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DOI: 10.1055/s-0029-1246936
Homograft descending aorta-to-biiliac bypass via left mini-thoracotomy and retroperitoneal incision in a patient with an infected subclavian-bi-femoral prosthetic graft
Introduction: The surgical treatment of prosthestic graft infections remains a challenge in major vascular surgery.
Case description/background: The case of a 84 year-old patient with long-lasting, complicated course of prothesio-enteric fistula following infrarenal aortic replacement is described. Nine years after after extra-anatomic reconstruction, aortic graft explantation and aortic stump closure, recurrent infections of the subclavio-bifemoral graft were treated by means of vacuum therapy. This treatment resulted in epithelialisation and localized supra-dermal exposure of the Dacron graft. PET-CT scan confirmed graft infection and angio-CT scan showed retrograde filling of the iliac bifurcations. Due to the extensive comorbidities of the patient (advanced age, CAD, impaired LVEF, pacemaker) a re-laparotomy was abandoned. Instead, a left mini-thoracotomy in the sixth intercostal space was performed to expose the distal descending aorta and the iliac bifurcations were exposed via a left retroperitoneal approach. A homograft bypass was anastomozed end-to-side to the partially clamped descending aorta, routed extraperitoneally to connect with both iliac bifurcations sequentially. The sublavia-bifemoral bypass was explanted one day thereafter. The patient had an uneventful postoperative course and was discharged on POD12.
Discussion: This is a representative example for a complicated course of a patient with prosthetic graft infection who was initially treated conventionally by means of extra-anatomic bypass and elimination of the infectious focus. The retroperitoneal and separate thoracic approach described here offer a valuable alternative in patients with hostile abdomen for aortic vascular reconstructions. Furthermore, in case of prosthetic vascular graft infections, the use of homografts should always be considered.