 � 28 � 75 mm suprarenal aortic extension

was placed below the renal arteries to exclude the small

aneurysm. Bilaterally, CookeZenith ZSLE (Bloomington,

IN) 13 � 90 mm extension limbs were deployed from

the new aortic bifurcation to the level of the inguinal liga-

ment. A 33-mmCoda balloon (Bloomington, IN)was used

to occlude the distal aorta while the iliac limbs were bal-

looned to a profile of 11 mm, purposely rupturing the

Fig. 3. Postoperative image after endovascular recon-

struction. An Endologix unibody with suprarenal exten-

sion was used to reconstruct the bifurcation and exclude

the aneurysm. Bilaterally, CookeZenith ZSLE extension

limbs were deployed to the level of the inguinal

ligament.

Vol. -, No. -, - 2014 Case Report 3

native vessels to provide greater flow (Fig. 3). Bilaterally,

10-mm rifampin-soaked Dacron grafts were then sewn

to the end of the ZSLE limbs, and the distal anastomosis

was spatulated onto the profunda femoris. The prior axil-

lobifemoral bypass graft was then explanted to the level

of the anterior superior iliac spine. Both groin anastomoses

were covered with sartorius muscle flaps with wound vac-

uum-assisted closure. At the completion of the case, the

patient had biphasic Doppler signals in the dorsalis pedis

and posterior tibial arteries bilaterally and was neurologi-

cally intact.

The following week, using the previous infraclavicular

incision, the right axillary artery was isolated and the

anastomosis was transected revealing a heavy calcified

native axillary artery. An endarterectomy was performed

and closedwith a saphenous vein patch and a local muscle

flap. The remaining infected bypass graft and capsule were

completely excised.

The patient was maintained on broad-spectrum I.V.

antibiotics while in the hospital and was transitioned to

lifetime suppressive oral Bactrim therapy on discharge.

At his 3-month evaluation, duplex examination showed

normal aortic stent velocities without evidence of endo-

leak or stenosis. He is able to ambulate without claudica-

tion symptoms.

DISCUSSION

Blaisdell and Hall first described axillofemoral re-

constructions in 1963 to treat lower extremity clau-

dication and critical limb ischemia in high-risk

patients with aortoiliac disease.1 The original tech-

nique used a lazy-S configuration from the ipsilat-

eral axillary artery to the CFA. Since then, several

graft modifications, as in our patient, have been

used to revascularize bilateral lower extremities.

Although short-term patency appeared promising,

the primary patency at 5 years was only 30e75%,

making them an inadequate long-term solution

to lower extremity claudication.2 These bypasses

have now found a niche for reperfusing the lower

extremities in patients with infected aortic grafts

and high physiologic risk critical limb ischemia pa-

tients that fail endovascular therapy.

As extra-anatomic bypasses are generally consid-

ered ‘‘bailout’’ procedures, graft infections in this

setting are associated with significant morbidity and

mortality. Most of the time, the infection starts in

the groin and progresses proximally along the graft.

Our case was unique in that the groins were unin-

volved, and the infection was limited to jump-graft

anastomosis in the subcutaneous tissues of the

abdomen. Previous reports noted an above-the-

knee amputation rate of 25e44% and operative

mortality of 18e22%, which are dependent on the

indication for the operation (tissue loss versus claudi-

cationversus infectedaortic graft)3,4.Openprosthetic

reconstructive options include axilloprofunda, axil-

lopopliteal, and obturator bypasses in unaffected

tissue planes, whereas autologous reconstruction

could be placed in the groin. These options all

require tunneling new grafts through the abdominal

subcutaneous tissues, and it would be challenging

to avoid the previous tracts. An endovascular

approach utilizing the uninvolved groins avoids

potential cross-contamination from the subcutane-

ous tissues.

