Technical details with the use of cryopreserved arterial allografts for aortic infection: influence on early and midterm mortality.

PURPOSE: In situ repair with cryopreserved vascular allografts improves the results in the surgical treatment of aortic infection. This study evaluated the technical pitfalls with the use of allografts that influence early and midterm mortality. METHODS: Between 1990 and 1999, 49 patients, 21 (43%) with a mycotic aneurysm and 28 (57%) with a prosthetic graft infection of the thoracic and abdominal aorta including pelvic and groin vessels, underwent in situ repair with cryopreserved arterial allografts. Seventeen patients (35%) had aortobronchial, aortoesophageal, or aortoenteric fistulas. RESULTS: Allograft-related technical problems occurred in eight patients (16%) in this series, and they included: intraoperative rupture caused by allograft friability; allograftenteric fistula from ligated allograft side branches rupturing 8, 18, and 48 months after implantation; anastomotic failure caused by inappropriate mechanical stress; anastomotic stricture after partial replacement of infected prosthetic grafts; allograft failure caused by inappropriate wound drainage; and recurrence of infection after inappropriate duration of antifungal treatment. Seven of the eight technical problems (87%) occurred in the first 10 patients (80%) in this series. There was one technical failure in the remaining 39 patients (2.6%; P =.0002) because of various technical adaptations, such as critical selection of allografts, use of allograft strips supporting large anastomoses, sealing with antibiotic-impregnated fibrin glue, and change in technique of allograft side-branch ligature. The 30-day mortality rate was 6% for the whole series; however, it was 2.6% for last 39 patients, with no recurrence of infection or allograft-related late death. CONCLUSIONS: In situ repair with cryopreserved arterial allografts achieves excellent early and late results in the treatment of aortic infection. However, distinct allograft-related technical problems had to be overcome to improve the outcome of patients with major vascular infections.     

Management of infected grafts and mycotic aneurysms of the aorta using cryopreserved homografts

OBJECTIVE: To evaluate the efficacy of the treatment of infected prosthetic grafts and mycotic aneurysms of the aorta with cryopreserved homografts. MATERIALS AND METHODS: Between April 1994 and May 2002, 15 cryopreserved aortic homografts were used in 13 patients in the thoracic and abdominal aortic position with supplementary omental or pectoral muscle wrapping for infected grafts (n=11), and mycotic aneurysms (n=2) (mean age: 57.5). RESULTS: One patient died due to multiorgan failure and the other due to postoperative cerebral hemorrhage (15.38%). Another patient died four months after the operation due to septic arthritis, and coronary heart disease. Ten patients are still alive without evidence of infection (76.92%) during a follow up of 44+/-23.03 (range 4-71) months. CONCLUSION: The use of cryopreserved homografts with supplementary omentum and/or muscle flap coverage, assures an anatomical reconstruction with good results in this difficult group of patients.     

Mycotic aneurysms of the suprarenal abdominal aorta: prolonged survival after in situ aortic and visceral reconstruction

Necrotizing infection of the arterial wall causes rupture and false ("mycotic") aneurysm formation, with a very poor prognosis if untreated. Cure can be achieved by surgical drainage and debridement, with restoration of arterial continuity through uncontaminated tissues. The dilemma of applying these principles to the treatment of mycotic aneurysms of the suprarenal aorta is that no remote or extraanatomic routes are available to maintain perfusion to the viscera. We report the first case of Klebsiella suprarenal mycotic aortic aneurysm successfully treated with in situ prosthetic reconstruction of the aorta and visceral arteries, and we have reviewed the 21 other suprarenal mycotic aortic aneurysms reported in the English-language literature. Repair was performed in 20 of the 22 cases, with in situ prosthetic reconstruction performed in 18. Prolonged survival has been achieved in 16 patients after in situ repair. No long-term survival has been reported after extraanatomic reconstruction of the aorta and visceral arteries in patients with such aneurysms. We conclude that in situ prosthetic reconstruction, accompanied by thorough drainage and debridement, prolonged parenteral antibiotic therapy, and permanent suppressive oral antibiotics, offers the best chance for survival in these patients.     

Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases

OBJECTIVE: A mycotic aneurysm of the aorta and adjacent arteries is a dreadful condition, threatening life, organs, and limbs. With regard to the aortic segment involved, repair by either in situ replacement or extra-anatomic reconstruction can be quite challenging. Even when surgery has been successful, the prognosis is described as very poor because of the weakened health status of the patient who has developed this type of aneurysm. The aim of our study was to find out whether any progress could be achieved in a single center over a long time period (18 years) through use of surgical techniques and antiseptic adjuncts. MATERIAL AND METHODS: From January 1983 to December 1999, a total of 2520 patients with aneurysms of the thoracic and abdominal aorta and iliac arteries underwent surgery for aortic or iliac replacement at our institution. During that period, 33 (1.31%) of these patients (mean age, 64.3 years) were treated for mycotic aneurysms of the lower descending and thoracoabdominal (n = 13), suprarenal (n = 4), and infrarenal (n = 10) aorta and iliac arteries (n = 6). Twenty (61%) of these 33 patients had histories of various septic diseases; in the other 13 (39%), the etiology remained uncertain. Preoperative signs of infection, such as leukocytosis and elevated C-reactive protein, were found in 79% of the patients, and fever was apparent in 48%; 76% of the patients complained of pain. At the time of surgery, eight (24%) mycotic aneurysms were already ruptured, and 20 (61%) had penetrated into the periaortic tissues, forming a contained rupture. Five (15%) aneurysms were completely intact. The predominant microorganisms found in the aneurysm sac were Staphylococcus aureus and Salmonella species. Careful debridement of all infected tissue was essential. In the infrarenal aortic and iliac vascular bed, in situ reconstruction was performed only in cases of anticipated "low-grade" infection. Alternative revascularization with extra-anatomic procedures (axillobifemoral or femorofemoral crossover bypass graft) was carried out in eight of 16 cases. All four suprarenal and all 13 mycotic aneurysms of the thoracoabdominal aortic segment were repaired in situ. Antibiotics were administered perioperatively, and all patients were subsequently treated with long-term antibiotics. RESULTS: In-hospital mortality was 36% (n = 12). Because of the smallness and heterogeneity of the sample, we could not demonstrate significant evidence for any influence of aneurysm location or type of reconstruction on patients' outcome. However, survival was clearly influenced by the status of rupture. During long-term follow-up (mean, 30 months; range, 1-139 months), 10 patients (48%) died-one (4.8%) probably as a consequence of the mycotic aneurysm, the others for unrelated reasons. Eleven patients (52%) are alive and well today, with no signs of persistent or recurrent infection. CONCLUSIONS: A mycotic aneurysm of the aortic iliac region remains a life-threatening condition, especially if the aneurysm has already ruptured by the time of surgery. Although the content of the aneurysm sac is considered septic, as was proved by positive cultures in 85% of our patients, in situ reconstruction is feasible and, surprisingly, was not more closely related to higher morbidity and mortality in our series than ligation and extra-anatomic reconstruction, although most of the aneurysms repaired in situ were located at the suprarenal and thoracoabdominal aorta. We assume that our operative mortality rate of 36%, which relates to a rupture rate of 85%, could be substantially lowered if the diagnosis of mycotic aneurysm were established before rupture.     

