Explantation of infected DETOUR bypass and repair of associated arteriovenous fistula using Esmarch-assisted vascular isolation technique

Abstract

Percutaneous transmural arterial bypass (PTAB), or DETOUR, is a technique for treatment of femoropopliteal occlusive disease with endovascular, extra-anatomic bypass stent grafting. Although studies show promise, reports on the management of infection and structural failure of the PTAB stent graft system are lacking. We describe the case of an 80-year-old man who developed an enlarging infected femoral artery pseudoaneurysm, arteriovenous fistula, and deep venous thrombosis following PTAB. Removal of the stents was performed using total vascular isolation of the limb with open arterial exposure and clamping, Esmarch exsanguination of the venous system and iliofemoral reconstruction with rifampin-soaked Dacron and vascularized soft tissue coverage.

Percutaneous transmural arterial bypass (PTAB), commercially known as the DETOUR procedure, provides an alternative revascularization strategy for patients with critical limb ischemia and long-segment femoropopliteal occlusions who lack conventional endovascular or open options.^1,2 The technique uses covered stents tunneled through the femoral and popliteal veins, creating an extra-anatomic bypass through an endovascular approach. Results from foundational clinical trials DETOURI and DETOUR2 have demonstrated encouraging patency and low rates of major adverse events.

To date, reported complications have centered on mechanical issues—most notably component separation—managed with endovascular relining.^3,4 No published case report has described infection of the PTAB construct requiring open removal. Based on our review of published PTAB trials and case reports, this appears to be the first report of explantation of an infected PTAB stent graft system. We describe our operative strategy, which used total vascular isolation of the limb with Esmarch exsanguination, allowing safe control of both arterial and venous bleeding in a heavily scarred and infected reoperative field. The patient provided written informed consent for publication of this case report, including clinical details and images, with reasonable steps taken to protect patient privacy.

Case report

An 80-year-old man presented with thigh swelling and systemic symptoms following treatment for chronic limb-threatening ischemia. His vascular history included right popliteal aneurysm repair with covered stents (VIABAHN, 2013; W. L. Gore & Associates), a femoral-tibioperoneal trunk bypass with great saphenous vein performed for rest pain (2018), a redo femoral-anterior tibial bypass with great saphenous vein performed for rest pain (2021), and multiple endovascular attempts at bypass preservation and salvage. When his bypass was abandoned in 2023, conventional recanalization attempts failed because of dense calcification and chronic occlusion of the superficial femoral and popliteal arteries. Ultrasound revealed no suitable arm or leg vein for redo bypass.

He was deemed a poor candidate for redo open surgery and subsequently underwent a PTAB procedure in June 2025, restoring inline flow via a covered stent graft construct traversing the femoral vein and reentering the below knee popliteal artery. Indication for procedure was rest pain. Within weeks, duplex ultrasound demonstrated proximal graft disconnection and distal thrombosis, prompting relining and catheter-directed thrombolysis. He later developed fever and Corynebacterium bacteremia and returned to the hospital.

Computed tomography angiography showed a large multilobed pseudoaneurysm (9 × 4.2 × 3.3 cm) at the proximal superficial femoral artery (SFA) stent junction with a type IA endoleak. The pseudoaneurysm communicated with the femoral vein, forming an arteriovenous fistula. Multiple deep venous thrombi surrounded the venous portion of the graft. Positron emission tomography imaging revealed fluorodeoxyglucose uptake along the stent pathway consistent with infection (Fig 1). We surmised that this infection likely developed during secondary intervention. Given progressive enlargement of the pseudoaneurysm, the patient was taken for urgent surgical repair.

Fig 1.

Preoperative imaging. A, Pre- and Post-DETOUR procedure. B, Computed tomography angiography (CTA) demonstrating a large multilobed pseudoaneurysm at the proximal superficial femoral artery (SFA) stent with type IA endoleak. C, Positron emission tomography (PET) showing fluorodeoxyglucose (FDG) uptake along the stent graft pathway consistent with infection.

Operative technique

Through a redo groin incision, the external iliac artery and vein, common femoral artery, profunda femoris artery, and femoral vein were circumferentially controlled. A second medial thigh incision exposed the mid-SFA and femoral vein containing the venous segment of the stent. A third incision below the knee exposed the distal popliteal vein and P3 segment of the popliteal artery, both containing stent material.

