The results of in situ prosthetic replacement for infected aortic grafts (original) (raw)
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In-situ replacement and extra-anatomic bypass for the treatment of infected abdominal aortic grafts*
European Journal of …, 1991
We reviewed the surgical results of 21 patients who had infected abdominal aortic grafts to determine the efficacy ofin-situ graft replacement and extra-anatomic bypass in the management of these patients. Twelve patients had a primary perigrafl infection, and nine had an infection secondary to an aortoenteric fistula (AEF). Whereas the infected graft was replaced with a new aortic prosthesis in 18 patients, an axillobifemoral bypass operation followed graft excision in three patients. Twelve of the graft replacement patients (two AEF patients) had a low-grade infection, with negative perigraft and blood cultures. All 12 patients were alive at a mean follow-up of 8 years. Two had required above-knee amputation because of severe occlusive disease, and one had required an axillobifemoral bypass because of reinfection. The remaining six graft replacement patients (five AEF patients) had severe graft infections, with positive perigraft fluid and blood cultures in which one or more bacteria were present. Five died of sepsis within 1 month of operation. The remaining patient, who later required an axillobifemoral bypass because of reinfection, was alive at follow-up 4.3 years after operation. The three patients (two AEF patients) who had axillobifemoral bypasses had severe graft infections, with positive perigraft fluid and blood cultures. They survived the extra-anatomic bypass operation and were alive at a mean follow-up of 4.5 years. We conclude that patients who have a low-grade graft infection and negative blood and perigraft cultures can be treated safely by graft excision and in-situ replacement with a new prosthesis. In contrast, patients who have severe graft infection with positive cultures and sepsis are better managed with the excision of the graft and extraanatomic bypass.
Journal of Vascular Surgery, 2006
The primary purpose of this study was to analyze the clinical outcome in patients treated for aortic graft infections with in situ reconstruction (ISR). As a secondary aim, the outcomes were compared between patients who had similar clinical characteristics and extent of infection, needed total graft excision, and had either ISR or axillofemoral reconstruction (AXFR). Methods: 117 consecutive patients treated for aortic graft infection over a 20 year period from January 1981 to December 2001 were identified. 52 patients had prosthetic ISR, 49 had AXFR, and 16 had other reconstructions. The ISR patients treated with total (n ؍ 35) or partial (n ؍ 17) graft excision comprised the primary analysis. A second analysis was done between 34 ISR and 43 AXFR patients (non-concurrent groups), as stated above. Primary outcome measures were early and late procedure-related death, primary graft patency and limb loss. Secondary outcomes were operative morbidity, patient survival, and graft reinfection rates. Results: There were 40 males and 12 females with a mean age of 69 years treated with ISR. 43 patients had Rifampin-soaked grafts and 39 had omental flap or other autogenous coverage. Operative morbidity occurred in 23 patients (44%). There were 4 early and no late procedure-related deaths after a median follow up of 3.4 years (range, 2 months to 9.6 years). Primary patency and limb salvage rates at 5 years were 89% and 100%, respectively. Graft reinfection occurred in 6 patients (11.5%) and was not associated with procedure-related death. In the comparative analysis, the procedure-related death rate for patients treated with ISR was not different than those treated with AXFR (9% versus 23%; P ؍ 0.11). There was a significant improvement in primary patency between ISR and AXFR at 5 years (89% versus 48%; P ؍ .01). Limb salvage was 100% for ISR and 89% for AXFR at 5 years (P ؍ .06). The incidence of graft reinfection was similar in both groups: 11% for ISR and 17% for AXFR (P ؍ .28). Major complications or procedure-related deaths occurred in 12 patients after ISR (30%) and 26 patients (60%) after AXFR (P < .04).
Journal of Vascular Surgery, 2009
Objective: Graft excision and neo-aortoiliac system (NAIS) reconstruction with large caliber, femoral popliteal vein (FPV) grafts have been reported as successful treatment of aortic graft infection (AGI) in several small series with limited follow-up. The goal of this study was to evaluate long-term outcomes in large cohort of consecutive patients treated with NAIS for AGI. Methods: From 1990 to 2006, 187 patients (age: 63 ؎ 10 years) with AGI were treated with in situ reconstructions using 336 FPV grafts. Data from a prospectively maintained data base were analyzed. Results: NAIS reconstruction was performed for 144 infected aortofemoral bypasses, 21 infected aortic-iliac grafts, and 22 infected axillofemoral bypasses that had been placed to treat AGI. Polymicrobial cultures were present in 37% while 17% showed no growth. There were 55% gram positive, 32% gram negative, 13% anaerobic, and 18% fungal infections. The mean Society for Vascular Surgery run-off resistance score was 4.5 ؎ 2.3. Concomitant infrainguinal bypass was necessary in 27 (14%) patients (32 limbs). Major amputations were performed in 14 (7.4%) patients. Out of 14 amputations, five patients had irreversible ischemia and in four, there was no conduit available. Graft disruption from reinfection occurred in 10 patients (5%). While 30-day mortality was 10%, procedure-related mortality was 14%.