Cryopreserved Arterial Allografts in the Treatment of Prosthetic Graft Infections

AIM: The purpose of this study was to evaluate the effectiveness of cryopreserved arterial allografts in the management of prosthetic graft infection. MATERIAL AND METHODS: Over a 5-year period 45 patients with infection of prosthetic vascular grafts were treated. There were 39 intra-abdominal infected grafts (group I) and six extra-abdominal infected grafts (group II). Treatment consisted of total graft removal and in situ or extra-anatomic implantation of cryopreserved arterial allografts. Six patients were operated on as an emergency. Four patients presented with aorto-enteric fistula. Follow-up ranged from 30 to 78 months. RESULTS: There were six in-hospital deaths and two additional patient deaths during follow-up, yielding an overall mortality rate of 18%. Six patients died due to complications directly related to infection or insertion of an allograft. Combined short and long-term mortality rate was much higher in patients operated on as an emergency (67%) compared to elective cases (11%). Patients with aorto-enteric fistula had the highest mortality rate (75%). Primary and secondary 3-year allograft patency rates for group I were 84 and 94%, respectively and for group II were 60 and 80%, respectively. CONCLUSIONS: Aortic allografts are useful in the treatment of infection of major vascular prosthetic grafts, except for patients with aorto-enteric fistula. Patients with infection of the prosthetic graft should be promptly assessed for graft removal, since results of elective surgery are much better than results of emergency procedures.     

Arterial Infections in the New Millenium: An Old Problem Revisited

The natural history of infected aneurysms or arterial infections is characterized by rapid expansion leading to rupture, pseudoaneurysm formation, and sepsis. Treatment options include in situ grafting either with prosthetic or autogenous grafts or with cryopreserved allografts (CPAs), resection of the aneurysm with remote bypass grafting, and ligation. The purpose of this study was to review our recent experience with these infections and to present long-term follow-up with in situ CPAs. From January 2000 through June 2005, we treated nine patients with infected aneurysms and one patient with an infection without aneurysm formation. The infection involved the infrarenal abdominal aorta in six patients and the femoral artery in three patients. One patient had an infected splenic artery aneurysm. Aortic rupture occurred in five of the six patients with infected aortas. Two of the three patients with infected femoral aneurysms presented with recurrent hemorrhage. Of the six patients with aortic infections, five were treated with in situ CPAs. One patient was treated with aortic resection and axillofemoral grafting. Two patients with femoral aneurysms were treated with in situ CPAs, and the third patient underwent aneurysm resection and prosthetic grafting through the obturator foramen. The patient with the splenic aneurysm underwent combined valve replacement, aneurysm resection, and splenectomy. Three of the six patients with aortic infections died postoperatively, all of whom were septic at presentation. The cause of death in these three patients was multiple organ failure in two and overwhelming sepsis in one. The three survivors are alive and well with up to 5-year follow-up. The three patients with infected femoral aneurysms are alive and well with follow-up extending to 44 months. The patient with the splenic aneurysm is doing well. No recurrent infections have been noted among the survivors. The CPAs have remained structurally intact in all. The mortality rate among patients with abdominal aortic infections remains high and is likely related to their preoperative septic state. In situ grafting with CPAs appears to be a reasonable treatment option for arterial infections. CPAs appear to maintain their structural integrity and to be resistant to recurrent infection.     

Arterial allografts in treating aortic graft infections: something old, something new

Surgical treatment of major aortic infection remains the most demanding challenge in aortic surgery. Excellent results with cryopreserved allograft heart valves in the treatment of acute infectious endocarditis prompted the use of allografts for in situ replacement of mycotic aortic aneurysms and prosthetic aortic graft infection. This review summarizes the indications for use of allografts in the management of major aortic infection, describes technical pitfalls at the time of implantation, presents clinical results, and analyzes the findings in explanted segments of failed allografts. In addition, the current status of the use of allografts will be compared with competitive techniques for treatment of vascular infections.     

