腹膜后途径行主髂动脉重建的体会

目的总结腹膜后途径行主髂动脉重建的经验体会。方法28例患者在全身麻醉或硬膜外麻醉下接受了腹膜后途径主、髂动脉重建术,其中右侧8例,左侧20例。术式包括腹主动脉瘤切除加人工血管置换;腹主动脉内膜剥脱加补片成形;降主-腹主动脉人工血管转流;腹膜后肿物切除加髂总-股动脉人工血管转流;髂动脉瘤切除加腹主-髂外动脉人工血管转流;腹主-右髂总动脉异物取出;髂总动脉内膜剥脱;腹主-股动脉人工血管转流;髂总动脉．股动脉人工血管转流;髂总．股．胭动脉人工血管转流。术毕腹膜后腔放置胶管引流24例。结果28例患者手术全部成功,围手术期无死亡,术毕重建血管动脉搏动良好。术中出血150—400ml(平均240m1);术中2例患者输血;术后腹膜后腔引流量为50—170ml(平均85m1);术后平均28h拔除胃管。术后除心功能不全、应激性溃疡及腹膜后血肿各1例外,其余患者均未出现明显心、脑、肾、呼吸及消化系统并发症。22例患者随访3个月至2．5年。1例患者术后2年死于急性心梗,1例髂-股-腘动脉转流的患者术后10个月股-腘动脉段转流血管闭塞,1例患者术后近1．5年时虽患肢情况良好,但突发脑出血,其余患者均正常生活。结论腹膜后途径在充分显露主髂动脉的基础上,保证了腹膜腔的完整性,大大降低对胃肠道以及呼吸系统的影响,减少了术后肠麻痹以及呼吸系统并发症,避免了术后肠黏连、机械性肠梗阻的发生,是一种较为简便安全的主髂动脉手术途径。     

主髂动脉闭塞外科治疗的早期并发症预防及处理

目的探讨主髂动脉闭塞的外科治疗早期并发症的预防与处理方法。方法分析1998年3月至2005年3月收治的83例急、慢性主髂动脉闭塞的临床资料。急性主髂动脉闭塞的治疗主要是导管取栓;慢性主髂动脉闭塞根据病变情况分别行腔内支架植入、人工血管旁路术以及支架联合远端动脉重建等术式。结果急性主髂动脉闭塞14例,取栓后6例发生并发症(42·9%),死亡率7·1%(1例);慢性主髂动脉闭塞69例,并发症16例(23·2%),其中支架植入17例,并发症23·5%(4例);人工血管旁路术23例(24次),并发症30·4%(7例),死亡率4·3%(1例);支架联合动脉重建29例(58条肢体),并发症5例(17·2%)。结论开展微创技术或外科手术结合腔内治疗主髂动脉闭塞可以降低手术期风险、减少手术并发症和病死率。     

股-股动脉人工血管转流术21例临床分析

目的 探讨股-股动脉人工血管转流手术的临床应用及并发症.方法 回顾性分析我院2001年1月至2011年5月21例施行股-股动脉搭桥手术患者的临床资料,其中单侧髂动脉严重狭窄或闭塞行手术者16例,主髂动脉瘤腔内修复术同时行该手术者5例.结果 本组21例手术均成功完成.2例术后残留轻度间歇性跛行,1例在术后11个月出现静息痛.2例分别于术后6、17个月发现人造血管闭塞,术后平均2年通畅率为90％.结论 股-股动脉人工血管转流术是治疗单侧髂动脉严重狭窄或闭塞的一种简单而有效手术,也适用于特殊类型动脉瘤的腔内联合治疗.     

