Management of Infected Grafts and Aneurysms of the Aorta (original) (raw)
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Management of an Aortic Graft Infection after Endovascular Aneurysm Repair
Angiology and Vascular Surgery, 2019
A 77-years-old hypertensive patient who underwent EVAR for an enlarging 7-cm Abdominal Aortic Aneurysm (AAA) Using a Lombard Aorfix Graft. Protective embolization of the patient inferior mesenteric artery. The post-operative CT Angiography confirmed a successful treatment of the aneurysm without need of further intervention. The patient attends for follow up controls afterward. Twenty-one months after the EVAR, the patient admitted due to abdominal pain and elevated infection parameters for further investigations. An abdominal CT scan is done and demonstrated a remarkable contrast enhancement of the aneurysm wall and periaortic fluid collections (Figure 1). An empirical antibiotic therapy was started with Meropenem. The following days started the patients to develop high fever. The blood cultures revealed infection with Staphauereus; accordingly the antibiotic was changed to Linezolid. For both diagnostic and potentially therapeutic purposes, CT guided drainage of the periaortic fluid collections was done (Figure 2). Two days later we decided to operate the patient. A complete surgical excision of the infected aortic stent was done. The intraoperative findings were remarkable for inflamed aneurysmal sac with thick purulent exudates surrounding the loosely incorporated graft (Figure 3).
Surgical management of infected abdominal aortic grafts: Review of a 25-year experience
Journal of Vascular Surgery, 1986
Eighty-four patients with infected abdominal aortic grafts managed from 1961 through February 1985 were reviewed. Thirty-three patients had associated aortoenteric fistula formation. Twenty-eight infections (33%) and 13 aortoenteric fistulas (39%) originated at The Cleveland Clinic, yielding an incidence of aortic graft infection a,f 0.77% (28 of 3652 grafts) and aortoenteric fistula formation of 0.36% (13 of 3652: grafts) at this center. Staphylococcus organisms alone or in combination with other organisms were isolated from 34% of the series. Management consisted of graft removal and extra-anatomic bypass in 54 patients (64%), graft removal alone in 14 (17%) patients, partial graft removal and extra-anatomic bypass in seven (8%) patients, and miscellaneous operations in nine (11%) patients. Twenty-three patients (27%) required major amputations, nine of which were bilateral. Life-table analysis yielded 30-day and l-year survival rates of 72% and 42%, respectively. Thirty-day survival of the aortoenteric fist&a subset (49%) was less than that (86%) of the nonaortoenteric fistula subset (p = 0.003). One-year survival of patients treated since 1980 (54%) was superior to that of patients treated before 1980 (31%, p = 0.035). No difference in operative or l-year survival was demonstrated between the group treated with extra-anatomic bypass and subsequent graft removal and another in which both procedures were performed simuhane:ously, although the staged group experienced substantially fewer (p = 0.04) amputations (7%) than the combined group (41%). (J VASC SURG 1986; 3:725-31.) Since the initial experience with abdominal aortic reconstruction more than 30 years ago, many advances have been made in the management of patients who require this procedure. Despite dramatic improvements in antibiotic prophylaxis, synthetic graft materials, and surgical treatment, infection in an abdominal aortic prosthesis remains one of the most serious complications in vascular surgery. Formnately, its incidence is low, approximating 2% in most reported series.'-4 Although it is a rare event, aortic graft infection still is associated with mortality rates ranging from 25% to 75% and with morbidity in the form of amputation in approximately 30% of patients in whom it does occur.'-' Because of the low incidence of graft sepsis in general, most published series of patients have been small and many include patients with infected arterial prostheses that do not involve the aorta. Consequently, it has been difficult to draw statistically valid From the Department of Vascular Surgery, The Cleveland Clinic Foundation.
European Journal of Vascular and Endovascular Surgery, 1997
Objectives-In a retrospective non-randomised study we assessed the outcome after in situ replacement of infected knitted Dacron abdominal aortic grafts in patients without septicaemia or retroperitoneal abscesses. We also assessed whether the specific bacterial infection influenced outcome. Materials and methods: Over the 5 years studied, 18 patients (9 with perigraft infection and 9 with aortoenteric erosion) underwent in situ replacement of aortofemoral grafts. All patients were haemodynamically stable, none required emergency treatment. Preoperative assessment included CT, MRI, leukocyte-labelled scintigraphy, and bacterial cultures whenever possible. Infected grafts were totally excised and replaced in situ with standard PTFE prostheses. Bacterial diagnosis included intraoperative Gram-staining and postoperative graft cultures. None of the patients had retroperitoneal collections or proximal anastomotic dehiscence. All patients had 6 week intravenous antibiotic therapy. Results: One patient died of myocardial infarction, and another of haemorrhagic shock from proximal anastomotic dehiscence, accounting for a graft-related mortality of 6%. Dehiscence resulted from a polymicrobial infection. Mean 37 month surveillance showed no amputations and no graft-related infections. Conclusions: In clinically and bacteriologically selected patients, total in situ replacement of infected abdominal aortic grafts offers an excellent outcome.
