Arterial homografts in the management of infected axillofemoral prosthetic grafts.

Two lower limb amputees with infected contralateral axillofemoral prosthetic grafts received preserved human arteries after removal of the infected materials. Both grafts grew organisms (Enterococcus species, plus Staphylococcus species in one). Long length arterial conduits were fashioned from freshly harvested (in one patient) and cryopreserved (in another one) cadaveric iliac and femoral arteries. One arterial homograft had ABO-compatibility with the recipient. No immunosuppressive drugs were administered after repeat arterial reconstructions. After 12 and 15 months both grafts are still patent, without parietal changes at ultrasonography; the patients have a viable remaining lower extremity and are free of symptoms or re-infection.     

Infection of artificial vascular prostheses. Case reports

Four patients with prosthetic graft infection are presented. In 3 patients infection occurred in a Dacron aortobifemoral graft. In all 4 patients the infection originated at the femoral anastomoses. In 2 patients the entire aortofemoral graft was removed; one patient died of septicaemia and the other required an above-knee amputation. In 1 patient partial removal of the graft limb proved successful after a femorofemoral bypass using an autogenous venous graft. Above-knee amputation was performed in a further patient after removal of an infected axillofemoral graft. Staphylococcus was consistently isolated from the infected grafts in all the patients.     

Successful renal transplantation with ipsilateral femoral arteriovenous grafts

BACKGROUND: The choice of location for revascularization of a renal allograft is frequently influenced by the presence of previous pelvic surgery or failed allografts that remain in situ. The presence of polytetrafluoroethylene (PTFE) loop grafts in the femoral vessels may potentially result in iliac venous hypertension, thereby compromising the function of a renal allograft placed nearby. The purpose of this study is to report the hemodynamic changes within the iliac veins as a result of PTFE femoral grafts and report the outcome of renal allografts placed ipsilateral to such grafts. METHODS: THREE patients with a failed renal allograft in the right iliac fossa and functioning left groin PTFE loop grafts underwent left iliac venography and hemodynamic measurements of the iliac venous system. All three patients underwent renal transplantation in the left iliac fossa without ligation or alteration of the loop graft. Standard clinical data were collected after transplantation. RESULTS: All three patients demonstrated widely patent external iliac and common iliac veins ipsilateral to the loop graft. Elevated pressures measured within the venous limb of the loop graft dissipated rapidly within the common femoral and external iliac veins. All three kidneys were well perfused, as documented by posttransplant technetium 99m-diethylenetriaminepentaacetic acid nuclear renography. All three patients have normal renal function past 7 months after transplant, and all three femoral loop grafts are still functioning. CONCLUSIONS: PTFE loop grafts to the femoral vessels are not associated with local venous hypertension in the ipsilateral external iliac veins. Revascularization of a renal allograft may be performed ipsilateral to a femoral loop graft provided other venous diseases, such as strictures, have been excluded.     

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 outcome after treatment of aortic graft infection with staged extra-anatomic bypass grafting and aortic graft removal

