Salvage of occluded aortobifemoral graft using elevated covered stent reconstruction of the aortic bifurcation

Occluded aortobifemoral (ABF) bypass grafts in multilevel peripheral artery disease pose a complex challenge. A 52-year-old female with prior ABF grafting and recent large ventral hernia repair presented with tissue loss and bilateral graft limb occlusion. Thrombectomy and angioplasty of the graft limbs with deployment of elevated covered stent grafts and bilateral common femoral artery (CFA) endarterectomy initially improved flow. However, thrombosis of graft limbs necessitated two successive re-interventions. Extension stent angioplasty converted the previous end-to-side configuration into an end-to-end, addressing progression of proximal progression of disease maximizing distal flow dynamics. Postoperative workup revealed antiphospholipid antibody positivity. Subacute ABF graft occlusion can be managed endovascularly in the setting of a hostile abdomen.