Molecular diagnosis of Staphylococcus aureus prosthetic aortic graft infection: a case report
Le infezioni in medicina : rivista periodica di eziologia, epidemiologia, diagnostica, clinica e terapia delle patologie infettive, 2012
Aortic graft infection is a widely debated topic in the literature, it represents about 1% of post-surgical complications and is associated with a high complication and mortality rate. In most cases, such infections are treated empirically because patients are already under antibiotic coverage so as not to allow isolation of the pathogen. The literature in this regard is very attentive to new molecular diagnostic possibilities, and especially the operating of such complications in a precise diagnostic algorithm and management of the patient. We present the case of a 62-year-old patient with abdominal aortic aneurysms (AAA) treated in 2004 by endovascular repair of abdominal aortic aneurysms (EVAR). In 2009, a type II endoleak (the most frequent complication in this kind of surgery) was treated by CT-guided direct puncture and embolization of aneurysm, due to progressive enlargement of the aortic aneurism sac during annual follow-up. After nine days the patient was hospitalized for s...
Graft infection after endovascular abdominal aortic aneurysm repair
Journal of Vascular Surgery, 2011
Introduction: Although the natural history and management of infected open abdominal aortic aneurysm (AAA) repair is well described, only sporadic case reports have described the fate of patients with infected endografts placed in the abdominal aorta. The present study describes a tertiary referral center's experience with infected endovascular aneurysm repairs (EVARs). Methods: The medical records of 1302 open and endovascular aortic procedures were queried from January 2000 to January 2010. The cases were reviewed for prior aortic procedures, prosthetic implants, and etiology of current open procedure. Demographics, operative details, and perioperative courses were documented. Results: Nine patients (1 woman) with a mean age of 71 years had an EVAR that later required an open procedure for explantation and surgical revision for suspected infection. All grafts were explanted through a midline transperitoneal approach, with a mean time to explant of 33 months. The explanted endografts included 4 Zenith (Cook, Bloomington, Ind), 2 Ancure (Endovascular Technologies, Menlo Park, Calif), 2 Excluders (Gore, Flagstaff, Ariz), and 1 AneuRx (Medtronic, Minneapolis, Minn). Eight of the nine original EVARs were performed at other hospitals; 1 patient had EVAR and open explant at the University of Michigan. All patients had preoperative computed tomography scans, except one who was transferred in extremis with a gastrointestinal hemorrhage. Three patients also had a tagged leukocyte scan, and two had magnetic resonance imaging to further reinforce the suspicion of infection before explantation and bypass planning. Rifampin-soaked Hemashield (Boston Scientific) in situ grafts were used in four patients, with extra-anatomic (axillary-bifemoral) bypass used in the other five. The in situ group had no positive preoperative or postoperative cultures, with the exception of the unstable patient who died the day of surgery. For the other five patients, positive tissue cultures were found for Bacteroides, Escherichia coli, coagulase-negative Staphylococcus, Streptococcus, and Candida. Three patients were found to have aortic-enteric fistula, two of whom died before discharge from the hospital. The remaining seven survived to discharge. Average length of stay was 22 days, with a median follow-up of 11 months. Conclusion: This series of infected EVARs is the largest group of infected AAA endografts reported to date. Because EVAR of AAAs is presently the most common method of repair, development of endograft infection, while rare, can be managed with acceptable mortality rates. Patients presenting with aortic-enteric fistula after EVAR appear to have a more virulent course.
The Cardioplastic Approach to the Treatment of Infected Aortic Grafts
Annals of Plastic Surgery, 2017
Background: Aortic graft infection (AGI) is a rare complication following reconstructive aortic surgery, yet it represents a significant source of morbidity and mortality. There is no consensus regarding the optimal surgical management, due in part to the small cohorts of patient reports. Pedicled muscle or omental flap coverage of AGI has been shown to improve outcomes, making them a valuable consideration in the treatment algorithm. Thus, we aim to compile and evaluate cases of autologous vascularized tissue (AVT) in the treatment of infected aortic grafts, summarizing location specific trends, treatments, and outcomes. Methods: A comprehensive review of peer-reviewed literature regarding the management of AGI was performed. Data collected included patient characteristics, original procedure, pathogen, infection location, tissue utilized, technique of tissue isolation and delivery, staging, outcome, length of follow-up, and level of evidence. Results: Ninety-four cases of AGI managed with AVT transfer were identified. Infection of ascending aorta grafts accounted for 59% of cases, followed by a combination of ascending aorta and aortic arch (21%), the descending thoracic aorta (18%), and the thoracoabdominal aorta (2%). The infected graft was preserved in 81% of cases, followed by debridement and AVT coverage. The omentum was the most commonly applied flap (69%) for all divisions of the aorta followed by the pectoralis major (19%), the rectus abdominis (5%), and latissimus dorsi (4%). Mortality was limited, and the Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation overall survival was 93% (7 deaths), with a mean follow-up of 33.5 months. Conclusions: Autologous vascularized tissue coverage has proven to be a successful approach for treatment of infected aortic grafts. Although the incidence of AGI is rare, it represents an area of scarce evidence-based literature that warrants increased attention and surgical refinement. These results, which show a remarkably low infection-related mortality rate (3%), should encourage interdisciplinary collaboration with the plastic surgeon, cardiothoracic surgeon, and infectious disease specialists with the goal of improving outcomes in the treatment of infected aortic grafts.
