Case Report

Vascular and Endovascular Surgery

2016, Vol. 50(5) 363-365
Late Leakage of the Aortic Stump ª The Author(s) 2016
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After Removal of an Infected Graft: DOI: 10.1177/1538574416652247
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Successful Surgical Treatment

Bonardelli Stefano, MD1,2,3, Nodari Franco, MD1,

Botteri Emanuele, MD1, and Barbetta Iacopo, MD1,3

Abstract
The residual stump after excision of an infected aortic graft may be subject to acute blowout due to chronic mechanical stress on a
weak arterial wall. We present a case of late aortic stump disruption that required revision after 12 months from graft removal.
Our strategy consisted of avoiding reexposure of the pararenal aorta by creating a new supraceliac stump with healthy aortic wall
after antegrade visceral debranching. This case confirms the need for long-term surveillance of aortic stumps. The use of a
supraceliac approach minimizes the risk of intraoperative blowout and postoperative disruption.

Keywords
aortic stump, aortic stump blowout, aortic stump revision, supraceliac aortic stump, aortic stump follow-up

Introduction progression of the renal stenosis by the residual thrombosis

Secondary blowout of the aortic stump is one of the main
causes of mortality after excision of aortic grafts. When stump
dilation/disruption is detected, surgical treatment should be
offered to the patient in order to prevent acute hemorrhage.
Reports of successful reinterventions on disrupting aortic
stumps are lacking in the literature. In this article, we describe
our surgical strategy to treat a disrupting aortic stump with a
good mid-term outcome.
Case Report
In January 2013, a 68-year-old male patient with a history of
aortobifemoral bypass (20 years earlier), and endovascular
repair of a late anastomotic pseudoaneurysm (2 years earlier)
was admitted for hemorrhagic shock to the emergency depar-
tement of another hospital. Upon diagnosis of a secondary
aortoduodenal fistula, the patient underwent emergency axil-
lobifemoral bypass, direct duodenorrhaphy, and removal of
both the aortic graft and the aortic cuff. Pararenal aorta was
sutured with sacrifice of the right renal artery. After 2 weeks
of hospitalization, the patient was discharged. Three months
later, an angio-computed tomography (CT) showed a normal
aortic stump of 32  30 mm with intraluminal thrombosis
(Figure 1A-D). A second control at 6 months revealed dimen-
sional stability, but retrograde progression of the thrombus
causing severe stenosis of the left renal artery (LRA; Figure
1B-E). A third control at 12 months showed stump reperfu-
sion and significant enlargement (52  38 mm) with further
(Figure 1C-F). The diagnosis of contained rupture of the
lower edge of the aortic suture urged us to perform a stump
revision.
After bilateral subcostal incision, the supraceliac aorta and
the common hepatic artery (CHA) were exposed through sec-
tion of the lesser omentum and mobilization of the left hepatic
lobe. Then, the superior mesenteric artery (SMA) was con-
trolled by gentle downward retraction of the pancreatic head.
Finally, the LRA was reached by partial left-sided medial visc-
eral rotation.
An antibiotic-soaked Dacron bifurcated graft (14  7 mm)
was modified on bench into a trifurcated graft (Figure 2A).
End-to-side anastomosis of the main prosthetic body was
performed immediately below the diaphragmatic hiatus. An
end-to-end anastomosis with the LRA was performed after
retropancreatic tunnelization of the first prosthetic branch.
Finally, 2 end-to-end anastomoses with the SMA and the CHA
were performed with the 2 remaining prosthetic branches
(Figure 2B). A new aortic stump was then created suturing
the aorta upstream of the coeliac trunk with a double-layer
1
Azienda Ospedaliera ‘‘Spedali Civili di Brescia’’, U.O. Chirurgia I, Brescia,
Lombardia, Italy
2
Università degli studi di Brescia
3
Università degli studi di Milano
Corresponding Author:
Barbetta Iacopo, Università degli studi di Milano.
Email: iacopo.barbetta@gmail.com
364
Figure 1. Evolution of the pararenal aortic stump in the coronal and sagittal reconstructions. Angio-CT at 3 (A-B), 6 (C-D) and 12 months (E-F).
Note. A late dilation is clearly observed together with preocclusive stenosis of the residual left renal artery.
