Explant of an infected four-vessel fenestrated and bilateral iliac branch stent graft in a patient of Jehovah's Witness faith

Abstract

Infection of fenestrated-branched stent graft is an uncommon but potentially catastrophic complication. The technical challenge of total stent graft explant and reconstruction of the renal-mesenteric arteries is associated with high mortality and morbidity. Among patients of Jehovah Witness faith, refusal to accept blood transfusion adds to the risk given the invasiveness of these operations. We report a Jehovah's Witness faith patient with a recurrent infection of a four-vessel fenestrated and bilateral iliac branch stent graft treated in two stages by axillofemoral bypass, followed by extra-anatomical reconstruction of the mesenteric, renal, and left internal iliac arteries and total stent graft explant and aortic stump closure.

Keywords: Aortic explantation; Extra-anatomical bypass; Fenestrated endovascular aneurysm repair (F-EVAR); Jehovah's Witness; Stent graft infection.

Fig 1

Surgical steps. (A) Supraceliac aortotomy and excision of the proximal stent. (B) Transection and ligation of the proximal celiac axis and end-to-end anastomosis using a cryopreserved allograft. (C) Hepato-right renal artery bypass using an autologous great saphenous vein (GSV) graft. (D) Superior mesenteric artery (SMA) bypass with a cryopreserved allograft limb and left renal bypass using an autologous GSV graft.

Fig 2

(A) Complete explantation of the fenestrated segment and side stents. (B) Aortic stump closure. (C) Reinforcement with harvested fascia lata. (D) Final surgical result. (E) The explanted endograft.

Fig 3

Artistic illustration and computed tomography angiography (CTA) three-dimensional reconstructions demonstrating. (A and B) the four fenestration, company-manufactured, patient-specific endograft with bilateral iliac branch devices in the setting of endoprosthesis infection and right iliac axis occlusion; and (C and D) the final result after axillobifemoral bypass, revascularization of the visceral vessels using a composite graft (cryopreserved aortoiliac allograft and inverted GSV graft) via the J. Ballard technique, complete explantation of the infected endograft, and retrograde revascularization of the left hypogastric artery with a cryopreserved allograft.