Simultaneous stent grafting of the descending thoracic aorta and aortofemoral bypass for "shaggy aorta" syndrome.

A 65-year-old man was referred for bilateral, painful cyanosis of the toes, of sudden onset. He was taking warfarin for a previous aortic and mitral valve replacement and aortocoronary bypass grafting 2 years earlier. On physical examination, “blue toe” syndrome, with normal pedal pulses, was evident bilaterally. A transesophageal echocardiogram excluded the presence of valvular or intracavitary embolism. Multislice CT showed irregular atherosclerotic plaques, lined with thrombus in the descending thoracic and infrarenal aorta as well as in the iliac arteries, without significant stenoses (Fig. 1). Because the visceral aorta, from the celiac trunk to 2 cm below the renal arteries, was free of disease, we decided to exclude the thrombus in the descending thoracic aorta with a stent graft and to perform a standard, excluding aortobifemoral bypass. The stent graft (Zenith Endovascular Graft; Cook Group Inc., Bloomington, Ind.) was first inserted through the left common femoral artery and deployed from below the left subclavian artery to the diaphragm. Then a standard, Dacron, aortobifemoral bypass graft, originating 1 cm below the renal arteries was inserted. The common femoral arteries were both ligated immediately above the distal anastomoses of the graft. A postoperative CT scan showed satisfactory exclusion of the diseased aorta (Fig. 2). The patient’s pain resolved and the pedal lesions healed. He was discharged home with a prescription for oral warfarin. At 26-month follow-up, he was well and had had no further embolic episodes.