Bilateral Leg Ischemia Due to Descending Aortic Dissection:Combined Treatment with Femoro-Femoral Cross-Over Bypassand Unilateral Aorto-Iliac Stenting

Christian Frahm,1 Matthias K. Widmer,2 Joachim Brossmann,1 Dai-Do Do3

1Department of Diagnostic Radiology, University Hospital Kiel, Arnold-Heller-Strasse 9, D-24105 Kiel, Germany2Division of Cardiovascular Surgery, University Hospital/Inselspital Bern, Freiburgstrasse, CH-3010 Bern, Switzerland3Division of Angiology, University Hospital/Inselspital Bern, Freiburgstrasse, CH-3010 Bern, Switzerland

AbstractWe report a case of aorto-iliac occlusion due to descending aorticdissection treated initially with femoro-femoral cross-over bypassand secondarily with unilateral aorto-iliac stenting because of pro-gression of the dissection. A 75-year-old man presented with acuteischemia of the right leg. CT revealed occlusion of the right iliacartery due to descending aortic dissection with a clotted falselumen. Three days after femoro-femoral cross-over bypass, isch-emia of both legs developed and angiography demonstrated occlu-sion of the infrarenal aorta and left common iliac artery. Twooverlapping stents were deployed in these vessel segments. Com-pletion angiography confirmed successful recanalization with ade-quate distal flow and good patency of the cross-over bypass.Peripheral pulses were restored and the patient’s symptoms werealleviated. Combined treatment with cross-over bypass and endo-vascular recanalization may be considered as a viable alternative toopen aortic surgery in selected cases of complicated aorto-iliacdissection with bilateral leg ischemia.

Key words: Aortic dissection—Leg ischemia—Balloon angio-plasty—Stent

Treatment of acute descending aortic dissection is mainly conser-vative unless complications such as intractable pain, aneurysmalenlargement of the false lumen, ischemia of the legs or visceralorgans, or even rupture occurs [1–3]. Surgical therapy varies ac-cording to the specific complication and includes direct aorticreplacement, thromboexclusion with permanent stapling of the dis-tal aortic arch and creation of an extra-anatomic bypass graft, distalfenestration of the dissection membrane, and open endovascularstent grafting across the primary entry tear [4, 5]. Transfemoralendovascular stent-graft repair is a promising and less invasivealternative for closing the entry site [4, 6]. Percutaneous endovas-cular stenting within the abdominal aorta or the aortic branches andpercutaneous balloon fenestration of the dissection membrane pro-vide a safe and effective method for managing peripheral ischemiccomplications of aortic dissection [7–9] and allow treatment of

patients who are unsuitable for conventional open surgical proce-dures and/or general anesthesia.

We report a case of aorto-iliac occlusion due to complicateddescending aortic dissection treated with both femoro-femoralcross-over bypass grafting and subsequent unilateral percutaneousaorto-iliac stenting.

Case ReportA 75-year-old man presented with acute ischemia of the right leg. Imme-diately before these symptoms developed, the patient had experienced anattack of severe pain in the right groin. No abdominal symptoms werereported. He was a chronic heavy smoker and had a history of chronicobstructive lung disease and arterial hypertension. Two years before admis-sion, he had undergone a 2/3 resection of the stomach for cancer.

On physical examination there was no inguinal pulse or peripheralpulses palpable on the right side. CT revealed a type B aortic dissection andan occlusion of the right common and external iliac artery as well as a mildstenosis of the infrarenal aorta due to expansion of the clotted false lumen(Fig. 1). As the patient was at high risk for general anesthesia, femoro-femoral cross-over bypass grafting (from left to right) was performed usingan 8 mm diameter PTFE graft, and the symptoms of the right leg improved.Three days after surgery, ischemia of both legs developed. Color-codedduplex sonography revealed patency of the left common iliac artery and ofthe cross-over bypass but with severely reduced flow. Instead of conven-tional aortic surgery, percutaneous endovascular treatment was considered.

