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We present the case of a young patient who sustained a gunshot wound to the abdomen initially treated with laparotomy and repair of small bowel, splenic vein and diaphragmatic injuries. Subsequent computed tomography (CT) performed for hemodynamic instability demonstrated a pseudoaneurysm involving the aorta and proximal celiac artery, with an associated aortocaval fistula. An attempt at transperitoneal repair of these injuries was aborted due to extensive inflammatory changes in the region encountered during exposure. Subsequently, a hybrid repair was performed. This consisted of exclusion of the aortic and celiac artery pseudoaneurysm using an endovascular aortic cuff (22 × 39 mm, Cook Medical) via infrarenal aortic access, surgical ligation of the celiac artery branches, and revascularization via bypass from the infrarenal aortic access site arteriotomy to the common hepatic artery.

OBJECTIVE: Revascularization options for critical limb ischemia are often limited by the lack of autologous vein conduit, particularly in the setting of infection or distal targets that render the use of synthetic graft undesirable. Cryopreserved saphenous vein allograft (CSVA) may provide an important alternative. We conducted a retrospective study of patients undergoing lower extremity revascularization at a single institution using CSVA. METHODS: Between April 2009 and June 2011, 18 CSVA were used for bypass (12 men) with a median age of 65 (range, 45-88) years. Procedures included 14 femoral-distal bypasses (5 femoral-below-knee popliteal, 9 femoral-tibial bypasses) and 4 femoral-femoral bypasses. No immunosuppression was used. Follow-up was continued until conduit revision, amputation, death, or the end of the study period. End points included patency, limb salvage, and survival. RESULTS: Comorbidities included smoking history (95%), hyperlipidemia (73%), hypertension (68%), coronary artery disease (52%), diabetes (32%), obesity (16%), and atrial fibrillation (21%). The majority of patients had undergone multiple failed endovascular or open revascularization procedures prior to the use of CSVA. Clinical presentations included initial bypass thrombosis (26%), infection involving synthetic conduit (16%), stenosis (16%), and anastomotic pseudoaneurysm (5%). CSVA was used at the index procedure in 31% of cases, only when autologous vein was found to be inadequate for distal bypass. Complications following CSVA implantation included thrombosis (31%), stenosis (16%), infection (5%), aneurysmal degeneration (15%), and anastomotic pseudoaneurysm (5%). Survival was 78% with a median follow-up time of 285 (range, 2-850) days. Limb salvage was achieved in 12 of 14 surviving patients (86%) with graft patency maintained in 10 of 14 patients (71%) over a median 300 (range, 60-850) days. CONCLUSION: CSVA may provide an important option in clinical situations where autologous vein is not available and prosthetic bypass graft undesirable due to low patency rates or high rates of reinfection. Further elucidation of factors related to CSVA bypass patency should guide patient selection and management.