Stenting for proximal para-anastomotic stenosis of an infrarenal aortic bypass graft.

We present a case in which endovascular stenting was used for recurrent proximal para-anastomotic stenosis 11 years after aorto-bi-iliac bypass grafting for severe aorto-iliac occlusive disease. A 55-year-old woman presented with worsening bilateral hip and buttock claudication. At presentation, her resting ankle-brachial indices were 0.87 bilaterally and decreased to 0.39 on the right and 0.40 on the left with exercise. Aortography demonstrated a proximal para-anastomotic aortic graft stenosis without distal outflow obstruction, patent superficial femoral arteries, and good triple-vessel runoff bilaterally The stenosis was dilated with a 9- x 4-cm OPTA balloon angioplasty catheter. A Palmaz stent (P424, Cordis) was mounted on a 10- x 4-cm OPTA balloon catheter and deployed across the proximal stenosis. Completion arteriography confirmed adequate placement and reduction in the degree of stenosis. There was no pressure gradient across the proximal anastomosis. At our patient's 1-week follow-up visit, her resting ankle-brachial indices were both greater than 1.0 and her exercise ankle-brachial indices were 1.0 bilaterally She remained asymptomatic at 13 months. Most late sequelae of aortic graft surgery involve the distal anastomosis and are resolved surgically without complicated techniques. However, revision at the proximal anastomosis involves the aorta directly and therefore requires open abdominal dissection and aortic cross-clamping. Percutaneous aortic stenting for primary aortoiliac disease has been shown to reduce operative time, cost, and hospital stays, to improve patency and to be durable. Our clinical experience with aortic stenting for primary disease led us to consider this procedure for recurrent proximal stenosis.