Late rupture of knitted Dacron graft.

An 87-year-old man who had suffered from rest pain in the right leg underwent aorto-bifemoral bypass using bifurcated Bionit II knitted Dacron grafts for high aortic occlusion and right femoro-popliteal bypass for stenosis of superficial femoral artery using an autologous saphenous vein graft (ASVG) in 1987 at an other hospital. The right leg of the bifurcated graft was anastomosed to the profunda artery and the ASVG was anastomosed to the graft end-to-side. The postoperative course was unremarkable. He had been medicated for hypertension by his family doctor for many years. He had a past history multiple brain of infarcts without any sequelae. In November, 2004, he was admitted to our institution due to difficulty in walking because of swelling and tenderness in the right groin. We found a pulsatile mass in the groin with subcutaneous hemorrhage. The right thigh was swollen. There was also a pulsatile mass in the left groin without any color change. Emergent angiography showed an aneurysm of the right artificial graft near the proximal anastomosis of the ASVG with some extravasations. The bilateral grafts were slightly dilated just below the inguinal ligaments. There was no extra-vasation in the left thigh (Fig. 1). Computed tomography (CT) scan indicated bilateral aneurysms of the grafts with mural thrombus. The size of the right and left aneurysms were 73 mm and 52 mm, respectively. There was some enhancement in the right mural thrombus which indicated rupture of the graft. The right thigh was swollen with hematoma amongst the muscles (Fig. 2). His vital signs were stable and he was operated on two days after the diagnosis was made. The operation was done under general anesthesia in a supine position. We started with the right leg. The proximal and the distal part of the aneurysm were encircled and clamped. On opening the aneurysm, there was much thrombus and we could not find any artificial graft segments. The graft was absent at the graft-to-profunda artery anastomosis leaving the ASVG intact. We were able to see the entire orifice of the profunda artery. We attributed the rupture of the pseudo-aneurysm to disruption of the dacron graft near the distal anastomosis. Control of back flow from the profunda artery by balloon catheter was not enough, hence we first did the distal anastomosis to the orifice using a new 10 mm-ringed Dacron graft. The detached ASVG was interposed by ringed GoreLate Rupture of Knitted Dacron Graft