Extra-anatomic revascularization and aortic exclusion for mycotic aneurysms of the infrarenal aorta and iliac arteries in an Asian population

OBJECTIVES: To study the clinical presentation, management and eventual outcome of patients with mycotic abdominal aortic aneurysms managed with aortic exclusion and extra-anatomic reconstruction. DESIGN: A retrospective chart review of 18 cases treated at a single institution. METHODS: Medical records of 18 patients admitted to our institution from October 1997 to July 2006 with a diagnosis of mycotic abdominal aortic aneurysms were reviewed. In all cases, the diagnosis was confirmed by abdominal computed tomography and empirical parenteral antibiotics were administered. Seventeen patients had surgical debridement, aneurysm exclusion, and extra-anatomic reconstruction. The antibiotics were continued in the postoperative period for 6 weeks. RESULTS: Immunosuppression was present in 72%, with diabetes mellitus present in 56%. Salmonella sp was the causative organism in 72% of cases. Most patients presented late, with a 67% incidence of contained rupture. Seventy-two percent needed early or emergency surgery with less than 1 week of preoperative antibiotics. Disease-specific mortality was 39% (7/18). There was 1 late death during the mean follow-up period of 34 +/- 26 months. One patient with an infrarenal aneurysm arising relatively close (neck, 2 cm) to the renal arteries died on table when proximal ligatures cut through the friable aortic wall, resulting in uncontrollable exsanguination. One third of patients on long-term graft surveillance developed mild to moderate stenosis at the anastomotic site. CONCLUSIONS: Empirical antibiotics must be started early, aiming to achieve 1 week of antibiotics prior to surgery. In the Asian population, 3 characteristics are apparent: (1) most patients are immunocompromised; (2) patients present late in the course of disease; and (3) Salmonella is usually responsible. Extra-anatomic bypass may provide a safe option for revascularization of mycotic aneurysms of the iliac arteries and infrarenal aorta.     

Abdominal aortic reconstruction in infected fields: early results of the United States cryopreserved aortic allograft registry

OBJECTIVE: Aortic reconstructions for primary graft infection (PGI), mycotic aneurysm (MA), and aortic graft-enteric erosion (AEE) bear high morbidity and mortality rates, and current treatment options are not ideal. Cryopreserved grafts have been implanted successfully in infected fields and may be suitable for abdominal aortic reconstructions. Registry data from several institutions were compiled to examine results of cryopreserved aortic allograft (CAA) placement. METHODS: The experience of 31 institutions was reviewed for CAAs inserted from March 4, 1999, to August 23, 2001. Indications for CAA, organisms, mortality, and complications were identified. RESULTS: Fifty-six patients, 43 men and 13 women, with a mean age of 66 years (range, 44 to 90 years) had in situ aortic replacement with CAA. Indications for CAA placement were PGI in 43 patients (77%), MA in seven (14%), AEE in four (7%), and aortic reconstruction with concomitant bowel resection in two (4%). Infectious organisms were identified in 33 patients (59%); the most frequent organism was Staphylococcus aureus in 17 (52%). Thirty-one patients (55%) needed an additional cryopreserved segment for reconstruction. The mean follow-up period was 5.3 months (range, 1 to 22 months). One patient died in the operating room, and the 30-day surgical mortality rate was 13% (7/56). Seven additional patients died during the follow-up period, yielding an overall mortality rate of 25% (14 patients). Two patients (4%) had graft-related mortality as the result of hemorrhage from the CAA and persistent infection. Graft-related complications included persistent infection with perianastomotic hemorrhage in five patients (9%), graft limb occlusion in five (9%), and pseudoaneurysm in one (2%). Three patients (5%) needed amputation. CONCLUSION: In situ aortic reconstruction with CAA in infected fields carries a high mortality rate, but most deaths are not the result of allograft failure. However, CAA infection and lethal hemorrhage caused by graft rupture occurs and is concerning. Early reinfection was not reported. Late graft-related complications, such as reinfection, thrombosis, or aneurysmal changes, are unknown. Preliminary data from this registry fail to justify the preferential use of CAA for PGI, MA, or AEE. A multicenter, randomized study is needed to compare results with established techniques.     