As the perfused and expanding pseudoaneurysm communicated with both arterial and venous systems, there was significant risk of simultaneous, life-threatening hemorrhage during stent graft extraction, a scenario complicated by inability to use an autologous blood recovery system (eg, “cell saver”) in the setting of a virulent infection/abscess. To mitigate bleeding risk and allow complete extraction of all infected prosthetic stent material, a technique of total vascular isolation of the limb was used.

After systemic heparinization, the external iliac artery and profunda were clamped. The leg was elevated and exsanguinated using two long Esmarch bandages from foot to groin, providing total arterial and venous decompression. After exsanguination of the leg, the femoral vein above the arteriovenous fistula was occluded by tightening a silastic vessel loop. The Esmarch bandage was secured in place, still tightened, using a hemostat.

With arterial inflow controlled and the venous system decompressed, the pseudoaneurysm sac was opened. Minimal bleeding was encountered, permitting clear visualization of the proximal DETOUR stent, which was dislodged from the artery and seen entering the femoral vein (Fig 2). Approximately 25 to 30 cm of stent was removed from this exposure. The venous defect and diseased SFA stump were oversewn.

Fig 2.

Intraoperative findings. A, Redo groin exposure with infected pseudoaneurysm. B, Below-knee exposure showing transvenous stent. C, Opened pseudoaneurysm with stent dislodged from the superficial femoral artery.

After staged removal of the Esmarch wrap, the popliteal vein was opened below the knee, and an additional 25 to 30 cm of infected stents were removed from the venous and arterial segments. The distal popliteal artery and popliteal vein defects were oversewn. We were able to remove the DETOUR stent material in its entirety, totaling 50 to 60 cm of stent material in addition to the old VIABAHN stent in the native popliteal artery. The stents were poorly incorporated and required minimal traction to remove. Clamps were removed from the arterial inflow in the groin, and the vessel loop around the femoral vein was loosened, restoring flow to the limb via the profunda femoris artery.

As the common femoral artery showed degenerative changes from infection, it was resected and iliofemoral reconstruction performed. An 8-mm Dacron conduit was soaked in 600 mg of Rifampin and sterile normal saline for 30 minutes and used as an interposition graft sewn end-to-end from healthy external iliac to normal profunda femoris artery 3 to 4 cm beyond its origin (Fig 3). A sartorius flap was mobilized, rotated and in-set over the reconstruction providing good vascularized soft-tissue coverage, closed suction drains were placed, and an incisional vacuum-assisted closure applied. Total operative time was 516 minutes with 500 cc blood loss.

Fig 3.

Explant and reconstruction. A, Explanted DETOUR and popliteal VIABAHN stent. B, Rifampin-soaked Dacron interposition graft reconstruction.

Despite preservation of flow to the profunda, the patient developed rest pain postoperatively. Redo revascularization was not pursued given patient’s level of chronic debility, poor skin quality, lack of suitable vein conduit, and single vessel runoff. He ultimately underwent above knee amputation and was discharged to inpatient rehabilitation facility shortly thereafter. The patient died at home of unrelated causes 4 months postoperatively.

Discussion

This patient presented with an enlarging infected pseudoaneurysm, stent migration, arteriovenous fistula, and deep venous thrombosis in a multiple-redo groin. Standard proximal and distal arterial control during repair would not address the possibility of torrential back-bleeding from the chronically enlarged and arterialized femoral venous system.

The strategy of total vascular isolation—occlusion of arterial inflow combined with Esmarch-assisted venous exsanguination—allowed safe entry into the pseudoaneurysm, complete removal of the venous-arterial stent construct, and iliofemoral reconstruction with minimal blood loss. We selected a Dacron conduit for reconstruction because of its tendency toward reduced need for reintervention, accepting a slightly higher risk of reinfection. However, both Rifampin-soaked Dacron and cryopreserved arterial homograft are well-described conduit choices in this situation.⁵ Deep venous thrombosis occurs in around 4% of PTAB cases and is well-managed with anticoagulation.²

Conclusions

Explantation of infected PTAB stent grafts poses a unique challenge because of their transvenous course and potential for simultaneous arterial and venous hemorrhage. Total vascular isolation of the limb in this case proved an effective strategy to obtain control of the arterial and venous systems which allowed for safe explantation of the stent construct. This appears to be the first reported case of complete explantation of an infected DETOUR bypass and describes a safe operative approach for managing this rare but potentially life-threatening complication.

Funding

None.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work, the authors used ChatGPT to assist with grammar and language editing. The authors reviewed and edited the output as needed and take full responsibility for the content of the publication.

Disclosures

None.