Extra-Anatomic Aortic Bypass Paralleling the Right Ventricle with Arch Reconstruction for Treatment of an Infected TEVAR Graft
Andrew P. Rabenstein, Thomas V. Bilfinger, Shang Loh, Allison J. McLarty.
Stony Brook University Hospital, Stony Brook, NY, USA.
Objective: We present the clinical progression, evaluation and management of an infected TEVAR graft in a patient who initially presented with an aortic arch pseudoaneurysm.
Methods: A 42 year old woman presented with atypical chest pain five years after TEVAR placement for a traumatic aortic transection. A pseudoaneurysm proximal to the stent was diagnosed and she underwent carotid-subclavian bypass and subsequent TEVAR extension. She represented one week after discharge with Pseudomonas bacteremia. She developed recurrent hemoptysis. CT angiography showed a new periesophageal collection without endoleak. Over the next month she had sepsis and recurrent hemoptysis with concern for aortoenteric fistula but multiple angiograms showed no aortic leak. Ultimately she became acutely hypotensive and anemic – imaging confirmed a contained aortic rupture proximal to the stent and she went emergently to the OR for a two-stage repair.
Stage 1: median sternotomy, extra-anatomic bypass graft from ascending aorta to descending aorta parallel to right ventricle, resection of necrotic aortic arch under circulatory arrest, implantation of bifurcated hemashield graft from ascending aorta to innominate and left carotid arteries, removal of proximal TEVAR extension; oversewing of proximal and distal ends of stent graft.
Stage 2 :left thoracotomy with resection of descending thoracic aorta and removal of the TEVAR
Conclusion: Patient recovered from surgery and was discharged from the hospital after 30 days. Extra-anatomic aortic bypass represents a rare but valuable tool in management of infected TEVAR grafts.
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