Title : Management of infected aortobifemoral bypass graft with ureteral fistula in a patient with complex vascular history: A case report
Abstract:
Introduction
Aortobifemoral (ABF) bypass grafting is a standard surgical approach for severe aortoiliac occlusive disease, though vascular graft infections (VGIs) remain a serious, albeit rare, complication. VGI can lead to life-threatening outcomes such as sepsis and fistula formation. Aorto-ureteral fistulas (AUFs) in particular are notoriously difficult to diagnose, often presenting with hematuria and associated with delayed diagnosis due to inconclusive imaging. This case highlights the diagnostic and therapeutic complexity of a VGI complicated by AUF.
Case Presentation
A 46-year-old man with a complex history including diabetes, IV drug use, peripheral artery disease, and prior rectal cancer surgery underwent ABF grafting for severe aortoiliac disease. Postoperative complications included a femoral artery pseudoaneurysm, left foot gangrene, and multiple amputations. The patient endured several wound infections, including MRSA and ESBL-producing Klebsiella pneumoniae, and required repeated antibiotic regimens. Ten months post-surgery, he developed a persistent groin wound and gross hematuria, raising concern for VGI.
On transfer, imaging confirmed thrombosed and infected graft with suspected AUF. Surgical exploration revealed a fistula between the graft and the left ureter, necessitating left nephrectomy, graft removal, and complex vascular reconstruction using a femoral vein conduit. Intraabdominal cultures grew Candida glabrata, prompting antifungal therapy with micafungin, later transitioned to fluconazole. Subsequent surgeries addressed wound dehiscence and suspected bowel involvement. After a multidisciplinary effort, including psychiatric support and infectious disease consultation, the patient stabilized and was discharged on a prolonged antibiotic regimen.
Discussion
This case underscores the critical importance of recognizing AUF as a potential complication of VGI, particularly in patients with prior pelvic surgeries, ureteral stenting, or immunocompromising conditions. Diagnosis is often clinical, as imaging may be non-revealing. Early surgical consultation is essential given the high mortality risk. Antibiotic regimens must cover gram-positive cocci, gram-negative bacilli, and fungi, with adjustments based on culture data. The management of biofilm-associated infections on prosthetic material is particularly challenging and often requires combined surgical and medical strategies. AUFs are often precipitated by friction, fibrosis, or ischemia caused by indwelling stents, vascular grafts, or radiation therapy. Although nephroureterectomy is a rapid solution, it may not be viable in patients with compromised renal function. In this case, the use of a venous conduit and tailored antifungal therapy led to favorable recovery.
Conclusion
This case illustrates the need for heightened suspicion of AUF in patients with hematuria and prior vascular or urologic surgery. A multidisciplinary approach involving vascular surgery, urology, infectious disease, and critical care teams is vital for effective treatment of complex VGI cases. Prompt surgical intervention and targeted antimicrobial therapy can significantly improve outcomes in these life-threatening conditions.)