人工血管重建术治疗腹主动脉瘤

目的 总结人工血管重建术治疗肾动脉平面以下腹主动脉瘤的临床经验.方法 对38例肾动脉平面以下的腹主动脉瘤行人工血管重建手术,其中9例采用直桶形人工血管,29例采用"人"字形分叉人工血管.分别采用保留后壁或完全切断瘤颈的方法吻合近心端,对于远心端根据病情分别吻合在腹主动脉末端、髂总动脉或髂外动脉.重建髂内动脉8支,结扎髂内动脉3支.依据术中测压结果重建肠系膜下动脉11支,缝扎21支.结果 术后死亡1例,于手术后6d发生结肠破裂,14d死于感染性休克;二次开腹止血1例,37例患者痊愈出院,并分别随访3个月～2.5年,1例于术后2年死于心肌梗死.其余患者预后良好,无人工血管内血栓形成、吻合口假性动脉瘤和移植血管感染等中、远期并发症发生.结论 人工血管重建术是腹主动脉瘤最彻底、有效的治疗方法,正确选择手术适应证、良好的手术设计、手术技巧以及重视并发症的防治是保证手术成功的重要因素.     

孤立性髂动脉瘤19例诊治经验

目的 探讨孤立性髂动脉瘤(solitary iliac aneurysms,SIA)的诊治方法.方法 回顾性分析1985年1月至2008年1月23年间19例SIA患者的临床资料.其中,男性18例,女性1例,年龄39～77岁,平均(62±7)岁.19例患者中16例行择期动脉瘤切除、人工血管移植,1例行腔内修复术,1例破裂性SIA急诊行动脉瘤切除、人工血管移植,1例破裂性SIA未手术即死亡.结果 19例患者共有30个SIA,其中25个(83.3%)位于髂总动脉,4个(13.3%)位于髂内动脉,1个(3.3%)髂外动脉瘤.11例(57.9%)患者具有多发性动脉瘤,其中9例(47.4%)为双侧髂动脉瘤,另2例合并其他部位的动脉瘤.2例(10.5%)合并动脉闭塞性疾病.2例破裂SIA,1例抢救成功,1例抢救无效死亡.开腹手术的17例患者无围手术期死亡,无盆腔脏器缺血等并发症;1例腔内修复术治疗后无内漏等并发症.术后移植血管通畅,无新发动脉瘤形成早期诊断和治疗SIA非常重要,应通过CTA等方法明确诊断及有否合并多发性动脉瘤或动脉闭塞性疾病.SIA的手术效果良好,术后应长期随访,注意有否吻合口动脉瘤或新生动脉瘤.     

人工血管移植治疗孤立性髂动脉瘤的手术探讨

目的探讨孤立性髂动脉瘤的手术治疗方法,包括复杂病理情况下动脉瘤切除、人工血管移植以及吻合口处理和缝合问题。方法回顾性总结1997年1月至2007年6月间收治的33例孤立性髂动脉瘤的临床资料,其中单侧髂动脉瘤29例,双侧4例。均在全身麻醉下行动脉瘤切除、人工血管移植血管重建术。结果4例双侧病变中,行主动脉-双侧股动脉人工血管移植1例,主动脉-双侧髂总动脉人工血管移植3例;29例单侧病变中,主动脉-髂总动脉人工血管移植1例,髂动脉-股动脉人工血管移植3例,髂总动脉-髂外动脉人工血管移植21例,髂总-髂总动脉转流4例。33例平均随访5（0.5-10）年。2例分别于术后3年和6年死于急性脑梗塞和心肌梗塞,1例术后2年死于交通事故,余健康存活,无复发,无吻合口狭窄或下肢缺血表现。结论动脉瘤切除人工血管移植是治疗孤立性髂动脉瘤的良好措施,仍然是目前医疗条件下有效治疗本病的主要手术方式。     

