Late Disrupture of Aortic Dacron Graft
Article Outline
We report a case of a late complication following an aortic graft replacement in a 69-year-old lady who presented with huge pseudoaneurysm from retroperitoneal tunneled thoracofemoral Dacron graft performed 22 years earlier. The pseudoaneurysm was treated by hematoma evacuation and the Dacron graft was replaced by an interposition PTFE bifurcated graft. The patient made an uneventful recovery.
Keywords: Aorta, Aorto-bifemoral graft, Rupture of graft, Pseudoaneurysm
Introduction
Occlusion, anastomotic pseudoaneurysms and infection are the main known late complications of arterial grafts. In the English vascular literature dilatation and aneurysms of grafts and graft rupture have been described when long term follow-up had been carried out.1, 2, 3, 4, 5 We present a case report of late Dacron aortic graft body rupture without extrinsic etiologic factors. Diagnosis of the complication is readily apparent by clinical examination and imaging studies.
Case Report
A 69-year-old woman was admitted to our hospital with worsening low back and left flank pain. The surgical history revealed a thoracic aortofemoral bypass with knitted Dacron graft performed 22 years earlier after several abdominal operations for intestinal ischemia and chronic ischemic leg. Other medical history included coronary artery disease and chronic obstructive pulmonary disease.
Three days before surgery she was admitted to the orthopedic spinal surgery unit, suffering from severe low back pain for a month.
On examination, the patient was afebrile, normotensive and with a heart rate of 88. The lung sounds were clear, bilaterally. Her abdomen was soft, but mildly tender in the left upper quadrant. The patient's femoral, popliteal and pedal pulses were all palpable.
Laboratory results showed hemoglobin 12.7
g/dl and platelet count of 330.0000/mm3.
A chest radiograph showed no effusion or infiltrate. A computerized tomography (CT) scan of abdomen and chest showed a large hematoma in the left low quadrant of the abdomen, centered around the retroperitoneal tunneled thoracofemoral graft (Fig. 1). Suspicion that this hematoma was a pseudoaneurysm led us to obtain an aortogram, which demonstrated a pseudoaneurysm arising from the body of the graft, without involvement of anastomosis (Fig. 2).
Fig. 1
CT – computerized tomography scan: large hematoma in the left side of abdomen around the retroperitoneal tunneled graft.
Fig. 2
Aortography – a pseudoaneurysm arising from the body of the bifurcated graft (extravasation).
In the absence of clinical and laboratory findings of infection, no further tests were undertaken and the patient was transferred to the operating room. At operation, through a left subcostal retroperitoneal incision, without opening the chest, a pseudoaneurysm arising from the body of the graft and blood clots just below the left hemidiaphragm were found. The anastomoses were intact. The pseudoaneurysm was repaired using a PTFE polytetrafluoroethylene bifurcated graft. The postoperative course was uneventful.
At histological examination the graft was encapsulated by dense fibrous tissue, the wall of the graft was thinned and widely fragmented and filled with connective tissue with no signs of inflammation. Bacterial cultures from the excised graft were negative.
At 4-year follow-up she is doing well, with a patent thoracofemoral graft on spiral CT angiography (Fig. 3).
Fig. 3
CT computerized angiography 4 years afterwards. Follow-up: normal thoracofemoral graft.
Discussion
Over the last 40 years, Dacron grafts have been the most commonly used, such as knitted and woven, with different velour types.
The factors leading to the graft failure include: infections, bleeding, thrombosis, anastomotic pseudoaneurysm, primary structural defect.1, 2, 3, 4, 5
Non-anastomotic graft rupture is rare and reports of such indicate that they usually occur more than 5 years from the time of implantation.3, 4
To our knowledge, thoracofemoral graft rupture has not been reported previously. Diagnosis of graft failure may be done on clinical examination, with a high index of suspicion for pseudoaneurysm or rupture. It can be confirmed by angiographic examination or CT (computerized tomography) studies.
In conclusion: this unusual entity may often be misdiagnosed and may lead to catastrophic outcomes: life threatening hemorrhage. A routine monitoring of the implanted graft by ultrasonographic examination is mandatory.
References
- . Late rupture of knitted Dacron double velour arterial prosthesis. Acta Chir Scand. 1985;151:391–395
- . Late rupture of prosthetic aortic grafts. Am J Surg. 1987;153:453–458
- . Postoperative dilatation of knitted Dacron aortic bifurcation graft. J Vasc Surg. 1990;12:291–297
- . The late complications of aorto-ilio-femoral Dacron prosthesis: dilatation and anastomotic aneurysm formation. Eur J Vasc Surg. 1992;6:282–287
- . Morbidity and mortality of reconstructive surgery of non-infected false aneurysms detected long after aortic prosthetic reconstruction. Arch Surg. 1998;133:45–49
PII: S1533-3167(07)00014-3
doi:10.1016/j.ejvsextra.2007.03.002
© 2007 Elsevier Ltd. All rights reserved.
Refers to article:
- Late Disrupture of Aortic Dacron Graft , 22 May 2007
