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Objective: The number of access routes for endovascular treatment is limited in patients with a history of aorto-femoral bypass surgery. Here, we present a patient with stenosis of the coronary, left carotid, and innominate arteries. We performed simultaneous stenting of each stenotic lesion by direct puncture of a femoral artery graft with surgical exposure and purse string suture ligation. Case Presentation: The patient was a 74-year-old male with a history of aorto-bifemoral bypass surgery, coronary artery stenting, and coronary artery bypass grafting for systemic atherosclerotic disease. Coronary artery stenting became necessary because of recurring angina pectoris. The three lesions were treated simultaneously by surgical exposure and direct graft puncture and 9 Fr sheath insertion. The punctured graft was sutured for hemostasis. No puncture site complications were noted. Conclusion: This case suggests that when the number of possible access routes for endovascular treatment is limited, it is feasible and safe to perform direct graft puncture with surgical exposure, and to achieve hemostasis by suturing the puncture site.

Direct Puncture of a Surgically-exposed Femoral Artery Graft for Simultaneous Stenting of Coronary, Carotid and Innominate Artery Stenoses