Neointimal dissection - a rare complication to endovascular treatment in grafts and stent grafts

Abstract

Background: Neointima formation and hyperplasia in vascular grafts may lead to graft complications threatening the patency of the vascular reconstruction. A rare complication to endovascular treatment of grafts and stent grafts is dissection inside the graft.

Case report: We present here a case of a 69-year-old female with acute occlusion of the limb of an aorto-bifemoral graft for the third time, 16 years after the primary operation. As at the first two occasions, catheter-based intra-arterial thrombolysis was performed, but with residual stenosis inside the graft. During stent placement, dissection of the neointima or fibrin sheet occluded the inflow to the stent. The complication was resolved with placement of kissing stents.

Conclusions: It is important to recognize iatrogenic neointima dissection inside graft and stent grafts, as continued thrombolysis will not solve this, but increase the risk of hemorrhagic complications.

Keywords: Dissection; Endovascular treatment; Fibrin sheet; Graft; Neointima; Stent graft.

Fig. 1

After 12 h of thrombolysis, there is residual stenosis in the proximal part of the left aortofemoral limb (a). After placement of a sheet in the left groin, there is some thrombus formation or loosening (arrow), as well as a dissection of thrombus or neointima (broad arrow) (b)

Fig. 2

After placement of kissing stents, there are some irregularities proximal to the left stent (a). The stents were extended proximally, but control angiogram show dissection at two levels (arrows) (b)

Fig. 3

Final angiogram after kissing stents all the way up to the proximal anastomosis of the graft (a), and after repositioning of the sheet to the true lumen (b)

Fig. 4

The kissing stents was been prolonged up thru the main body of the graft, and balloon inflated. Occluded stents from prior treatment in the background