Thread by @XavierBerardMD

1/8 Aortic graft enteric fistula & chronic occlusion of the SMA, A mini thread to explain our strategy in this high-risk scenario. #aortaEd

2/8 Early seventies patient, fever & weight loss w/ history of aortobifemoral graft done 9 years ago. CTA revealed duodenal fistula on the proximal aortic graft anastomosis

3/8 Detailed analysis of the CTA showed long occlusion of the SMA, it is highly likely that IMA would be lost during the redo surgery

4/8 In this setting, starting with antegrade SMA GSV bypass revascularization thanks to short lateral aortic cross clamping was our choice. After eversion of the first 2 cm of the SMA, inverted GSV was interposed

5/8 Distal anastomosis was done on endarteriectomized portion of distal SMA. Clamp release showed nice peristaltic waves

6/8 during the following steps: duodenal repair, infected graft total retrieval (under infrarenal cross clamp) and in situ repair w/ omentoplasty, the bypass perfused right colon & small bowel

7/8 The in situ repair was done with an already made bovine bifurcated graft (BioIntegral Surgical), as expect IMA was sacrificed. The abdomen was closed with Abthera V.A.C. & 2nd look was planned at 2 days to reassess bowel viability

8/8 during 2nd look L colectomy w/ colostomy was done, the remaining bowel was viable, the abdomen was closed. Microbiological Analysis revealed fungi and gram-negative strains, antimicrobial treatment was adapted accordingly for the following weeks period pubmed.ncbi.nlm.nih.gov/34507894/