A majority of aortoiliac atherosclerotic occlusive

disease patterns are now amenable to endovascular

procedures. Angioplasty with uncovered stents are

standard for short segment TASC-II types A and B le-

sions with a 10-year assisted patency rate of 71%;

however, their 2-year primary and secondary

patency rates are significantly lower ranging from

69% to 76% and 85% to 95%, respectively, for

TASC-II types C and D lesions.5 On the other hand,

covered stent repair of TASC-II types C and D lesions

have a primary and primary-assisted patency of 70%

and 88% at 1-year and 80% and 95% at 5 years.5

This is comparable to the 5-year patency rate of an

open aortobifemoral reconstruction at 95%without

4 Case Report

the associated morbidity and mortality of a major

operation.6 Our patient had TASC-II type D lesions

amenable to endovascular repair. We chose an

Endologix unibody because of its low-profile (17Fr

and 8Fr) and ability to reconstruct the aortic bifurca-

tion while excluding the aneurysm. We chose

CookeZenith limbs to extend to the inguinal liga-

ment because the Dacron fabric is easy to construct

the iliofemoral anastomosis. As concomitant femoral

artery disease is a significant predictor of stent-graft

failure,5 bilateral outflow procedures were con-

structed to improve patency.

Any reconstruction with prosthetic material for

an existing infection is at risk for a recurrent

graft infection. While the incidence of endograft

infection is w0.2% after clean procedures, the

incidence after placement in a contaminated pro-

cedure is unknown.7 The risk of infection is high-

est in the first 4 weeks after implantation as a

pseudointimal lining forms over the luminal sur-

face; however, it has been reported to occur

several years after implantation.8 Therefore, sup-

pressive antibiotic therapy is recommended to pre-

vent graft seeding from the transient bacteremia

that occurs after an infection (urinary tract/pneu-

monia) or after routine procedures (i.e., repeat

endovascular, colonoscopy, dental work).9 Only

small case series have reported on the manage-

ment of endograft infections, but the consensus

recommends following the same dictum for open

repairs of complete graft excision.

In conclusion, axillofemoral bypass graft infec-

tions present a formidable challenge with few good

reconstructive options. We present the use of

endoaortoiliac reconstruction for limb salvage in

this patient.

Authorship: Study conception and design was performed by T.H.,

Y.C., S.H., and Z.M.A. Study analysis and interpretation was

done by M.C. and D.S. Data collection was performed by T.H.,

M.C., and S.H. The article was written by T.H. and M.C.

Critical revision of the article was performed by M.C., D.S.,

Y.C., and S.H. Final approval of the article was performed by

all the authors.

Authors’ Note: The opinions and assertions contained herein

are the private views of the authors and are not to be construed as

official or reflecting the views of the Department of the Army,

Department of the Air Force, Navy Department, or Department

of Defense.

REFERENCES

1. Blaisedell FW, Hall AD. Axillary-femoral Artery Bypass for

Lower Extremity Ischemia. Surgery 1963;54:563.

2. Schneider J. Extra-Anatomic Bypass. In: Saunders ed. Ruth-

erford’s Vascular Surgery. Philadelphia: Elsevier, 2005. pp

1633e52.

3. De Virgilio C, Cherry KJ, Gloviczki P, et al. Infected lower ex-

tremity extra-anatomic bypass grafts: management of a

serious complication in high-risk patients. Ann Vasc Surg

1995;9:459e66.

4. Marston W, Risley G, Criado E, et al. Management of failed

and infected axillofemoral grafts. J Vasc Surg 1994;20:357e65.

5. Powell R, Rzucidio E. Aortoiliac disease: endovascular treat-

ment. In: Saunders ed. Rutherford’s Vascular Surgery. Phila-

delphia: Elsevier, 2005. pp 1667e81.6. Menard M, Belkin M. Aortoiliac disease: direct reconstruc-

tion. In: Saunders ed. Rutherford’s Vascular Surgery. Phila-

delphia: Elsevier, 2005. pp 1613e32.7. Blanch M, Berj�on J, Vila R, et al. The management of aortic

stent-graft infection: endograft removal versus conservative

treatment. Ann Vasc Surg 2010;24:554.e1e5.

8. Chiesa R, Astore D, Frigerio S, et al. Vascular prosthetic graft

infection: epidemiology, bacteriology, pathogenesis and treat-

ment. Acta Chir Belg 2002;102:238e47.

9. Back M. Local complications: graft infection. In: Saunders ed.

Rutherford’s Vascular Surgery. Philadelphia: Elsevier, 2005.

pp 643e62.

Annals of Vascular Surgery