continuous suture and bovine pericardium pledgets (Figure 2C).
Postoperative hospitalization was uneventful. The patient was
discharged on postoperative day 11. After 18 months of
follow-up, the patient was alive and free from recurrent infec-
tions, the supraceliac aortic stump showed no sign of disruption,
and the 3 visceral vessels were all patent (Figure 3).
Discussion
Prosthetic infection is a devastating complication of aortic sur-
gery, and it is widely accepted that complete removal of the
infected graft is the only definitive treatment. In case of gross
intraabdominal contamination, extra-anatomic bypass and
suture of the abdominal aorta is the best option to avoid
reinfection.
Creation of a solid aortic stump, however, may be difficult
because the perianastomotic wall has been weakened by the
infectious/inflammatory process. Indeed, suturing a portion of
healthy aortic wall and at the same time preserving both renal
arteries may not be possible. Despite surgeons’ best efforts, up
to 30% of abdominal aortic stumps are subject to secondary
rupture1) and such catastrophic complication can unpredictably
Vascular and Endovascular Surgery 50(5)
occur at an early or a late stage after surgery.2 Stump rupture is
a consequence of chronic systolic stress on a segment of aortic
wall contaminated by the infection. It is known that in case of
enteric fistulization, the risk of stump blowout is higher than in
other prosthetic infections because the involved germs are
more virulent.3
Prevention of stump blowout is only possible if the initial
signs of leakage or dilation are detected. In our opinion, a
regular CT follow-up is mandatory to monitor the stump dia-
meter and morphology (we check it at 3, 6, 12 months, and then
once a year). Upon detection of stump disruption, surgical
revision is indicated unless patient’s general condition prohi-
bits a new procedure requiring general anesthesia and aortic
cross-clamp. The goal of surgery is to create a new and more
cranial aortic suture in order to use uncontaminated healthy
aortic wall.
These procedures are generally challenging as the abdomen
is full of adhesions due to previous surgery, and the infectious/
inflammatory process has effaced retroperitoneal anatomy.
Furthermore, the risk of intraoperative stump blowout during
aortic exposure is extremely high, and a supraceliac aortic
clamp should always be prepared as the first step of the
Stefano et al
Figure 2. A trifurcated antibiotic-soaked Dacron graft is anastomosed
on the supraceliac aorta (A). The three branches (B) are then anasto-
mosed to the left renal artery (arrow), the hepatic artery (arrow-head)
and superior mesenteric artery (asterisk). Finally a new supraceliac
aortic stump is created with the help of bovine pericardium (C).
Figure 3. Control angio-CT at 18 months from the procedure:
antegrade debranching of the visceral vessels (A) with patency of the
three prosthetic branches and no sign of stump disruption/dilation/
evolution (B-C).
365
procedure. In this case, reexposure of pararenal aorta and
access to periaortic retroperitoneum was simply avoided. In
order to suture the aorta in the uncontaminated supramesocolic
space, a 3-branched extra-anatomic aortovisceral bypass was
performed. The use of an extra-anatomic reconstruction to treat
paravisceral aortic infection has already been described with
either retrograde4 or antegrade5 approach, however, not in case
of stump disruption. We think that this technique should be the
standard of care for the treatment of disrupting stumps, in order
to minimize the risk of intraoperative blowout and postoperative
reinfection. Endovascular treatment of aortic stump leakage or
aortic stump fistulization with duodenum by release of various
plugs (iliac plugs or Amplatzer plugs, according to stump size)
has also been reported as an alternative to surgery.6,7 We are
strongly convinced, though, that this approach is to be reserved
to either patients whose conditions preclude any surgical attempt
or to emergent cases as a bridge to surgery.
Acknowledegment
The authors appreciate the patient’s permission to submit the case.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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