Journal of Vascular Surgery, 2003
Background: Total graft excision with in situ or extra-anatomic revascularization is considered mandatory to treat infection involving the body of aortic grafts. We present a series of nine patients with this complication and such severe comorbid medical illnesses or markedly hostile abdomens that traditional treatments were precluded. In these patients selective complete or partial graft preservation was used. Methods: Over the past 20 years we have treated nine infected infrarenal aortic prosthetic grafts with complete or partial graft preservation, because excision of the graft body was not feasible. In all nine patients infection of the main body of the aortic graft was documented at computed tomography or surgery. Essential adjuncts included percutaneous or operative drain placement into retroperitoneal abscess cavities and along the graft, with instillation of antibiotics three times daily, repeated debridement of infected groin wounds, and intravenous antibiotic therapy for at least 6 weeks. Results: One patient with purulent groin drainage treated with complete graft preservation died of sepsis. One patient with groin infection treated with complete graft preservation initially did well, but ultimately required total graft excision 5 months later, after clinical improvement. In four patients complete graft preservation was successful; two patients required excision of an occluded infected limb of the graft; and one patient underwent subtotal graft excision, leaving a graft remnant on the aorta, and axillopopliteal bypass. In summary, seven of nine patients survived hospitalization after complete or partial graft preservation; amputation was avoided in all but one patient; and no recurrent infection developed over mean follow-up of 7.6 years (range, 2-15 years). Conclusions: Although contrary to conventional concepts, partial or complete graft preservation combined with aggressive drainage and groin wound debridement is an acceptable option for treatment of infection involving an entire aortic graft in selected patients with prohibitive risks for total graft excision. This treatment may be compatible with long-term survival and protracted absence of signs or symptoms of infection.
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.
SpringerPlus, 2014
We report a case of a 29-year-old Marfan patient who developed prosthetic graft infection 10 months after Bentall operation and successive replacement of the remaining ascending aorta and the entire aortic arch for acute aortic dissection. Instead of an aggressive high-risk aortic redo procedure with removal and replacement of the infected prosthetic graft we elected a staged graft-sparing surgical approach. After 18 months of close follow-up the patient is in good condition and free from infectious sequela. This case and our review of the literature suggest that open extensive disinfection followed by tissue flap coverage is highly effective in controlling thoracic aortic prosthetic graft infection and may be considered as first-line treatment in such high-risk aortic arch redo patients.
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.
Journal of Vascular Surgery, 2011
We previously reported that in situ rifampin-soaked grafts (ISRGs) were safe in select patients with aortic graft infections, with the best results in those with aortic graft enteric erosion or fistula (AGEF). This study evaluates the late results of ISRG for AGEF. Methods: From 1990 to 2008, 183 patients were treated for aortic graft infections (121 primary and 62 AGEF). We reviewed 54 patients treated for AGEF with a standard protocol, which included excision of the infected part of the graft, intestinal repair, ISRG with omental wrap, and long-term antibiotics. We excluded 8 patients with AGEF (13%) treated with axillofemoral grafts (AXFG, n ؍ 5) or in situ femoral vein (n ؍ 3) due to excessive perigraft purulence. Endpoints were early morbidity and mortality, late survival, reinfection, and graft-related complications. Results: There were 45 male patients and 9 female patients with a mean age of 69 ؎ 9 years. Presentation was gastrointestinal bleeding in 33 patients, fever in 25 patients, and hemorrhagic shock in 10 patients. Other features were perigraft fluid in 29 patients and purulence in 9 patients. Forty-two patients (80%) had infections isolated to a portion of the graft body or limb, with the remainder of the graft well incorporated. Total graft excision was performed in 31 patients and partial excision in 23 patients. Total operating time was 6.2 ؎ 1.9 hours. Postoperative complications occurred in 28 patients (52%), and there were 5 deaths (9%). Operative mortality was 2.3% in stable patients (1 of 44) and 40% in those with hemorrhagic shock (4 of 10; P < .001). The hospital stay was 20 ؎ 18 days. Mean follow-up was 51 months (range, 3-197 months). Five-year patient survival, primary graft patency, and limb salvage rates were 59 ؎ 8%, 92 ؎ 5%, and 100%, respectively. There were no late graft-related deaths. There were two (4%) graft reinfections, one that was treated with axillofemoral bypass, and the other with perigraft fluid aspiration and oral antibiotic suppression. Conclusion: ISRGs with omental wrap and long-term antibiotics are associated with low reinfection rates in patients with AGEF who do not have excessive perigraft purulence. Graft patency and limb salvage rates are excellent.
Operative strategies in aortic graft infections: is complete graft excision always necessary?
Annals of vascular surgery, 2005
The classic approach to aortic graft infections involves complete excision of the graft material with remote reconstruction of the distal circulation. Certain patients may not be well suited for this approach for physiologic or anatomic reasons. This study was undertaken to determine the outcome of partial graft excision in selected patients with aortic graft infection who were not felt to be candidates for complete graft excision. Retrospective analysis of 30 consecutive patients treated with infected grafts arising from the aorta over the past 10 years was performed. Mean interval between graft placement and infection was 5.5 years. Complete graft excision with bypass via clean tissue planes was achieved in 15 patients (group A), and partial or complete graft salvage or in situ graft replacement was performed at the discretion of the surgeon in 15 patients (group B). Perioperative mortality occurred in eight subjects (27%), including six in group A (40%) and two in group B (13%; p = NS). Six patients (20%) developed recurrent infection following graft excision, two (13%) in group A and four (27%) in group B (p = NS).