OBJECTIVE: The purpose of this study was to determine long-term outcome in patients with infected prosthetic aortic grafts who were treated with extra-anatomic bypass grafting and aortic graft removal. METHODS: Between January 1989 and July 1999, 36 patients were treated for aortic graft infection with extra-anatomic bypass grafting and aortic graft removal. Extra-anatomic bypass graft types were axillofemoral femoral (5), axillofemoral (26; bilateral in 20), axillopopliteal (3; bilateral in 1) and axillofemoral/axillopopliteal (2). The mean follow-up was 32.3 +/- 4. 8 months. RESULTS: Four patients (11%) died in the postoperative period, and two patients died during follow-up as a direct consequence of extra-anatomic bypass grafting and aortic graft removal (one died 7 months after extra-anatomic bypass graft failure, one died 36 months after aortic stump disruption). One additional patient died 72 months after failure of a subsequent aortic reconstruction, so that the overall treatment-related mortality was 19%, whereas overall survival by means of life table analysis was 56% at 5 years. No amputations were required in the postoperative period, but four patients (11%) required amputation during follow-up. Twelve patients (35%) had extra-anatomic bypass graft failure during follow-up, and six patients underwent secondary aortic reconstruction (thoracobifemoral [2], iliofemoral [2], femorofemoral [2]). However, with the exclusion of patients undergoing axillopopliteal grafts (primary patency 0% at 7 months), only seven patients (25%) had extra-anatomic bypass graft failure, and only two patients required amputation (one after extra-anatomic bypass graft removal for infection, one after failure of a secondary aortic reconstruction). Furthermore, primary and secondary patency rates by means of life table analysis were 75% and 100% at 41 months for axillofemoral femoral grafts and 64% and 100% at 60 months for axillofemoral grafts. Only one patient required extra-anatomic bypass graft removal for recurrent infection, and only one late aortic stump disruption occurred. CONCLUSIONS: Staged extra-anatomic bypass grafting (with axillofemoral bypass graft) and aortic graft removal for treatment of aortic graft infection are associated with acceptable early and long-term outcomes and should remain a primary approach in selected patients with this grave problem.     

Inadequacy of saphenous vein grafts for cross-femoral venous bypass

A mathematic model of unilateral iliac vein obstruction was used to establish the theoretic basis for selecting saphenous vein or a larger diameter prosthetic cross-femoral venous bypass graft for relief of obstructive venous hypertension. Common femoral vein resting and postexercise peak flows, and common femoral vein and saphenous vein diameters were measured in 18 healthy individuals and used to estimate the pressure gradient (dP) across 20 cm long cross-femoral venous bypass grafts of saphenous vein or 4, 6, 8, 10, and 12 mm prosthetic conduits, in the presence of a transpelvic venous collateral network of varied cross section. The upper limits of normal for the gradients in our model (dPstd) were set at 4 mm Hg for resting flows and 6 mm Hg after exercise. Mean saphenous vein diameter was 4.3 +/- 0.22 mm, which was 36.5% +/- 1.73% of common femoral vein diameter. When the saphenous veins of two thirds of the individuals in our study were used as theoretic cross-femoral venous bypass conduits, greater than 80% of postobstruction peak cross-femoral venous bypass graft flow had to be carried by collaterals to maintain a gradient less than or equal to dPstd. We demonstrated that 4.5 to 6.0 mm diameter saphenous cross-femoral venous bypass grafts would be hemodynamically efficacious in relieving venous hypertension, but only when implanted in parallel with an existing venous collateral network that limited the preoperative dP to 4.5 to 7.5 mm Hg at resting flows and 7.0 to 11.5 mm Hg after exercise; only 44% of saphenous veins were adequate for cross-femoral venous bypass grafts by these criteria.(ABSTRACT TRUNCATED AT 250 WORDS)     

Successful preservation of an infected common femoral vein to common femoral vein crossover prosthetic graft

We used selective graft preservation to treat an infected anastomosis of a functioning common femoral vein to common femoral vein crossover PTFE bypass performed for iliac vein occlusion. The graft was successfully salvaged by operative debridement and placement of a rectus abdominis muscle flap. With the growing interest in venous reconstructive surgery, bypass infections may be seen more frequently. This case illustrates that selective preservation of infected prosthetic grafts anastomosed to a peripheral vein may be a simple and improved method to treat these complications.Supported by a grant from the John F. Connelly Foundation.Presented at the Sixth Annual Meeting of the North American Society of Phlebology, Orlando, Fla., February 21, 1993.     

Autologous fashioned graft for aneurysm repair in a contaminated field.

BACKGROUND: In situ synthetic grafts are not routinely used for aortoiliac reconstruction in the presence of active or potential infection, while the use of a venous autologous graft in these circumstances is limited by the size and length of the venous conduit that is required, the superficial femoral vein being most frequently used. METHODS: We describe a new technique in which an autologous venous conduit was constructed with side-to-side anastomosed segments of a longitudinally opened greater saphenous vein. Thus the diameter of the new conduit was increased. RESULTS: This venous graft was successfully used to repair an isolated common iliac aneurysm in a patient with sigmoid cancer, as part of a combined procedure. At 1 year follow-up the venous graft has not shown any signs of dilatation or stenosis on CT scanning. CONCLUSIONS: If validated by further work, our novel graft could be used in cases of intraabdominal graft infections and mycotic aneurysms instead of deep leg veins.     