Cadaveric aorta implantation for aortic graft infection
International Journal of Surgery Case Reports, 2016
This case report describes a 73-year-old gentleman who underwent explantation of an infected prosthetic aorto-iliac graft and replacement with a cryopreserved thoracic and aorto-iliac allograft. The patient has been followed up a for more than a year after surgery and remains well. After elective tube graft repair of his abdominal aortic aneurysm (AAA) in 2003, he presented to our unit in 2012 in cardiac arrest as a result of a rupture of the distal graft suture line due to infection. After resuscitation he underwent aorto-bifemoral grafting using a cuff of the original aortic graft proximally. Distally the new graft was anastomosed to his common femoral arteries, with gentamicin beads left in situ. Post discharge the patient was kept under close surveillance with serial investigations including nuclear scanning, however it became apparent that his new graft was infected and that he would require aortic graft replacement, an operation with a mortality of at least 50%. The patient underwent the operation and findings confirmed a synthetic graft infection. This tube graft was explanted and a cryopreserved aorta was used to the refashion the abdominal aorta and its bifurcation. The operation required a return to theatre day one post operatively for a bleeding side branch, which was repaired. The patient went on to make a full recovery stepping down from the intensive therapy unit day 6 post operatively and went on to be discharged 32 days after his cryopreserved aorta implantation.
The results of in situ prosthetic replacement for infected aortic grafts
The American Journal of Surgery, 1999
BACKGROUND: Treatment of aortic graft infection with graft excision and axillofemoral bypass may carry an increased risk of limb loss, aortic stump blowout, and pelvic ischemia. A review of patients with aortic graft infection treated with in situ prosthetic graft replacement was undertaken to determine if mortality, limb loss, and reinfection rates were improved with this technique.
Aortic Graft Infections: Treatment With Arterial Allograft
Transplantation Proceedings, 2005
Since its reintroduction by Kieffer in 1991, many authors have used arterial allografts for surgical management of vascular prosthetic graft infection. During a decade, 25 patients with aortic graft infection were treated using in situ revascularization with arterial allograft. There were 23 male and 2 female patients of mean age of 65.7 Ϯ 8.8 years (range, 43-78). Antibiotic therapy was administered for a mean time of 26 Ϯ 5 days (range, 21-45) in the postoperative period. The mean follow-up time was 2.3 Ϯ 3 years (range, 22 days-8.7 years). The mean in-hospital postoperative stay was 29.6 Ϯ 14 days (range, 9 -68). An aorto-enteric fistula (AEF) was present in 11 patients (44%), producing gastrointestinal bleeding. The overall mortality rate was 13 of 23 (56.5%) patients. The allograftrelated mortality rate was 5 of 23 (22%). The overall allograft-complicated patient rate was 15 of 23 (65%); we observed 18 allograft ruptures in 12 patients and 8 allograft thromboses in 6 patients. The overall amputation rate was 8.7% (2 of 23). Age of the recipient older than 69 years (P ϭ .02), positive preoperative marked-leukocyte scanning (P ϭ .04), and persistent postoperative leukocytosis (P ϭ .03) were significant variables associated with an increased risk of allograft-related complications. The use of arterial allografts for aortic graft infections represents an interesting alternative for the treatment of graft infection. Nevertheless, there are some problems related to the durability of this type of graft, which can still be considered as a "bridge transplant."
Conservative surgery for aortic graft infection
Cardiovascular Surgery, 1996
Surgeryfor aortic graft infectionis a major challengeoften characterizedby the need for ingenuityand improvisation. Traditional treatmentis by total graft excisionand extra-anatomic bypass. /n situ replacement of the infectedgraft usingeither autogenoustissue or antibiotic-impregnatedDacronis effectivein selectedcases but it is not clearwhen such conservative treatment may be employed. Graftexcisionand thorough debridementof infectedtissue are important,whichever techniqueis used.It would'seemunwiseto performin situ reconstruction unless the remainingoperativefieldis free from contamination. Whenin situ replacementis selected,a rifampicin-soaked Dacrongraftis the easyoption,but largestudieswillbe neededto determinewhetherthis is a suitablelong-termalternativeto conventional treatment.