73-year-old Female With Delayed Intra-abdominal And Systemic Sepsis Following Complicated Aortobifemoral Bypass
Luis C. Cajas-Monson, MD, Myung Park, MD, Manju Kalra, MBBS.
Mayo Clinic, Rochester, MN, USA.
Demographics 73-year-old female transferred with sepsis and passage of staples and blood per rectum.
History Patient was transferred from an outside institution with a 2-week history of fevers, chills, and passage of blood and staples per rectum. Management had included intravenous (IV) antibiotics for Pseudomonas aureginosa septicemia and computed tomography angiography (CTA) guided percutaneous drainage of retroperitoneal abscess. Past history included aortobifemoral bypass graft (ABFG) for lifestyle limiting claudication 4 years previously. Procedure was complicated by cardiac arrest, colonic ischemia treated with left hemicolectomy with end colostomy, and 3rd intervention for retroperitoneal hematoma with coil embolization of the right common and internal iliac arteries. CTA revealed residual abscess cavity surrounding the Dacron graft and heavy calcification of the entire abdominal aorta. Sinogram revealed communication with the rectal stump. The proximal graft anastomosis was end-to-side located immediately infrarenal. Positron emission tomography (PET) scan revealed active uptake within the proximal graft with sparing of distal limbs.
Plan Through a midline transperitoneal approach the high supraceliac aorta (SCA) was exposed and controlled with a side-biting clamp. A bifurcated graft composed of two cryopreserved femoropopliteal (CPFP) segments was anastomosed to the SCA end-to-side. Left medial visceral rotation and Kocherization of the duodenum were performed to tunnel the conduits in the lateral retroperitoneal spaces and anastomose them end-to-end to the well incorporated distal ABFG limbs near the inguinal ligament. Next, the remaining ABFG was exposed in the midline and completely excised under pararenal aortic balloon control. The anterior aorta was closed with a double layered cryopreserved arterial patch. The rectal pouch was revised and a 12 Fr Jackson-Pratt drain was placed. Patient recovered uneventfully and was discharged home on POD 9 with a 6-week course of IV antibiotics. Pseudomonas was resistant to all oral agents. She was last seen 4 years post-operatively with patent grafts and no re-infection on PET scan.
Discussion Extra-anatomic arterial reconstruction allowed re-establishment of blood flow distally without entering the abscess cavity. Use of Rifampin soaked Dacron was precluded since no lifelong antibiotic suppression was possible. Use of cryopreserved arterial conduits has been associated with satisfactory long-term patency and freedom from infection.
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