Cryopreserved saphenous vein allogenic homografts: an alternative conduit in lower extremity arterial reconstruction in infected fields.

Autologous saphenous veins are considered the best arterial substitute for lower extremity revascularization in infected fields. The search continues for a vascular conduit in instances when an autologous biologic grafting is not feasible. Herein we report our experience with eight patients in whom cryopreserved saphenous vein allogenic homografts were used in 10 lower extremity arterial reconstructions for limb salvage with coexisting infection. Six patients with eight prosthetic grafts including four femoropopliteal, two femorotibial, a femorofemoral, and a femoroperoneal graft required complete or partial graft excision as a result of overt infection. The two remaining patients included one with an infected femoral pseudoaneurysm and another with extensive chemical burns. All cryopreserved saphenous vein allogenic homografts were of identical match to the ABO/Rh blood groupings of the recipient patients. No immunosuppressive drugs were administered after operation. Mean follow-up was 9.5 months (range, 6.0 to 14.0 months). One patient died 5 weeks after operation with a patent graft. Two grafts occluded during follow-up; in one graft, patency was restored with thrombectomy alone. The remaining seven arterial reconstructions continue to be patent with no evidence of aneurysmal dilation with complete eradication of the primary infection. These preliminary findings suggest that cryopreserved saphenous vein allogenic homografts can serve as interim conduits for lower extremity arterial reconstruction to preserve limb viability when autogenous conduits are unsatisfactory or unavailable. Further definitive reconstruction may thereafter be necessary once sepsis is eradicated and sufficient wound healing is achieved.     

Repair of a saccular aortic aneurysm with superficial femoral-popliteal vein in the presence of a pancreatic abscess

When one is faced with impending rupture, repair of an aortic aneurysm cannot be delayed. In the presence of coexisting intra-abdominal sepsis, traditional therapy would call for aneurysm exclusion and axillofemoral bypass grafting. Consequences of this choice of treatment include limited long-term graft patency and recurrent prosthetic infection. Autogenous deep veins from the lower extremities have demonstrated exceptional patency and resilience to infection when used to replace infected aortic grafts. We now report a case of concomitant open drainage of a pancreatic abscess and repair of a saccular abdominal aortic aneurysm using the superficial femoral-popliteal vein as a conduit.     

In situ autogenous reconstruction of the thoracoabdominal aorta and branches for treatment of an infected thoracoabdominal aortobifemoral bypass graft

Graft infection is an uncommon but potentially lethal complication of prosthetic aortic repair. We describe a novel technique for upper abdominal aortic and visceral revascularization after percutaneous drainage and antibiotics failed to cure a thoracofemoral prosthetic graft infection. One week after axillofemoral and femorofemoral bypass grafting, the infected thoracoabdominal graft was removed and a bifurcated iliac artery autograft was used to replace the upper abdominal aorta and revascularize the abdominal viscera. The infected graft was removed from the thorax and retroperitoneum, the infection resolved, and the patient remained well until his death of lung cancer 9 years later. (J Vasc Surg 1998;27:977-80.)     