毒品注射致股动脉假性动脉瘤破裂出血的诊治

目的探讨注射毒品引起股动脉假性动脉瘤形成并破裂出血的诊断与治疗方法。方法回顾性分析2003年3月—2009年12月收治的22例因反复注射毒品致股动脉假性动脉瘤形成并破裂出血患者的临床资料。结果 22例患者均接受手术治疗,术中行瘤体切除、清创后,8例行股动脉破口修补术;4例行破口两侧股动脉结扎术;10例行髂外动脉-股动脉人工血管移植术。22例均手术成功,手术后早期出现人工血管与股动脉吻合口破裂出血1例,急诊手术重新吻合,随后出现切口感染,经换药后切口愈合。术后患侧下肢功能均好。随访6个月至7年,平均3年。1例患者术后2年出现人工血管感染,1例出院后14d发生吻合口出血,均经再次血管吻合治愈;2例股动脉结扎患者遗留轻间歇性跛行。结论治疗股动脉假性动脉瘤形成并破裂出血的手术方式,以股动脉假性动脉瘤切除+清创+股动脉修补术最为简单、安全有效;人工血管移植术疗效确定,能最大限度保证患肢血供;股动脉修补或结扎术在选择病例中也是有效的治疗方法。     

髂动脉成形术中发生髂动脉破裂的处理

目的 探讨覆膜支架在髂动脉成形术中发生髂动脉破裂时的应用价值.方法 回顾性分析郑州大学第一附属医院腔内血管外科2010年1月至2012年1月运用覆膜支架行腔内髂动脉成形术中髂动脉破裂9例的临床资料.结果 9例患者覆膜支架均置入成功,8例即刻复查髂动脉造影显示,髂动脉管腔通畅,无造影剂外溢;1例患者覆膜支架近心端出现Ⅰ型内漏,立即开腹行“髂动脉人工血管置换术”.9例患者术后临床症状均缓解,术后失访1例,8例患者随访14 ～45个月,平均(22±9)个月.1例患者术后1年覆膜支架远心端(髂外动脉)狭窄,行髂外动脉球囊扩张裸支架成形术,继续随访5个月,无不良事件发生;人工血管置换术患者1例随访18个月,彩超复查人工血管通畅良好.结论 髂动脉成形术中发生髂动脉破裂时,首选置入覆膜支架治疗.对治疗不满意者,外科治疗是最后的保障.     

腔内修复术治疗孤立性髂动脉瘤14例

目的探讨腔内治疗孤立性髂动脉瘤的疗效。方法回顾性分析2004年10月至2006年5月腔内修复孤立性髂动脉瘤14例的临床资料。其中,右髂总动脉瘤8例,左髂总动脉瘤5例,左髂内动脉瘤破裂1例。髂动脉瘤腔内修复的标准是瘤体直径〉3．0cm。结果14例均取得技术成功。8例右髂总动脉瘤,钢圈栓塞右髂内动脉后选用分叉支架型人工血管行腔内修复术。其中1例右髂总动脉瘤累及腹主动脉下端,选用AUl支架型人工血管腔内修复加股．股动脉旁路术。5例左髂总动脉瘤栓塞同侧髂内动脉后选用直型支架型人工血管。1例左髂内动脉瘤破裂急诊行钢圈栓塞后选用直型支架覆盖左髂内动脉开口。术后即刻数字减影血管造影显示动脉瘤消失,远近端支架型人工血管与宿主动脉结合处均未见明显渗漏。1例术后出现急性左心功能不全和肺水肿,经抢救痊愈,其余13例无手术并发症。术后CTA随访10．2个月（3～19个月）,瘤体无增大,支架无移位,无内漏,旁路人工血管通畅。结论腔内修复术治疗孤立性髂动脉瘤具有可行、安全、微创等特点,近期疗效较好,远期效果需进一步随访。     