Use of superficial femoropopliteal vein for suprainguinal arterial reconstruction in the presence of infection

BACKGROUND: Conventional treatment of mycotic aneurysms or graft infections of the aortoiliac segment by in situ or extra-anatomic prosthetic reconstruction has a high mortality and morbidity rate, with a substantial risk of persistent graft infection. The use of autologous vein may reduce this. METHODS: Eleven patients with suprainguinal arterial infections including two with mycotic aortic aneurysms, four with aortic graft infections, four infected femorofemoral grafts and an infected axillofemoral graft were treated by debridement and in situ reconstruction with autologous superficial femoropopliteal vein. All patients received appropriate antibiotic therapy and were followed by regular postoperative duplex imaging. Preoperative femoral vein duplex imaging was performed in eight of the 11 patients. RESULTS: Ten of the 11 patients survived with a functioning graft and without limb loss or evidence of infection at 4-33 months. One patient died from myocardial infarction after operation. Three patients had minor swelling of one leg. Four patients required subsequent angioplasty of anastomotic stenoses detected by duplex surveillance. CONCLUSION: Superficial femoropopliteal vein is an excellent conduit for suprainguinal reconstruction in the presence of infection. Duplex imaging is useful for confirming the suitability of deep veins for use as a graft and for postoperative surveillance.     

Long-term results of cryopreserved arterial allograft reconstruction in infected prosthetic grafts and mycotic aneurysms of the abdominal aorta.

PURPOSE: This prospective, observational study determined the long-term outcome in patients with abdominal aortic infection (primary or prosthetic graft) who were treated with simultaneous aortic/graft excision and cryopreserved arterial allograft reconstruction. METHODS: From April 1992 to March 2000, patients with abdominal aortic infection underwent complete or partial excision of the infected aorta/prosthetic graft and cryopreserved arterial allograft reconstruction. Arterial allografts were harvested from multiple organ donors and cryopreserved at -80 degrees C without rate-controlled freezing. The patients were observed for survival, limb salvage, persistence and/or recurrence of infection, and allograft patency. The results were calculated with life-table methods. RESULTS: During the 8-year study period, 28 consecutive patients (27 men, 1 woman; mean age, 64 years) underwent treatment for abdominal aortic infection (23 graft infections, including 7 graft-enteric fistulas and 5 primary aortic infections). Allograft reconstruction was performed as an emergency procedure in 13 patients (46%). The mean follow-up period was 35.4 months (range, 6-101 months). The overall treatment-related mortality rate was 17.8% (17% for graft infection, 20% for primary aortic infection). The overall 3-year survival was 67%. There was no early or late amputation. There was no persistent or recurrent infection, and none of the patients received long-term (> 3 months) antibiotic therapy. Reoperation for allograft revision, excision, or replacement was necessary in four patients (17%) who were available for examination, with no reoperative perioperative death. The 3-year primary and secondary allograft patency rates were 81% and 96%, respectively. CONCLUSION: Our experience with cryopreserved arterial allograft in the management of abdominal aortic infection suggests that this technique seems to be a useful option for treating one of the most dreaded vascular complications.     

Treatment of Mycotic Aneurysms with Involvement of the Abdominal Aorta: Single-centre Experience in 44 Consecutive Cases

