Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 47-48

Stent Endarterectomy and patch closure of occluded infrarenal aortic bare metal stent for critical limb ischemia


Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication8-Mar-2019

Correspondence Address:
Prof. Ajay Savlania
Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_54_18

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  Abstract 


The technological advances in the field of percutaneous procedures have facilitated the increased use of endovascular modalities for peripheral arterial disease management with benefit of decreased morbidity. Progression of disease in this group of patients has further led to the rise of difficult-to-manage group of patients. We report a case of occluded bare metal infrarenal aortic stent, which was managed by stent endarterectomy of the stent-bearing segment of aorta followed by repair of aortic segment with patch aortoplasty. The patient is doing fine at 8 months of follow-up. This case describes the feasibility of the management of occluded aortic stents placed for occlusive disease by endarterectomy with explantation of stents as revascularization procedure in good-risk patients for surgery.

Keywords: Aortic endarterectomy, patch aortoplasty, stent explantation


How to cite this article:
Savlania A, Reddy A, Pandey A, sandeep M. Stent Endarterectomy and patch closure of occluded infrarenal aortic bare metal stent for critical limb ischemia. Indian J Vasc Endovasc Surg 2019;6:47-8

How to cite this URL:
Savlania A, Reddy A, Pandey A, sandeep M. Stent Endarterectomy and patch closure of occluded infrarenal aortic bare metal stent for critical limb ischemia. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Mar 21];6:47-8. Available from: http://www.indjvascsurg.org/text.asp?2019/6/1/47/253738




  Introduction Top


Aortic endarterectomy[1],[2] is an uncommon procedure in modern vascular surgery. This procedure is a durable operation in selective patients with short aortic occlusions. We present an open infrarenal aortic stent endarterectomy procedure with patch aortoplasty for a patient with occluded infrarenal bare metal stent.


  Case Report Top


A 45-year-old female presented with gangrene of the left foot, with foul-smelling discharge and dry gangrene of toes of the right foot. She had a history of infrarenal aortic stenting with bare metal stent 1 year before, at another institute, for bilateral lower-limb claudication. The patient had quit smoking for 1 year. Clinical evaluation revealed the absence of pulses bilaterally and distally in the femoral arteries. Computed tomographic angiogram (CTA) showed occlusion of infrarenal aorta and proximal segment of the common iliac arteries, left longer than right [Figure 1]a. Since only the right lower limb was salvageable, revascularization was planned due to critical limb ischemia of the right lower limb along with the left side below-knee amputation.
Figure 1: (a) Computed tomography angiogram volume-rendered reconstruction showing occluded infrarenal aorta and proximal common iliac arteries with net-like stent in situ in aorta. (b) Explanted complete bare metal stent with neointimal hyperplasia in struts of stent with organized thrombus in the lumen of stent

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Intraoperatively during planned aortobifemoral bypass, both common iliac arteries were relatively soft to palpation, without characteristic of atherosclerotic changes. Because of likely organized thrombus in common iliac arteries, plan was changed to aortic stent explantation, with thrombectomy of common iliac arteries. After adequate mobilization and heparinization, infrarenal aorta and common iliac arteries were clamped. With the technique of conventional axial endarterectomy, the stent was explanted completely, along with organized clot tails from iliac arteries. The stent was completely clogged with neointimal hyperplasia in struts and intraluminal thrombus [Figure 1]b. The aorta was repaired by polyester patch aortoplasty [Figure 2]a. Good pulses were restored in the right foot and left popliteal artery. After closure of laparotomy and groin wounds, wounds were sealed with Ioban™ adhesive sheets followed by left below-knee amputation.
Figure 2: (a) Intraoperative picture showing repair of aorta with coated polyester patch. (b) Postoperative computed tomography angiogram volume-rendered images showing patent aorta and iliac arteries with intact repair

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The patient did well in the postoperative period and was discharged on day 9. CTA at 1-month follow-up showed patent aortoiliac segment with intact patch aortoplasty [Figure 2]b. The patient is doing well at 8 months of follow-up with palpable pulses in the right foot and left popliteal artery. Stump of left below-knee amputation site healed well along with healed stumps of third and fourth toes which were amputated during follow-up.


  Discussion Top


The first endarterectomy was reported by the Portuguese surgeon Dos Santos in 1947.[1] Aortoiliac endarterectomy became a widely practiced treatment of aortoiliac occlusive disease until the late 1970s[2] when prosthetic bypass replaced aortoiliac endarterectomy and established later as gold standard treatment modality due to durable results.[3] Stentgraft explantation has been reported widely for expansion of aneurysm sacs and rupture of aneurysms despite being treated with endovascular stentgraft repair,[4] but report of occluded bare metal stent removal used for the treatment of steno-occlusive lesion in infrarenal aorta by stent endarterectomy (as stent was embedded up to tunica media in the lower part of the infrarenal aorta) followed by patch aortoplasty is not classically described in literature.

Endarterectomy for short-segment aortoiliac segment has been described with durable long-term results. Endarterectomy may be used for localized disease confined to the distal aorta, aortic bifurcation, and common iliac arteries. In such patients, the long-term patency is excellent and equivalent to that of graft procedures.[5],[6],[7] The patient in our case could have been managed endovascularly, preferably with covered stent to avoid thrash from thrombus in stent, but due to long lesion which is often associated with higher reintervention rate with endovascular procedures and higher cost of covered stents, it was decided to proceed with open revascularization which has the merits of longer patency and lower reintervention rate.[8]


  Conclusion Top


We present a case of occluded infrarenal aortic bare metal stent implanted for occlusive lesion of infrarenal disease. Occluded stent was managed by stent endarterectomy of stent-bearing segment of aorta followed by aortic repair with polyester patch aortoplasty. As in the future we may get more and more occluded stents due to the increasing use of endovascular therapy, this technique will surely help some good-risk patients in the future.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dos Santos JC. Sur la desobstruction des thromboses arterielles anciennes. Mem Acad Chir1947;73:409-11.  Back to cited text no. 1
    
2.
Wylie EJ. Thromboendarterectomy for arteriosclerotic thrombosis of major arteries. Surgery 1952;32:275-92.  Back to cited text no. 2
    
3.
Brewster DC, Cooke C. Longevity of aortofemoral bypass grafts. In: Yao JST, Pearce WH, editors. Long-Term Results in Vascular Surgery. East Norwalk: Appleton and Lange, 1993. p. 149-61.  Back to cited text no. 3
    
4.
Forbes TL, Harrington DM, Harris JR, DeRose G. Late conversion of endovascular to open repair of abdominal aortic aneurysms. Can J Surg 2012;55:254-8.  Back to cited text no. 4
    
5.
Darling RC, Linton RR. Aortoiliofemoral endarterectomy for atherosclerotic occlusive disease. Surgery 1964;55:184-94.  Back to cited text no. 5
    
6.
Inahara T. Evaluation of endarterectomy for aortoiliac and aortoiliofemoral occlusive disease. Arch Surg 1975;110:1458-64.  Back to cited text no. 6
    
7.
van den Akker PJ, van Schilfgaarde R, Brand R, Hajo van Bockel J, Terpstra JL. Long-term results of prosthetic and non-prosthetic reconstruction for obstructive aorto-iliac disease. Eur J Vasc Surg 1992;6:53-61.  Back to cited text no. 7
    
8.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg 2007;45 Suppl S: S5-67.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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