CASE REPORT

Recanalization of an Occluded Infrainguinal Vein GraftComplicated by Graft Aneurysm

Nirmal Kakani Æ Simon Travis Æ John Hancock

Published online: 2 August 2007

� Springer Science+Business Media, LLC 2007

Abstract The technique of subintimal angioplasty has

been described for the recanalisation of native vessels after

occlusion of infrainguinal vascular bypass grafts. We re-

port a case in which an attempt at such treatment resulted

in inadvertent but successful recanalisation of the occluded

vein graft instead. This was complicated by graft perfora-

tion and subsequent graft aneurysm which was successfully

treated with a covered stent.

Keywords Angioplasty � Subintimal angioplasty �Native vessel graft � False aneurysm � Stent

Introduction

Subintimal angioplasty is now a recognized treatment for

recanalization of native vessels [1, 2]. Successful subinti-

mal angioplasty of native vessels following occlusion of

grafts has been described [3], but successful angioplasty of

an occluded vein graft has never been described in the

literature.

Case Report

The patient, a 73-year-old male, presented with a 6-month

history of short-distance left calf claudication. Ten years

previously he had undergone left-sided femoropoplit-

eal bypass with a reversed saphenous vein anastomosed

to the above-knee popliteal artery. Duplex ultrasound

demonstrated complete occlusion of the vein graft and

Fig. 1 A Image demonstrating extravasation of contrast from the

graft in the midthigh region following angioplasty, indicating

perforation. B Image following prolonged balloon inflation; the

extravasation has ceased, with a satisfactory angioplastic result

obtained

N. Kakani � S. Travis � J. Hancock

Department of Clinical Imaging, Royal Cornwall Hospital,

Cornwall, UK

J. Hancock (&)

Department of Clinical Imaging, Royal Cornwall Hospital,

TruroCornwall TR1 3LJ, UK

e-mail: John.Hancock@rcht.cornwall.nhs.uk

123

Cardiovasc Intervent Radiol (2007) 30:1271–1273

DOI 10.1007/s00270-007-9106-6

longstanding full-length occlusion of the superficial femo-

ral artery (SFA). Angiography confirmed this and also

showed extensive proximal crural artery disease. An initial

attempt at subintimal recanalization of the native SFA failed

through inability to enter the origin of the occluded SFA with

the guide wire. The patient was considered a high risk for

repeat bypass surgery and was treated conservatively, but re-

presented 18 months later with established rest pain and foot

ulceration. A second attempt at subintimal angioplasty was

made; on this occasion the wire passed relatively easily

through what was assumed to be the subintimal space of the

occluded SFA to re-enter the lumen in the above-knee

popliteal artery. After balloon dilatation of the guide-wire

track to 5 and 6 mm it became clear that it was the occluded

vein graft that had been recanalized rather than the native

SFA. Extravasation of contrast from the graft in the midthigh

region indicated perforation, which was treated with pro-

longed balloon inflation, and following this a satisfactory

angiographic result was obtained (Figs. 1A and B).

Clinically the angioplasty was a success but at 10 days

postprocedure the patient developed a painful and pulsatile

swelling in the medial aspect of the left thigh. Duplex

ultrasound demonstrated lobulated aneurysmal dilatation of

the graft in the midthigh. Angiography confirmed aneu-

rysmal change at the site of previous perforation (Fig. 2).

Via an antegrade common femoral artery puncture a 7-mm-

diameter, 15-cm-length covered stent (Hemobahn, W. L.

Gore & Associates, Inc., Newark, DE) was successfully

deployed within the vein graft (Fig. 3). At 12 months fol-

lowing the procedure duplex ultrasound demonstrated a

patent graft and the patient has remained asymptomatic

with no ulceration.

Discussion

Bolia et al. first described subintimal angioplasty in 1989

[1]. The technique has been widely adopted within Europe,

primarily for the treatment of critical limb ischemia in the

presence of infra-inguinal occlusive disease, with reason-

able clinical outcomes reported [2]. Subintimal angioplasty

of native vessels after bypass graft occlusion has also been

reported [3] but the results of this small study were dis-

appointing.

Although there are many reports of the results of per-

cutaneous angioplasty for vein graft stenosis and throm-

bolysis for vein graft occlusion [3], this is the first report to

our knowledge of percutaneous recanalization of a chron-

ically occluded vein graft.Fig. 2 Ten days following the initial procedure, angiography

demonstrated aneurysmal change at the site of previous perforation

Fig. 3 Following the successful deployment of a 15-cm covered

stent, images show the exclusion of the aneurysmal changes

1272 N. Kakani et al.: Recanalization of an Occluded Infrainguinal Vein Graft Complicated by Graft Aneurysm

123

Aneursymal change in vein grafts is a well-recognized

phenomenon, more often seen in coronary artery grafts.

Various etiologies for aneurysm formation have been

postulated, including ‘‘blowouts’’ at sites of side branch

ligation or at the site of venous valves [4]. In our case it is

impossible to determine the anatomical pathway that the

guide wire took through the vein graft but it is clear that the

effect of angioplasty was to cause a localized perforation

and subsequent pseudoaneurysm formation. It should be

noted that although vessel perforation during subintimal

angioplasty is not uncommon, it is usually managed

straightforwardly with prolonged balloon tamponade or,

occasionally, coil embolization [5]. Pseudoaneurysm of the

SFA caused by angioplasty and stenting has been reported

only once, and then in association with infection [6], but

iatrogenic SFA psudoaneurysm from other causes is well

recognized [7–9]. The use of stent-grafts for the treatment

of such aneurysms is now commonplace; however, data are

limited regarding their long-term patency.

Treatment options for occluded infra-inguinal grafts are

often limited. Although a satisfactory angiographic and

clinical outcome was achieved in our case, we feel the risk

of perforation or pseudoaneurysm is such that we would

not advocate deliberate attempts at recanalizing chronically

occluded grafts. However, if such a procedure is performed

unintentionally, we recommend regular follow-up imaging

with duplex ultrasound to exclude aneurysmal change in

the graft.

References

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