ObjectiveTo review our management of mycotic aneurysms involving the abdominal aorta over the past 2 decades to assess the safety and efficacy of in-situ and extra-anatomic repair combined with antibiotic treatment.Materials and methodsFrom March 1990 to August 2008, 44 patients with a mycotic aneurysm involving the abdominal aorta were treated at our University Hospital. For all patients, we recorded the aetiology, clinical findings and anatomic location of the aneurysm, as well as bacteriology results, surgical and antibiotic therapy and morbidity and mortality.ResultsTwenty-one (47.7%) of the mycotic aneurysms had already ruptured at the time of surgery. Free rupture was present in nine patients (20.5%). Contained rupture was observed in 12 patients (27.3%).Urgent surgery was performed in 18 cases (40.9%). Revascularisation was achieved by in-situ reconstruction in 37 patients (84.1%), while extra-anatomic reconstruction was performed in six patients (13.6%). One patient (2.3%) was treated with a combined in-situ and extra-anatomic reconstruction. In one case (2.3%), endovascular aneurysm repair (EVAR) was performed.In-hospital mortality was 22.7%, 50% in the extra-anatomic reconstruction group and 18.9% in the in-situ repair group. One-third (33.3%) of our patients, who presented with a ruptured mycotic aneurysm died in the peri-operative period. This mortality was 13% in the patient-group presenting with an intact aneurysm.Of the 34 surviving patients, 12 patients (27.3% of surviving patients died after discharge from our hospital. In half of these patients, an acute cardiac event was to blame. Three patients (8%) showed re-infection after in-situ reconstruction.ConclusionManagement of mycotic aortic aneurysms remains a challenging problem. The results of surgery depend on many factors. In our experience, in-situ repair remains a feasible and safe treatment option for patients who are in good general condition at the time of surgery.     

Bacteriologic and surgical determinants of survival in patients with mycotic aneurysms

Mycotic aneurysms are a fulminant infectious process frequently resulting in rupture and death if not properly treated. A review of the University of California, Los Angeles, medical records identified 10 patients with extrathoracic, extracranial mycotic aneurysms. In addition, a search of the English literature revealed 178 patients with 243 mycotic aneurysms. These patients were reviewed to identify the aneurysm location, etiology, bacteriology, and modality of treatment in order to determine the relationship between these factors and the outcome. The femoral artery was the most common site (38%), followed by the abdominal aorta (31%). Arterial trauma was the primary etiology in 42% of mycotic aneurysms. In 25% no clear source of infection could be identified. Staphylococcus aureus was cultured from 28% of mycotic aneurysms, and Salmonella from 15%. A trend toward the involvement of more gram-negative aerobes and anaerobes is noted. Aortic aneurysms were repaired with in situ Dacron in 61% of patients with a 32% mortality rate and 16% reinfection rate. Simple ligation of femoral artery mycotic aneurysms resulted in a 34% incidence of ischemia necessitating amputation. Methods of treatment of superior mesenteric, carotid, iliac, and peripheral arteries are also analyzed. On the basis of these data, specific surgical procedures are recommended for the treatment of mycotic aneurysms.     

Prosthetic graft infection after descending thoracic/ thoracoabdominal aortic aneurysmectomy: management with in situ arterial allografts

PURPOSE: Prosthetic graft infection is an uncommon but life-threatening complication of descending thoracic/thoracoabdominal aortic aneurysmectomy. The purpose of this study was to assess the value of in situ arterial allografts in the management of this complication. METHODS: From 1992 to 2000 we treated 11 consecutive patients with prosthetic graft infection after descending thoracic/thoracoabdominal aortic aneurysmectomy by replacing the prosthetic graft with an in situ arterial allograft. There were 10 men and one woman with a mean age of 50.8 years (range, 32-73 years). The primary aortic disease was degenerative aneurysm in 6 patients, chronic type B dissection in 2 patients, inflammatory aneurysm in 1 patient, Marfan's disease in 1 patient, and Beh?et's disease in 1 patient. Replacement involved only the descending thoracic aorta in three patients and more or less extensive segments of the thoracoabdominal aorta in eight patients. Signs of severe infection were present in all patients, and false anastomotic aneurysms were noted in six patients. Aortoenteric fistula occurred in three patients and aortobronchial fistula in two patients. The causative organisms were identified in nine patients. The mean interval between the primary surgery and reoperation was 33.4 +/- 27.5 months. Reoperation was performed under emergency conditions because of hemorrhage in three patients. Cardiopulmonary bypass with deep hypothermic circulatory arrest was used in seven patients. Allograft replacement of the aorta was associated with reimplantation of intercostal and/or visceral arteries in all patients. RESULTS: One patient died intraoperatively of heart failure during emergency surgery. Two patients died of persistent infection during the postoperative period at 19 and 58 days. Mean follow-up was 34 +/- 19 months. One patient died during the late follow-up period after surgery of the infrarenal aorta. Another patient underwent surgery for stenoses of one branch of a bifurcated allograft and a renal bypass graft to a solitary kidney. CONCLUSIONS: The use of in situ arterial allografts is a significant advance in the management of prosthetic graft infection after descending thoracic/thoracoabdominal aortic aneurysmectomy provided that reoperation is performed early.     