主动脉夹层的外科治疗

目的总结84例主动脉夹层患者的外科治疗经验,探讨手术技巧和围术期处理,以提高手术疗效。方法50例Stanford A型主动脉夹层患者在体外循环下（11例采用深低温停循环技术）行Bentall手术或Cabrol手术24例,升主动脉人工血管置换术8例,Trusler手术5例,Wheat手术5例,升主动脉＋主动脉全弓或半弓人工血管置换术8例;34例Stanford B型主动脉夹层采用带膜支架主动脉腔内修复术治疗。结果住院死亡11例,死亡率13．1％。术中死亡3例,其中1例升主动脉＋次全弓人工血管置换患者因术中主动脉开放后主动脉根部大出血无法止血;1例升主动脉部分切除＋人工血管置换患者心脏无法复跳;1例升主动脉＋半弓血管置换患者因降主动脉夹层破裂死亡。术后早期死亡8例,其中死于低心排血量综合征2例,肺部感染2例,肾功能衰竭2例,呼吸衰竭1例,永久性神经系统损害1例。术后发生并发症16例。随访62例（84．9％,62／73）,随访时间3个月～10年。随访期间死亡2例,其中1例死于心内膜炎,1例猝死（原因不明）。结论快速准确地诊断、个体化的手术方案和精确的手术技术是主动脉夹层手术成功的关键。     

Small-caliber heparin-coated ePTFE grafts reduce platelet deposition and neointimal hyperplasia in a baboon model

PURPOSE: Intimal hyperplasia and graft thrombosis are major causes of graft failure. Heparin prolongs graft patency and inhibits neointimal hyperplasia in animal models. The purpose of this study was to evaluate the effect of a heparin-coated expanded polytetrafluoroethylene (ePTFE) graft on platelet deposition and anastomotic neointimal hyperplasia after aortoiliac bypass grafting in a baboon model. METHODS: Heparin-coated ePTFE grafts (4-mm diameter) were incorporated into exteriorized femoral arteriovenous shunts placed in five baboons. Platelet deposition was analyzed by measuring the accumulation of indium 111-labeled platelets on the grafts, with dynamic scintillation camera imaging. Eight adult male baboons (mean weight, 9.3 kg) underwent bilateral aortoiliac bypass grafting with ePTFE grafts (4-mm internal diameter). In each animal a heparin-coated ePTFE graft was placed in one aortoiliac artery, and an uncoated graft, which served as the control, was placed in the contralateral aortoiliac artery. All grafts were harvested at 4 weeks, and were analyzed quantitatively for neointimal hyperplasia at graft-vessel anastomoses. RESULTS: Early platelet deposition on heparin-coated grafts after 1 to 4 hours of ex vivo circuitry was significantly reduced. All the harvested aortoiliac grafts were patent at 4 weeks. There was a significant reduction in neointimal area at both proximal (0.26 +/- 0.11 mm(2)) and distal (0.29 +/- 0.14 mm(2)) anastomoses in the heparin-coated grafts, compared with proximal (0.56 +/- 0.18 mm(2)) and distal (0.63 +/- 0.21 mm(2)) anastomoses in the untreated control grafts (P <.05). In addition, neointimal cell proliferation assayed with bromodeoxyuridine (BrdU) incorporation was reduced in the graft neointima (3.47% +/- 0.43%) in heparin-coated grafts compared with the graft neointima (6.21% +/- 0.59%) in untreated control grafts (P <.05). CONCLUSIONS: Small-caliber heparin-coated ePTFE grafts significantly reduce platelet deposition and anastomotic neointimal hyperplasia and cell proliferation, without measurable side effects, in baboons. Surface coating with heparin in small-caliber ePTFE grafts is useful for improving prosthetic bypass graft patency. Clinical relevance: An autologous vein graft is the ideal bypass conduit in peripheral arterial reconstruction; however, many patients who undergo bypass grafting do not have adequate or available autologous vein graft. As a result surgeons often must rely on prosthetic grafts as an alternative conduit in arterial bypass procedures. Clinical outcomes with prosthetic grafts in peripheral arterial reconstruction are generally inferior to those with autologous vein bypass grafts, in part because of anastomotic neointimal hyperplasia. This study evaluated the effect of small-caliber heparin-coated expandable polytetrafluoroethylene (ePTFE) grafts in aortoiliac reconstruction in a baboon model. The study found that heparin-coated ePTFE grafts resulted in less intimal hyperplasia and less platelet deposition after implantation, compared with noncoated control ePTFE grafts.     

Aortoiliac Endarterectomy: A Lost Art?

