Case Study: Occluded Stent Removal for Revascularization in Setting of Infection
Case Presentation - January 2013
W. Michael Park, MD
The patient is a 67 year old woman who was referred for management of an infected femorofemoral bypass graft. This graft was placed for a left common iliac artery occlusion. With the development of infection soon after creation of bypass, the outside surgeon resected the distal graft, packed the wound open, and transferred the patient for management. Prior to this graft, she had had left common iliac artery stent placement and a femorofemoral bypass, both of which had occluded in the past year.
On presentation, she was having ischemic rest pain in the left leg. The left groin wound was packed, and there was fluctuant in the right groin. A contrast CTA (Computed Tomographic Arteriogram) was performed showing an occluded left common iliac stent and left external iliac artery (Figure 1), and the remnant proximal redo femorofemoral graft (Figure 2) with surrounding fluid (Figure 3). The previous femorofemoral bypass appeared well incorporated.
Revascularization options included a third redo-femorofemoral bypass using deep femoral vein versus cryopreserved artery. On review of the CTA, it appeared that a revascularization of the native circulation using remote endarterectomy to remove the occluded stent and occlusive external iliac artery plaque was feasible, and this was chosen as first option.
In the operating room, the left groin incision was reopened to gain control of the common femoral artery. The first femorofemoral bypass appeared well incorporated. Using a Vollmer ring dissector, the occlusive left external iliac artery plaque was dissected up to the stent (Figure 4). With some manipulation and with the additional dissection with a wire, the ring was dissected around the stent and eventually to the origin of the iliac artery. A Moll ring cutter was then used to transect the heavily calcified plaque at the aortic bifurcation (Figure 5). This restored patency of the occluded left iliac system. The bifurcation was then treated with kissing iliac stents (Figure 6). The common femoral artery was then patched with vein and the wound closed applying a sartorius muscle flap onto the wound. The remnant femorofemoral bypass graft was not incorporated and easily removed from the right groin exposure and the artery repaired. The wound here was also closed with a sartorius muscle flap (Figure 7, an illustration).
Remote endarterectomy is a minimally invasive adaptation of an old and established revascularization technique. Endarterectomy was in fact the only method of revascularization available before the advent of vein grafts and tissue banked allografts. Remote endarterectomy uses endovascular techniques and fluoroscopy to manage with one wound what previously would have taken two or more incisions. It also has the advantage of avoiding prosthetic graft materials, making it an ideal technique for infected graft cases. We were able to avoid deep femoral vein harvest which would have lengthened the operation, and increased the morbidity of the procedure.
Had remote endarterectomy failed, the option of deep femoral vein harvest and bypass was still available as the backup plan. The reason why the remote endarterectomy was possible was because the common iliac stent was an undersized balloon expandable stent that the 12mm Vollmer ring easily accommodated. A larger stent or plaque would have precluded safe dissection. The patient was sent home with a wound VAC on the left groin, after having closed her right groin wound in the hospital, and has fully recovered since discharge over three months ago.