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Endovascular Repair of Anastomotic Disruption of External Iliac Artery to Superior Mesenteric Artery Bypass
Daniel Calderon, MD, Faisal Aziz, MD, John Radtka, MD.
Penn State Hershey Medical Center, Hershey, PA, USA.
OBJECTIVES:
Retrograde iliac artery to superior mesenteric artery (SMA) bypass is a well-documented treatment for acute mesenteric ischemia. Revisional surgery of these bypasses is challenging and has the potential for multiple complications. Retrograde SMA stenting for mesenteric ischemia has been described as an alternative to bypass. An endovascular approach for the repair of a pseudoaneurysm at the mesenteric anastomosis of an iliac-sma bypass is described.
METHODS:
We present a case of a 69 year old male who underwent a right external iliac to SMA bypass with bovine artograft and an ileo-cecectomy for gangrenous bowel and mesenteric ischemia. At the time of admission the patient had a patent inferior mesenteric artery, an occluded celiac artery, and a high grade stenosis of the SMA. Five weeks after the inital procedure, the patient presented with a disruption and pseudoaneurysm of the proximal anastomosis of the previous visceral bypass. The risk of a bowel injury is high with re-exploration only five weeks after the initial procedure. Therefore, an endovascular option was chosen. Access was obtained through a left brachial cutdown . Antegrade access to the SMA was attempted and was unsuccessful. The right common femoral artery was then accessed percutaneously. The SMA was accessed through the prior bypass and a retrograde stent was deployed at SMA origin. The bypass was then occluded with amplatzer plugs and the iliac anastomosis was sealed with a covered stent.
RESULTS:
Post-operative course was uneventful and was discharged on postoperative day 5 on long-term IV antibiotics. One month follow up reveals that the patient is doing well with a patent stent and no symptoms of mesenteric ischemia.
CONCLUSIONS:
Repair of an anastomotic pseudoaneurysm of an iliac to SMA bypass using open surgical techniques is challenging, especially in the window between 2 to 5 weeks after the initial procedure. Besides bleeding and bowel ischemia, adhesions can lead to multiple bowel injuries and difficult exposure. Endovascular techniques allow for repair of this complication with minimal morbidity.
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