Stenting of an antegrade aortomesenteric bypass complicated by stent fracture and migration to the aortic bifurcation

A 49-year-old woman with worsening postprandial abdominal pain and nausea showed a severe stenosis of the celiac trunk and occlusions of the superior mesenteric artery (SMA) and inferior mesenteric artery on computed tomography (CT) angiography. The diagnosis of chronic mesenteric ischemia was made. Because of her young age, open surgery was favored, and a reversed saphenous vein was used to create a short antegrade aorta-SMA bypass originating from the infraceliac aorta close to the anatomic origin of the SMA as this technique was preferred by the operating surgeon at the time. The patient recovered well from surgery and was discharged on postoperative day 6. At 3 years, she complained of recurring symptoms, and duplex ultrasound examination showed a >70% stenosis that was also confirmed by CT angiography. In light of these findings, the patient was referred for stenting of the aortomesenteric bypass. An 8- × 18-mm balloon-expandable stainless steel stent (Palmaz Genesis; Cordis, Santa Clara, Calif) was inserted through a right axillary access and was successfully deployed at the origin of the bypass, protruding 2 to 3 mm in the aorta. No complication was recorded, and the patient was discharged on the same day. Seven years later, the patient was still an active smoker and started complaining of intermittent claudication. An exercise program and smoking cessation were recommended. Three years later (10 years after stenting), claudication worsened, and the ankle-brachial index had dropped to 0.6. CT angiography revealed a high-grade stenosis at the aortic bifurcation. This stenosis was unusual as it was not simply caused by development of an atherosclerotic plaque. Indeed, it was complicated by an 8- × 8- × 9-mm fragment of the mesenteric stent that had fractured and migrated to the aortic bifurcation, where it was now located in a transverse position as shown on the axial, coronal, and sagittal views of CT angiography (A-C). The remaining portion (9 mm long) of the stent in the bypass remained patent. We could speculate that even though the patient had other risk factors, the growth of the plaque might have been accelerated by the presence of this intraluminal foreign body. Because the lesion was confined to the aortic bifurcation, she was treated with an aortobi-iliac bypass. Perioperative findings of the resected plaque at the aortic bifurcation were concordant with the three-dimensional CT images (D). The postoperative course was uneventful, and the patient was symptom free with palpable distal pulses at the 1-year follow-up visit. Informed consent was obtained from the patient for publication of this report.

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