Complete Erosion of an Aortobifemoral Bypass Graft Limb into Duodenum

A 67-year-old male with a history of aortobifemoral bypass graft (ABF) for critical limb ischemia 10 months prior at a regional hospital was transferred to our center with 1 week history of rigors and 3 months of a chronic discharging left groin sinus. Two months prior he had a right-sided ureteric stent inserted for ureteric obstruction. Routine bloods revealed an acute-on-chronic renal injury and subsequent noncontrast computed tomography (CT) demonstrated left-sided hydroureter and hydronephrosis suggestive of extrinsic compression by the left bypass graft limb. A new left-sided ureteric stent was inserted and the right exchanged with no gross signs of infection. His impaired renal function precluded intravenous contrast and so a CT with oral contrast showed circumferential oral contrast and gas surrounding the right limb of his ABF. Urgent gastroscopy revealed periprosthetic erosion with the ABF limb traversing the distal third part of the duodenum. He underwent bilateral axillofemoral bypass grafts, laparotomy with explantation of the ABF, and primary duodenojejunostomy. Bilateral ureters were compressed by overlying graft limbs. Bilateral groins were infected with frank pus on exploration and were associated with impending anastomotic disruption of his previous ABF distal anastomoses. His postoperative course was complicated by colonic ischemia with perforation leading to irreversible multiorgan failure. This patient was remarkably well on presentation with life-threatening pathology. He had no abdominal symptoms or gastrointestinal bleeding. This case demonstrates the diagnostic and management difficulties of periprosthetic erosions and the consequences of graft tunneling superficial to ureters.