Endarterectomy was first performed on a superficial femoral artery in 1946 by Cid dos Santos and subsequently on the abdominal aorta by Wylie in 1951. During the 1950s and 1960s, aortoiliac endarterectomy (AIE) was the standard procedure for treatment of aortoiliac occlusive disease. When prosthetic graft material became available, aortobifemoral bypass (ABFB) replaced AIE in most cases because occlusive disease commonly affects the external iliac arteries also, which were difficult to endarterectomize. As a result, aorto-common iliac endarterectomy became almost a lost art. However, we believe there is still a place for AIE in selected patients based on a review of our results with the procedure. We reviewed 205 patients who survived 10 years after undergoing operation for aortoiliac occlusive disease by either aorto-common iliac endarterectomy (n = 39) or ABFB (n = 166). Ten-year primary patency was 89.2% for AIE and 78% for ABFB. Graft infection or aneurysmal formation occurred in 5% of ABFB and 0% of AIE cases. Ten male patients who underwent AIE for leg and hip claudication with positive penile/brachial indices of ≤0.6 enjoyed improvement of erectile dysfunction. Twenty of the 39 AIEs were in female smokers with small vessels, localized disease, and elevated triglycerides. Three patients with end-to-side infected ABFB grafts, two with enteric fistula (one ours, two referred), had their grafts removed, followed by AIE with vein patching of their bypass sites. All three patients survived and at 10-year follow-up had patent reconstructed aortofemoral vessels. Since AIE avoids prosthetic material, it is preferable to ABFB in (1) patients whose aortoiliac occlusive disease does not involve the external iliac arteries; (2) male patients with aortoiliac occlusive disease who, in addition to claudication, have erectile dysfunction with penile/brachial indices of ≤0.6 and stenotic internal iliac origins; (3) patients with aortoiliac disease including the external iliac arteries who are not candidates for ABFB because of infection risk or small vessels; (4) patients with localized aortoiliac disease; and (5) patients after removal of an infected ABFB graft (with or without an enteric fistula) that had initially been placed end-to-side for aortoiliac occlusive disease.     

Patency of saphenous vein coronary artery bypass grafts from the vascular prosthesis of the ascending aorta.

BACKGROUND: Patients who have Stanford type A aortic dissection with impaired coronary arteries or who have aneurysms from the ascending aorta to the aortic arch with coronary artery disease need coronary artery bypass grafting (CABG) with tube graft replacement of the ascending aorta simultaneously. When vein grafts are used for CABG in these patients, the proximal anastomoses of vein grafts are attached to the prosthetic tube graft of the ascending aorta. However, the validity of proximal anastomoses of vein grafts to the prosthetic tube graft of the ascending aorta has not been confirmed. PATIENTS AND METHODS: We retrospectively analyzed patients who underwent venous coronary bypass grafting with prosthetic graft replacement of the ascending aorta. Between January 1984 and October 2002, 35 patients underwent CABG using saphenous vein grafts at the time of tube graft replacement of the ascending aorta, and the proximal anastomoses of the vein grafts were attached to the tube graft of the ascending aorta. Thirty-three venous bypass grafts were analyzed in 24 survivors. RESULTS: The postoperative catheterization showed only one early vein graft occlusion of 16 vein grafts anastomosed distally to the left anterior descending artery (LAD). All 14 venous grafts anastomosed to the right coronary artery (RCA) and 3 to the left circumflex artery (LCX) were patent. Therefore, the postoperative patency rate at discharge was 97.0% (32/33). Spiral computed tomography performed for long term follow-up revealed occlusion of two vein grafts (3.5 years and 9.7 years) anastomosed to the LAD. CONCLUSIONS: The patency rate of vein grafts anastomosed from prosthetic grafts of the ascending aorta to the native coronary arteries was similar to that of conventional CABG using saphenous vein grafts.     

