Minimally invasive treatment of vascular complications after neoaortoiliac system reconstruction using autologous vein grafts.

Treatment of complications after neoaortoiliac system vein reconstruction is a complex clinical problem with poor results. Endovascular treatment might offer an acceptable outcome in selected cases. We report two rare complications after neoaortoiliac system vein reconstruction for an infected aortic graft. These complications were treated with minimally invasive endovascular techniques. A 54-year-old man presented with an arterioureteral fistula located between the right ureter and the right branch of the venous reconstruction. The second case describes a 71-year-old man who developed a large dilation proximally in the venous reconstruction.

Neoaortoiliac system (NAIS) reconstruction using the femoral vein is one of the treatment options in aortic prosthetic graft infection; it was first described in 1993 by Clagett et al and Nevelsteen et al. NAIS vein reconstruction is an accepted procedure that provides good results with a primary patency rate of 81% and a secondary or assisted primary patency rate of 91% at 6 years. The perioperative (30-day) mortality rate is ≤10%, with a 30% to 50% mortality rate at 5 years.

Treatment of complications after NAIS vein reconstruction is a complex problem. A laparotomy and vascular reconstruction or local débridement is often needed, with poor results.3, 5, 6, 7 Minimally invasive endovascular treatment could be a good option in selected cases and might benefit outcome. Both patients consented to publication of this report.

Case reports

Case 1

A 54-year-old man had undergone an aortobifemoral graft interposition in Spain for ruptured infrarenal aortic aneurysm in 2011. Two months after the initial surgery, he presented at our hospital with complaints of progressive malaise and pain in his left flank. Based on his laboratory results (C-reactive protein level, 304 mg/L; leukocyte count, 11 × 109/L; and erythrocyte sedimentation rate, >140 mm/h) and computed tomography angiography (CTA) scan, an infected graft was diagnosed. An autogenous vein reconstruction was performed by in situ replacement of the aortobifemoral graft by a neobifurcation using both femoral veins. During this operation, a connection between the colon and the aortic graft was diagnosed as a probable cause of the graft infection; the defect was primarily closed. Furthermore, an iatrogenic ureteral injury occurred (no preoperative ureteral stents were placed) and was corrected by end-to-end anastomosis over a double J catheter. Antibiotics were given for 6 weeks postoperatively. This antibiotic regimen consisted of cefuroxime, metronidazole, vancomycin, and caspofungin based on cultures. Six weeks after the operation, the double J catheter was removed. Seven weeks after reconstruction, the patient presented with severe anemia caused by excessive hematuria. On examination of the abdominal CTA scan, there was a high suspicion of a fistula between the right ureter and the right leg of the venous bypass (Fig 1). An endovascular repair using an aortouni-iliac device (Endurant, Medtronic, Minneapolis, Minn) was performed on the right side (Fig 2). The left external iliac artery was ligated, and left leg circulation was restored by performing an 8-mm Dacron femorofemoral crossover bypass (Vascutek Ltd, Renfrewshire, Scotland). Perioperatively, the same antibiotics were restarted (cefuroxime, metronidazole, vancomycin, and caspofungin) for up to 1 week postoperatively. During follow-up, after 3 years, he developed a type B aortic dissection that was treated conservatively. Several months later, he developed a type A aortic dissection, for which he underwent a Bentall procedure. Up to now, follow-up by Doppler echocardiography and CTA scanning remains uneventful.

Fig 1

Case 1. Computed tomography angiography (CTA) image demonstrates a fistula between the right autogenous vein reconstruction and the right ureter with a double J stent in situ.

Fig 2

Case 1. Computed tomography angiography (CTA) maximum intensity projection reconstruction shows an overview of the aortouni-iliac device with Dacron femorofemoral crossover bypass.