Cryopreserved arterial allografts for in situ reconstruction of abdominal aortic native or secondary graft infection

Objective

The objective of this study was to evaluate the early and long-term outcome of cryopreserved arterial allografts (CAAs) used for in situ reconstruction of abdominal aortic native or secondary graft infection and to identify predictors of mortality.

Cryopreserved Arterial Allografts Used for the Treatment of Infected Vascular Grafts

n = 11) or partial removal (n= 7) of infected prosthetic grafts. Revascularizations were aortoaortic (n= 2), aortobifemoral (n= 8), aortounifemoral (n= 3), femorofemoral (n= 2), iliofemoral (n= 1), or femoropopliteal (n= 2) bypasses. Four patients died postoperatively (22%)—one of septic necrosis of the allograft, one of septic rupture of the aortic anastomosis of a previous bypass, one of multiorgan failure, and one of mesenteric infarction. One allograft occluded within 30 days (5.5%), leading to an above-knee amputation. In the remaining patients, routine arteriography or duplex scan showed patent allografts. For the 14 survivors, the mean follow-up period was 20 months (range: 1-45 months). Two patients died—one of septicemia not related to the allograft, and one of multiple organ failure. Among the 12 survivors, 3 patients with non-ABO-compatible allografts developed different types of long-term alterations. One patient had a hemorrhage due to femoral allograft rupture at 45 days, and two patients had aortic allografts dilatation with mural thrombus, necessitating a prosthetic replacement in one patient. Cryopreserved allografts used for the treatment of infected vascular graft are useful in selected cases, although they are not totally resistant to infection. Patients should be followed closely to detect significant long-term alterations of the allografts.     

Use of Cryopreserved Arterial Homografts for Management of Infected Prosthetic Grafts: A Multicentric Study

The objective of this study was to evaluate the effectiveness of cryopreserved arterial homografts for management of prosthetic graft infection. Between October 1992 and July 1998, 90 patients (84 men) with a mean age of 64 years from six different hospitals were treated for prosthesis infection by in situ replacement using a cryopreserved arterial homograft (CAH). In 43 patients (47%), the primary procedure had been performed at a nonparticipating center. Prosthetic graft infection occurred early (i.e., within 1 month after the primary procedure) in 15 cases and late in 75 cases. In the late group, the mean interval between the primary procedure and CAH replacement was 34 months (range, 3 to 330 months). In 41 patients, infection was located in the aortic region, including 17 presenting with enteroprosthetic fistula (EPF). In 49 patients, infection was confined to the femoral, popliteal, or subclavian region. Bacteriologic cultures were positive for one or more germs in 75 patients and negative in 15. The surgical procedure consisted of complete or partial removal of the infected prosthetic graft, debridement, and in situ reconstruction using one or more CAH. Our results showed that management of prosthetic graft infection, a grave complication, using a CAH is a promising technique, especially for patients in stable condition prior to reconstruction.     