A 4 Fr sheath was inserted percutaneously into the left common femoralartery. Angiography via the sheath confirmed patency of the cross-overbypass and showed a new left-side occlusion ending in the common iliacartery due to progression of the dissection (Fig. 2A). After exchanging the4 Fr sheath for an 8 Fr sheath, the occlusion on the left side was crossed andrecanalized using a 0.035 inch guidewire (Terumo Europe, Leuven, Bel-gium) guided by a 5 Fr Cobra 1 Catheter (Cordis Europe, Roden, TheNetherlands). Then, a calibrated 5 Fr pigtail catheter (Cordis Europe,Roden, The Netherlands) was placed in the abdominal aorta at the level ofthe renal arteries and subsequent angiography demonstrated the completeextent of the recanalized occlusion beginning in the infrarenal aorta about 6cm below the renal arteries and ending in the left common iliac artery witha total length of 5 cm (Fig. 2B). The systolic intra-arterial pressure gradientbetween abdominal aorta and left external iliac artery was 60 mmHg.Because no stent of suitable length was available to us at the time, wedecided to use two 12 mm � 58 mm balloon-expandable stents (Jostentperipheral, Jomed, Switzerland). The stents were deployed in an overlap-ping arrangement, beginning with the distal stent (Fig. 2C, D). Completionangiography demonstrated successful recanalization of the infrarenal aorta

Correspondence to: C. Frahm, M.D.; email: christian.frahm@rad.uni-kiel.de

CardioVascularand InterventionalRadiology

© Springer-Verlag New York, Inc. 2002 Cardiovasc Intervent Radiol (2002) 25:444–446Published Online: 27 March 2002 DOI: 10.1007/s00270-002-1918-9

and left common iliac artery (Fig. 2D) with good distal flow and properfunction of the cross-over bypass. The pressure gradient between aorta andleft external iliac artery was completely resolved. Femoropopliteal angiog-

raphy ruled out a peripheral embolism. Intravenous heparin infusion (1000U/h) was continued and the patient was subsequently anticoagulated withphenprocoumon.

Fig. 1. Initial CT scan revealed adescending aortic dissectionextending into the abdominal aorta(arrows: A, B) and right iliac artery(arrows; C, D). Within the infrarenalaorta and right iliac artery, the falselumen was clotted. Due toexpansion of the clotted falselumen, there was a mild stenosis ofthe infrarenal aorta (arrow; B) andan occlusion of the right commoniliac artery (arrow; C) and externaliliac artery (arrow; D).

Fig. 2. Angiography and documentation of left-sideaorto-iliac stenting 3 days after femoro-femoralcross-over bypass. A Retrograde angiography (vialeft groin puncture and a 4 Fr sheath) ruled out adysfunction of the femoro-femoral bypass, butrevealed a new occlusion of the left common iliacartery, resulting in an acute ischemia of both legs. BAortography (after recanalization via the left femoralroute) showed the complete extent of the newocclusion involving the distal end of the infrarenalaorta also. (Note the small sacculation of theinfrarenal aorta and aneurysmal sacculation of theleft common iliac artery. There was no contrastagent seen in the right kidney, because it wasperfused from the false lumen.) C Two balloon-expandable stents were deployed slightlyoverlapping each other in the left common iliacartery and distal aorta. Note that the curved run ofthe aorta is not due only to elongation but also toscoliosis. D Completion angiography after left-sideaorto-iliac stenting demonstrated successfulrecanalization with satisfactory recovery of thevessel lumen.

C. Frahm et al.: Bilateral Leg Ischemia Due to Dissection 445

Following the procedure, the patient’s symptoms were alleviated, allperipheral pulses were restored, and the ankle-brachial systolic pressureindex measured 0.96 on the right and 1.03 on the left. The patient wasdischarged from the hospital 7 days after stent placement and remainedasymptomatic up to now (9 months after discharge).

DiscussionAcute ischemia of the lower extremities due to complicated de-scending aortic dissection can be safely and effectively treated bypercutaneous endovascular stent placement and/or balloon fenes-tration [7–10]. These minimally invasive treatment options are ofparticular importance for the management of emergencies in pa-tients unfit or at high risk for open surgery. In this case of bilateralleg ischemia, combined treatment with femoro-femoral cross-overbypass and single-side aorto-iliac stenting was applied. Cross-overbypass grafting was performed at first because initially the patienthad suffered only unilateral iliac occlusion and leg ischemia. Incases of bilateral leg ischemia with simultaneous onset on bothsides, percutaneous treatment with stent deployment and/or balloonfenestration can be employed primarily and, if the percutaneousprocedure is successful only on one side, additional cross-overbypass grafting may be performed subsequently. If necessary, thebypass operation can even be carried out under local anesthesia.Thus, combined treatment with femoro-femoral bypass and percu-taneous endovascular recanalization may be considered as a viablealternative to open aortic surgery in selected patients with acute legischemia on both sides due to aortic dissection.

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