Arterial reconstruction with deep leg veins for the treatment of mycotic aneurysms

PURPOSE: Mycotic pseudoaneurysms (MPA) remain challenging clinical problems. Primary surgical management includes control of hemorrhage and debridement of the infected arterial wall. Because critical ischemia may develop after arterial resection, revascularization has been a secondary goal of treatment. Standard anatomic graft placement or prosthetic bypass grafting has been compromised by a high rate of recurrent infection. Extra-anatomic reconstruction is preferred, with the basic goals being threefold: (1) the use of autogenous graft material to reduce the risk of reinfection; (2) the avoidance of significant size mismatches; and (3) graft placement that is anatomically inaccessible, because drug abuse causes many of these lesions. This study reviews a recent series of MPAs applying these treatment goals. METHODS: In a 2-year period, the superficial femoral and proximal popliteal veins were used in the repair of eight MPAs of the common femoral (5), common iliac (1), and brachial (1) arteries, and the infrarenal aorta (1). Most patients (5 of 7) were known intravenous drug users, who had a painful pulsatile mass in an injection area. Two patients had systemic sepsis, one patient with an infected common iliac pseudoaneurysm and one patient with an MPA of the infrarenal aorta. The diagnosis of MPA was made by means of duplex/computed tomography scanning and confirmed by means of arteriography in all cases. RESULTS: Obturator bypass grafting was performed by using a reversed deep leg vein in the five femoral MPAs. An ilioiliac, cross-pelvic bypass grafting procedure with a deep vein was used to repair an MPA of the common iliac artery. A deep vein was also used as a "pantaloon" aortobiiliac graft and for a brachial artery repair. Staphylococcus aureus was revealed by means of cultures in nearly all cases. Distal arterial perfusion was normal after reconstruction. Patients had no significant postoperative leg swelling. No new venous thrombosis below the level of deep vein harvest was revealed by means of duplex scanning. There were no septic complications. CONCLUSION: The superficial femoral/popliteal veins may be particularly useful for limb revascularization in patients with MPAs. This autogenous conduit provides an excellent size-match and a suitable length for reconstruction, because peripheral, axial arteries are generally affected. No clinically significant limb morbidity was related to deep vein removal. Late follow-up is challenging in such cases, but will be required to accurately determine the durability of this strategy.     

A modified method for management of prosthetic graft infections involving an anastomosis to the common femoral artery

In the last 10 years we have treated 28 patients with 33 groin infections involving a common femoral artery anastomosis of prosthetic arterial grafts (2 aortic Dacron grafts, 31 peripheral polytetrafluoroethylene grafts). Management included complete graft preservation for patent infected grafts (11 cases), subtotal excision of occluded infected grafts leaving an oversewn 2 to 3 mm graft remnant attached to a patent artery critical for limb survival (16 cases), and total graft excision with arterial oversewing or ligation for anastomotic bleeding (6 cases). Essential treatment adjuncts included (1) radical operative wound debridement, and (2) secondary revascularization by means of bypasses tunneled via lateral uninfected routes, and unusual approaches to uninvolved patent outflow arteries (i.e., the distal superficial or deep femoral or popliteal arteries) after isolation of the infected wound. Follow-up averaged 3 years (1 to 10 years). This plan of treatment resulted in an 11% (3/28) hospital mortality and an amputation rate of 13% (4/30 threatened limbs). Of the 25 survivors with 30 infected groin grafts, 87% (26) of the wounds healed uneventfully by secondary intention within 1 to 8 weeks (mean, 4 weeks) and have remained healed. One infected groin wound did not heal and required delayed total graft excision. Three patients had late anastomotic disruption with hemorrhage at 8 months, 2 years, and 4 years after initial treatment. This selected use of complete or partial graft preservation and other essential treatment adjuncts are proposed as a safer, easier method for managing infected prosthetic arterial grafts in the groin.     

Aortic and peripheral prosthetic graft infection: differential management and causes of mortality

This report of 25 patients with prosthetic graft infection has compared the diagnosis, management, and outcome in 14 patients with infected aortic grafts with 11 patients with infected peripheral grafts (two axillofemorofemoral, five femorofemoral, five femoropopliteal, and one femoral interposition). Peripheral graft infection had a significantly shorter interval to diagnosis compared with aortic graft infection. Total graft removal combined with either autogenous revascularization or extraanatomic bypass using prosthetic graft was performed in all 14 patients with infected aortic grafts. Management of peripheral graft infection consisted of total graft removal in eight patients (four with autogenous revascularization and two with amputation) and partial graft removal in three patients (two with amputation). Mortality and amputation rates for infected aortic grafts were 43 percent and 25 percent, respectively compared with 36 percent and 27 percent for infected peripheral grafts. Recommendations for management of the infected aortic prosthetic graft include total graft removal, but methods and timing of revascularization are dependent on the specific features of the individual case. However, preferred management for the infected peripheral prosthetic graft includes total graft removal and, if indicated, revascularization using autogenous tissue.     