Case 2

A 71-year-old man with a history of hypertension and atrial fibrillation underwent an aortobifemoral graft for aneurysmal disease of the abdominal aorta and iliac arteries in 2008. Four years later, the aortobifemoral graft was replaced by in situ autogenous vein reconstruction using both femoral veins because of graft infection (Fig 3). During follow-up, a progressive dilation located directly above the bifurcation in the venous reconstruction was observed. In approximately 2 years' time, the dilation had grown from 39 mm to 77 mm (Fig 4). In July 2014, an endovascular repair using an aortouni-iliac device (Endurant) was performed on the left side, an occluder device was placed in the right external iliac artery, and the right leg circulation was restored by performing an 8-mm rifampicin-soaked Dacron femorofemoral crossover bypass (Fig 5). Before the operation, the patient showed no signs of infection; there was no fever, no increased infection parameters in the laboratory tests (C-reactive protein, 4.5 mg/L; leukocyte count, 5.66 × 109/L; and erythrocyte sedimentation rate, 9 mm/h), and no signs of infection on CTA. After surgery, the patient recovered well and was discharged from the hospital with no further complications. Three years later, the maximum diameter of the NAIS vein reconstruction is 32 mm. Furthermore, there is good patency of the stent and femorofemoral crossover bypass, and no endoleak was observed.

Fig 3

Case 2. Computed tomography angiography (CTA) maximum intensity projection reconstruction (from June 3, 2012) 4 weeks after surgery, in situ neoaortoiliac system (NAIS) autogenous vein reconstruction using both femoral veins. On the left side, a double system in the femoral vein was accepted. A, Coronal view. B, Sagittal view.

Fig 4

Case 2. Computed tomography angiography (CTA) maximum intensity projection reconstruction (from June 11, 2014) demonstrates an aneurysm of 77 mm 2 years after neoaortoiliac system (NAIS) vein reconstruction. In the meantime (January 2014), the patient underwent a laparoscopic nephrectomy (left) because of an afunctional kidney due to recurrent infections.

Fig 5

Case 2. Computed tomography angiography (CTA) maximum intensity projection reconstruction shows an overview of the aortouni-iliac device with Dacron femorofemoral crossover bypass. The aneurysm had resolved.

Discussion

Performing an in situ NAIS reconstruction using autologous veins can be a good option for treatment of an infected aortic graft. Vein graft reconstruction has several advantages, including a lower rate of reinfection compared with in situ replacement with a synthetic graft or cryopreserved allograft.3, 6 In addition, long-term patency with NAIS vein reconstruction is superior to extra-anatomic bypass.3, 8, 9, 10 Only a few studies have examined the long-term outcome of vein reconstruction.3, 5, 6, 7 The most common postoperative complication was stenosis. No postoperative dilation was reported by Ali et al (including 187 NAIS reconstructions), Daenens et al (including 49 NAIS reconstructions), or Gibbons et al (including 27 NAIS reconstructions). Only Ehsan and Gibbons diagnosed a false aneurysm in a subset of patients (4 of 48) after NAIS vein reconstruction. In our second case, the cause of the dilation is unclear. Perhaps it is due to the quality of the veins used or progressive arterial disease. Infection was deemed unlikely because of the absence of fever, increased infection parameters in the laboratory tests, or signs of infection on preoperative CTA.

A fistula between the ureter and autogenous vein reconstruction, as described in the first case, was not reported in the previously mentioned studies.3, 5, 6, 7 The fistula was presumably caused by iatrogenic ureteral injury at the NAIS vein reconstruction and subsequent poor healing due to the presence of local infection. Use of preoperative ureteral stents might have prevented iatrogenic ureteral injury during the NAIS vein reconstruction and therefore also the fistula. Seven weeks after the NAIS vein reconstruction and 1 week after removal of the double J catheter, the fistula was diagnosed, so presumably the ureter defect had not healed yet. A few studies reported a positive outcome using endovascular repair to treat a primary arterioureteral fistula.11, 12, 13, 14

An endovascular repair was chosen for both patients because of the high chance of having to deal with a “hostile abdomen,” which could make open repair difficult and high risk. In the first case, a short graft to control the bleeding was considered but not chosen because we wanted a definitive treatment. If a short graft became infected, open surgery would probably be needed to solve the problem. We considered the patient unfit for this type of abdominal surgery. Also, a left aortouni-iliac device and metal alloy plug placement of the right side was considered but did not have our preference because we wanted to seal the defect (fistula). If the fistula was not sealed, there was still an open connection between the urinary tract and vascular systems. Hence, there was more potential risk for development of a complication or infection (urinoma, thrombus or embolus, infected hematoma, abscess). The risk of stent infection in the first patient was accepted and reduced by antibiotic cover preoperatively and postoperatively. Both patients tolerated the procedure well, without complications.

Conclusions

By presenting these two cases, we wish to emphasize that an endovascular strategy can be a good alternative for a high-risk open repair in patients with complications after NAIS vein reconstruction.