Endovascular grafts and other image-guided catheter-based adjuncts to improve the treatment of ruptured aortoiliac aneurysms

OBJECTIVE: To report a new management approach for the treatment of ruptured aortoiliac aneurysms. METHODS: This approach includes hypotensive hemostasis, minimizing fluid resuscitation, and allowing the systolic blood pressure to fall to 50 mmHg. Under local anesthesia, a transbrachial guidewire was placed under fluoroscopic control in the supraceliac aorta. A 40-mm balloon catheter was inserted over this guidewire and inflated only if the blood pressure was less than 50 mmHg, before or after the induction of anesthesia. Fluoroscopic angiography was used to determine the suitability for endovascular graft repair. When possible, a prepared, "one-size-fits-most" endovascular aortounifemoral stented PTFE graft was used, combined with occlusion of the contralateral common iliac artery and femorofemoral bypass. If the patient's anatomy was unsuitable for endovascular graft repair, standard open repair was performed using proximal balloon control as needed. RESULTS: Twenty-five patients with ruptured aortoiliac aneurysms (18 aortic, 7 iliac) were managed using this approach. Balloon inflation for proximal control was required in nine of the 25 patients. Twenty patients were treated with endovascular grafts. Five patients required open repair. The ruptured aneurysm was excluded in all 25 patients; 23 survived. Two deaths occurred in patients who received endovascular grafts with serious comorbidities. The surviving patients who received endovascular grafts had a median hospital stay of 6 days, and the preoperative symptoms resolved in all patients. CONCLUSIONS: Hypotensive hemostasis is usually an effective means to provide time for balloon placement and often for endovascular graft insertion. With appropriate preparation and planning, many if not most patients with ruptured aneurysms can be treated by endovascular grafts. Proximal balloon control is not required often but may, when needed, be an invaluable adjunct to both endovascular graft and open repairs. The use of endovascular grafts and this approach using other image-guided catheter-based adjuncts appear to improve treatment outcomes for patients with ruptured aortoiliac aneurysms.     

Intraoperative flow waveform analysis aids in preventing early graft failure following reconstruction of arteries of the legs

To enable early detection and treatment of vascular defects leading to early graft failure, intraoperative flow waveform analyses were carried out during lower extremity arterial reconstructions in 226 patients undergoing 102 aortoiliac/femoral and 124 femorodistal bypass grafts. Flow waveform types III or IV indicated early graft failure. These were noted in seven grafts (6.9%) in the aortoiliac/femoral position and in eight grafts (6.5%) in the femorodistal position. The main cause of the abnormal flow waveform pattern was misinterpretation of preoperative arteriographic findings in aortoiliac/femoral reconstructions and technical errors in anastomoses in femorodistal reconstructions. Of 15 grafts with an abnormal flow waveform pattern, 13 were effectively repaired with patch angioplasty, graft extension, or replacement with thrombectomy. In two grafts, the repair failed and amputation had to be done. Thus, intraoperative flow waveform analysis is a simple, useful, and safe method to detect vascular defects leading to early graft failure. Unless assessment of preoperative arteriographic findings in aortoiliac/femoral reconstructions are accurate and anastomotic techniques in femorodistal reconstructions are refined, early graft failure may occur.     

Aortoiliac reconstruction in infants and toddlers: replacement with decellularized branched pulmonary artery allograft

Background

Aortic reconstruction in infants and small children has been reported with Dacron or polytef prosthetic material, hypogastric artery autograft, and saphenous vein autograft. In children, synthetic grafts are limited by a concern for late infection and a lack of potential growth. Available autogenous vessels have a limited length and diameter. Conventional allografts have not been durable. When the entire infrarenal aorta and aortoiliac bifurcation must be replaced, none of the historic options are optimal.

Methods

We report 2 cases of infrarenal aorta and aortoiliac bifurcation reconstruction using a new generation of cryopreserved allograft now decellularized for decreased immunogenicity. The branched pulmonary artery allograft is particularly attractive for reconstruction of the aortic bifurcation.

Results

The postoperative course in both cases was uncomplicated. Follow-up with serial abdominal duplex ultrasound has shown no evidence of graft stenosis or calcification at 29 and 32 months, respectively.