Experience with femoro-popliteal vein as a conduit for vascular reconstruction in infected fields.

OBJECTIVE: to review the outcome of femoro-popliteal vein grafts for arterial reconstruction in the presence of sepsis. PATIENTS AND METHODS: twenty-six patients underwent 27 arterial reconstructions with femoro-popliteal vein in the presence of infection. Five had mycotic aneurysms (3 aortic, 1 iliac and 1 femoral), 21 had prosthetic graft infections (9 aortic, 8 femoro-femoral, 2 axillo-femoral, 1 ilio-femoral and 1 femoral dacron patch) and one underwent superior mesenteric artery reconstruction following ischaemic small bowel perforation.Arterial reconstruction followed debridement of infected tissue, removing any infected graft, povidone iodine washout and appropriate antibiotic cover. Where possible, new grafts were placed in a clean field or wrapped in omentum. Four femoral anastomoses were covered by rectus femoris flaps. RESULTS: there was one early postoperative death (4%) and no limb loss. All others remained free from infection with patent grafts at 1 month to 5 years (median 22 months). Three major wound infections healed without exposing the graft. One infarcted rectus femoris flap required removal. Donor limb swelling was transient. Five required percutaneous angioplasty and one underwent open profundaplasty within 3 months. CONCLUSION: femoro-popliteal vein reconstruction with debridement and appropriate antibiotic therapy is recommended for the treatment of arterial or graft infections.     

Surgical experience with expanded polytetrafluoroethylene (PTFE) as a replacement graft for traumatized vessels.

With the increased nationwide incidence of major vascular injuries, the need for interposition grafting has become quite common in major trauma centers. Despite extensive experience with such injuries, the choice of a substitute conduit remains controversial. Recent studies have demonstrated the potential of expanded polytetrafluoroethylene (PTFE) as a replacement graft for small arteries and veins. The surgical services at the Ben Taub General Hospital began to use PTFE grafts in traumatic vascular wounds approximately 2 years ago. Eight axillary arteries and 12 brachial arteries have had interposition grafting with PTFE prostheses. Eleven patients have required PTFE interposition grafts in repair of traumatized common, superficial, and profunda femoris arteries and common femoral veins; eight patients had reconstruction in the popliteal artery or vein. Three patients had renal artery revascularization procedures following blunt abdominal trauma, three patient had segmental replacement of the superior mesenteric artery following gunshot wounds, and one carotid artery, one iliac vein, and two axillary veins were grafted with PTFE. All patients with segmental repair of axillary, brachial, femoral, and popliteal vessels have maintained good distal pulses and viable extremities. No grafts have thrombosed, nor become infected, in spite of soft-tissue injury encountered at time or repair. In situations requiring interposition graft placement for reestablishment of distal flow in small arteries and veins, PTFE grafts appear to be an acceptable prosthesis.     

Vascular reconstruction after extended resection of a retroperitoneal fibromatosis

We report the case of a 25-year-old man who underwent successful en-bloc resection of a retroperitoneal fibromatosis, extended to the right kidney and testis, with excision of the right iliac arteries and veins. Arterial replacement was done by means of a right iliofemoral prosthetic graft. A right femorocaval prosthetic graft with a temporary arteriovenous fistula was used for venous replacement. The patient is still alive and after 3 years shows no sign of recurrence on successive computed tomographic scans. He has preserved patency of the right arterial and venous iliac grafts. To our knowledge, this is the first documented case of simultaneous arterial and venous iliac replacement successfully performed after excision of a retroperitoneal tumor.     