Management of infected aortoiliac aneurysms

A 30-year retrospective review identified 13 patients treated for infected aneurysms of the abdominal aorta or iliac arteries, for an overall incidence of 0.65%. A constellation of clinical findings led to the correct preoperative diagnosis in 11 (85%) of 13 patients. Treatment methods included resection and in situ replacement grafting in seven patients, resection and extra-anatomic bypass in five patients, and resection-ligation in one patient. Four (31%) of 13 patients died within 30 days of operation, three of whom died of rupture. Overall, good results were achieved in five patients (38%), while poor results were noted in the remaining eight patients (62%). The determinants of outcome were aneurysm location or rupture, the presence of established infection, and the virulence of the infecting organism. In 10 (77%) of the 13 aneurysms, Salmonella species, Bacteroides fragilis, Staphylococcus aureus, and Pseudomonas aeruginosa accounted for all deaths, ruptures, and suprarenal aneurysm infections. These data suggest that patients with primary infections of the abdominal aorta or iliac arteries continue to present with advanced infections or aneurysm rupture that result in a high mortality.     

In situ repair of mycotic abdominal aortic aneurysms with rifampin-bonded gelatin-impregnated Dacron grafts: A preliminary case report

Treatment of mycotic aortic aneurysm by excision and extraanatomic bypass is difficult to apply when the infectious process involves the visceral arteries. On the basis of experimental studies in our laboratory that demonstrated prolonged antistaphylococcal activity of rifampin-bonded, gelatin-impregnated Dacron grafts after implantation in the arterial circulation, this conduit was successfully used for in situ replacement of a native aortic infection in two patients. Both patients had fever, leukocytosis, abdominal or back pain, and a computed tomographic scan that demonstrated contained rupture of a mycotic aneurysm. Preoperative computed tomography guided aspiration and culture of periaortic fluid from one patient grew Staphylococcus aureus. Treatment consisted of prolonged (6 weeks) culture-specific parenteral antibiotic therapy, excision of involved aorta, oxychlorosene irrigation of the aortic bed, and restoration of aortic continuity by in situ prosthetic replacement. A preliminary right axillobifemoral bypass was performed in the patient who had an infection involving the suprarenal and infrarenal aorta. In both patients intraoperative culture of aorta wall recovered S. aureus. Patients were discharged at 20 and 21 days. Clinical follow-up and computed tomographic imaging of the replacement graft beyond 10 months after surgery demonstrated no signs of residual aortic infection. In the absence of gross pus and frank sepsis, the use of an antibiotic-bonded prosthetic graft with antistaphylococcal activity should be considered in patients who have arterial infections caused by S. aureus when excision and ex situ bypass are not feasible. (J Vasc Surg 1996;24:472-6.)     

Cryopreserved arterial allograft reconstruction for peripheral graft infection

OBJECTIVE: This prospective, observational study evaluated the safety and efficacy of cryopreserved arterial allograft reconstruction in the management of major peripheral arterial graft infections. METHODS: From April 1996 to May 2003, data from patients with major peripheral arterial graft infection who underwent graft excision and cryopreserved arterial allograft reconstruction were prospectively collected. Arterial allografts were harvested from multiple organ donors and cryopreserved at -80 degrees C. The patients were observed for survival, limb salvage, persistence or recurrence of infection, and allograft patency. The results were calculated with the Kaplan-Meier method. RESULTS: During the 7-year study period, 17 patients (14 men, 3 women; mean age, 68 years) with major peripheral graft infection underwent graft excision and cryopreserved arterial allograft reconstruction. Eight patients (47%) had systemic sepsis, 5 (29%) had acute ischemia at the time of the allograft reconstruction, and 9 (53%) had experienced anastomotic rupture. Allograft reconstruction was performed as an emergency procedure in 7 patients (41%). There were no perioperative deaths or early amputations. Two patients had allograft ruptures in the groin during the early postoperative period. The mean follow-up period was 34 months (range, 8 to 80 months). There was no persistent or recurrent infection, and none of the patients received long-term (>3 months) antibiotic therapy. Reoperation for allograft revision, excision, or replacement was performed in 2 patients. The 18-month primary and secondary allograft patency rates were 68% and 86%; the overall limb salvage rate was 82% at 2 years. CONCLUSION: Our experience with cryopreserved arterial allograft in the management of major peripheral bypass graft infection suggests that this technique seems to be a useful option for treating one of the most dreaded vascular complications.