Conclusions

The use of commercially available, decellularized, and antigen-reduced allograft offers a nonsynthetic option for replacement of the pediatric abdominal aorta. We chose this novel approach in hopes of reducing the lifetime risk for graft infection and maintaining the potential for graft ingrowth by the child.     

Patency rate of bifurcated aortic grafts: comparative analysis of woven versus knitted prostheses in the same patient

To investigate the difference in patency rate between woven and knitted aortofemoral or aortoiliac prosthetic grafts, a special vascular prosthesis was manufactured with one limb of the graft knitted and the other, woven. The prosthesis was implanted in 143 consecutive patients with occlusive aortoiliac arteriosclerotic disease or aneurysms. Detailed statistical analysis failed to reveal any difference in the patency rate between the woven and knitted limbs of the grafts during an observation period ranging from one month to two years.     

Modified technique for recovering aortoiliac homografts

BACKGROUND: Infection of the prosthetic aortic graft bypass remains one of the most serious complications of aortoiliac bypass grafts. Use of an aortoiliac allograft as a replacement for an infected prosthetic graft is an effective treatment for this problem. However, the availability of aortoiliac grafts is affected by the high rate of procurement errors experienced during recovery. This overall error rate nationally averaged 32.5% in 2006, of which nearly a third (9.6%) were related to tears of the intima at or below the bifurcation of the abdominal aorta. OBJECTIVE: To analyze the potential of a new aortoiliac graft recovery method in reducing the error rate. METHOD: A modified technique of aortoiliac graft recovery was used to minimize the possibility of intimal tears. The essence of this technique is to change the sequence of mobilization of the graft, starting from the zone of low resistance, which is at the iliac arteries, and continuing upward to the abdominal aorta, which has higher resistance because of the greater thickness of the aortic wall. An additional modification of the standard technique is to use a tourniquet to raise the aortic edges. CONCLUSION: The aortoiliac graft has various resistances to tearing owing to the different wall thicknesses of the aorta and the iliac arteries. Mobilization of the abdominal aorta before dissection of the iliac arteries creates a high risk of tears at and around the bifurcation of the aorta and the iliac arteries.     

The results of in situ prosthetic replacement for infected aortic grafts.

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. METHODS: The clinical data of 25 patients, 19 males and 6 females, with a mean age of 68 years (range 35 to 83), with aortic graft infection, treated between January 1, 1989, and December 31, 1998, by in situ prosthetic graft replacement were reviewed. Follow-up was complete in the 23 surviving patients and averaged 36 months (range 4 to 103). RESULTS: Twenty aortofemoral, 3 aortoiliac, and 2 straight aortic graft infections were treated with excision and in situ replacement with standard polyester grafts in 16 patients (64%), or with rifampin-soaked collagen or gelatin-impregnated polyester grafts in 9 patients (36%). Fifteen patients (60%) had aortic graft enteric fistulas, 8 patients (32%) had abscesses or draining sinuses, and 2 patients (8%) had bacterial biofilm infections. Thirty-day mortality was 8% (2 of 25). There were no early graft occlusions or amputations. There was one late graft occlusion. There were no late amputations. The reinfection rate was 22% (5 grafts). All reinfections occurred in patients operated upon for occlusive disease. Only one reinfection occurred in the rifampin-soaked graft group (11% versus 29%, P = NS). Reinfection tended to be lower in patients with aortoenteric fistulas and without abscess. Autogenous tissue coverage provided statistically significant protection against reinfection. There were no late deaths related to in situ graft infection. CONCLUSIONS: Patients treated with in situ graft replacement had an 8% mortality and 100% limb salvage rate. Reinfection rates were similar to those of extra-anatomic bypass, but a trend of lower reinfection rates with rifampin-impregnated grafts was apparent. Patients with aortoenteric fistula and without abscess appear to be well treated by the technique of in situ prosthetic grafting and autogenous tissue coverage.