New concepts in the use of axillofemoral bypass grafts

Over a four-year period, 52 patients underwent axillofemoral bypass operations. Indications for operation were divided into three groups: those that were performed emergently (aortoenteric fistula, graft infection, and leaking aortic aneurysm), those performed electively for aneurysm, and those for ischemia. Operative procedures were categorized as follows: axillofemoral bypass alone, axillofemorofemoral bypass with the proximal femorofemoral anastomosis being graft to graft, or axillofemorofemoral bypass with the femorofemoral anastomosis to either a transected proximal common femoral artery or superficial femoral artery distal to the axillofemoral anastomosis. Thirty-three percent of the unilateral axillofemoral grafts failed, while only 14% of the axillobifemoral grafts failed. There was a further difference between the two methods of femorofemoral grafting with 22% failure in the former group but no failures in the latter.     

Infected lower extremity extra-anatomic bypass grafts: Management of a serious complication in high-risk patients

To determine optimal management and outcome of infected extra-anatomic bypass grafts (EABG), we reviewed 28 patients (19 men and 9 women; mean age 70 years) treated over a 13-year period. Mean follow-up was 42 months. There were 16 axillofemoral (AF), 10 femorofemoral (FF), and two axillopopliteal (AP) grafts. Risk factors included previous prosthetic graft infection in 13 patients, enterocutaneous fistula in two, and mycotic aortic aneurysm in one. Initial management involved complete graft excision in 12 patients, partial graft excision in 10, and nonresectional therapy in six. Failure of nonresectional therapy and partial excision in three patients each required further operative intervention with graft excision. Reconstruction in patients eventually requiring graft excision (n=25) entailed placement of a new prosthetic AF or AP graft in eight, an autogenous FF graft in five, combined prosthetic AF and autogenous FF bypass in two, autogenous iliofemoral bypass in one, obturator bypass in one, or no reconstruction in eight. Four autogenous FF reconstructions thrombosed immediately postoperatively, and three prosthetic reconstructions became infected. The mortality rate was 18% (FF=20%, AF=19%, AP=0%). The amputation rate was 25% (AP=100%, AF=25%, FF=10%) and was higher without arterial reconstruction (56% vs. 12%,p=0.02). Two patients required hemipelvectomies and one had bilateral hip disarticulation. We conclude that EABG infections can be successfully treated but carry significant morbidity and mortality. Optimal management includes EABG resection and prompt revascularization, bearing in mind the risk of early thrombosis in autogenous grafts and reinfection in prosthetic grafts.Presented at the Thirteenth Annual Meeting of the Southern California Vascular Surgical Society, Coronado, Calif., September 16–18, 1994.     

Arterial homografts - a possible solution to an infective dilemma

Seven patients with infected arterial conduits (six with prosthetic bypass grafts and one autogenous vein anastomosis) with ten limbs at risk (three patients with bilateral groin infection) are reported. The most common site for infection was the groin and the most frequent organism cultured was Staphylococcus aureus. These patients were selected for arterial homograft implantation through infected fields as they were unsuitable for extra-anatomical prosthetic bypass or had inadequate autogenous tissue available for use as a bypass conduit, i.e. the alternative to homograft insertion was arterial ligation and potential limb sacrifice. The arterial homografts were obtained from brain-dead organ donors (human immunodeficiency virus, hepatitis B- and hepatitis C-negative) and stored at −80°C until ready for use. All seven patients had initial success with their homograft procedures in terms of graft patency, limb salvage and control of infection, although two required early reoperation for haemorrhage. During the follow-up period (mean 24.5, range 6–52 months) three homografts have occluded at 6, 13 and 29 months resulting in limb loss. Two patients have died at 48 and 52 months from causes unrelated to their homograft procedures with functioning homografts and limb salvage. Two further patients remain alive with patent homografts at 7 and 20 months. The authors' experience suggests that arterial homografts have a role in overcoming arterial bypass infection, achieving wound healing and maintaining limb viability rather than resorting to arterial ligation and accepting major limb amputation. Copyright © 1996 The International Society for Cardiovascular Surgery.