Abscess Formation Requiring Extraluminal Arterial Graft Explantation and Bypass Surgery

Aggressive vessel dilation for the implantation of a stent-graft, known as the pave-and-crack technique, is used for severely calcified lesions in patients with lower extremity arterial disease.¹ An 81-year-old man who had undergone this procedure for his left superficial femoral artery (SFA) 3 months previously was referred because of a large mass around the artery that had penetrated the skin with pus discharge (Figure A). The patient had been prescribed dual antiplatelet therapy (DAPT). Computed tomography revealed that the abscess extended from the subcutaneous area to the adjacent graft (Figure B). In addition, multiple stent-grafts had been placed extraluminally to avoid calcification (Figure C) and were patent. We diagnosed a stent-graft infection and performed below-the-knee bypass using the saphenous vein, debridement of the abscess (Figure D), and removal of both the SFA and the stent-grafts.

Figure.

(A) Skin-penetrating mass in the left thigh. (B) Expansion of the mass (violet) to the adjacent SFA (green=the stent-graft). (C) Preoperative computed tomography shows the overlapping xtraluminal grafts (arrows; arrowhead=SFA calcification). (D) Intra-operative findings after debridement of the abscess (dotted line=SFA; arrowheads=the extraluminal stent-graft). SFA, superficial femoral artery.

No cases of stent-graft infection and abscess formation after this technique in the SFA have been reported. One possible explanation for the abscess is an infected hematoma. In that case, the following factors may have contributed to its persistence: (1) extraluminal placement of stent-grafts, (2) DAPT, and (3) type 3a endoleaks. Clinicians should be aware of this rare complication when a stent-graft is extraluminally placed with the pave-and-crack technique.

Disclosures

The authors declare that there are neither conflicts of interest nor funding.

The patient gave informed consent.

Reference

• 1.   Dias-Neto M, Matschuck M, Bausback Y, Banning-Eichenseher U, Steiner S, Branzan D, et al. Endovascular treatment of severely calcified femoropopliteal lesions using the “pave-and-crack” technique: Technical description and 12-month results. J Endovasc Ther 2018; 25: 334–342, doi:10.1177/1526602818763352.