Periaortic endograft infection due to Listeria monocytogenes treated with graft preservation

A 67-year-old man presented to our hospital with general malaise, fever and diffuse abdominal and lower back pain 7 weeks after endovascular aneurysm repair. Blood samples showed a leukocyte count of 10.9 x 10(9)/l and a C-reactive protein of 239 mg/l. The computed tomography (CT)-scan showed fluid collections behind the proximal part of the endovascular graft and dorsal to the aorta. CT-guided translumbar needle aspiration of these collections yielded growth with Listeria monocytogenes. Prosthetic endograft infection is an extremely rare event, especially when it is caused by L. monocytogenes. Given the scarcity of this complication, no consensus has been reached for its treatment. In the described case, radiological drainage and prolonged antibiotic treatment resulted in favourable outcome at midterm follow-up with preservation of the endograft.     

Aortic endograft infection due to Pasteurella multocida following a rabbit bite

Abdominal aortic endograft infection is a serious complication after an endovascular abdominal aortic aneurysm repair. Pasteurella multocida, a gram-negative bacterium, is a commonly found organism in the mouth flora of many house pets. We report a case of an aortic endograft infection caused by P multocida after a rabbit bite. Successful treatment was performed by extra-anatomic revascularization followed by endograft removal.     

Ruptured AAA: open surgical management

Ruptured abdominal aorta aneurysm (rAAA) is the 13th leading cause of death in the United States. Despite many advances in the field of vascular surgery, the improvement in mortality rates of rAAA have been very modest. Although endovascular repair has surpassed open repair for elective AAA repair in the United States, open rAAA repair remains the most common therapy for this devastating vascular emergency. In this article, we discuss open surgical management for rAAA. We also describe a fast-track algorithm we have developed at the University of Massachusetts where open and endovascular repairs play equally important roles in management of rAAA.     

Aortic endograft infection with aortoduodenal fistula associated with adjacent vertebral body mycobacterial osteomyelitis (Pott's disease)

Aortoenteric fistulas (AEFs) are a rare complication of infrarenal abdominal aortic aneurysm repair. They occur in <1% of aortic grafting procedures, result from graft defects, foreign bodies, and trauma, and are associated with a high mortality rate. We report a complex AEF associated with vertebral body osteomyelitis, likely secondary to tuberculous infection. A 78-year-old man presented with a 2-week history of abdominal pain, fever, and anemia. Past surgical history is significant for open repair of infrarenal abdominal aortic aneurysm followed later by an endovascular repair of a proximal para-anastomotic aneurysm. Computed tomography angiography revealed air in the aneurysm sac, without evidence of endoleak. The posterior aspect of the aneurysm was noted to be in continuity with a destructive osteomyelitis of the second lumbar vertebral body and an adjacent psoas abscess. Percutaneous drainage revealed purulent fluid containing mixed enteric flora. With fluoroscopic guidance, injection of contrast in the aortic sac drainage catheter demonstrated complex fistulous communications from the aortic sac to the overlying small intestine. After a course of drainage, antibiotic therapy, and parenteral nutrition, the patient underwent a transperitoneal repair of the AEF with duodeno-duodenectomy and wide debridement of the aortic sac and Dacron graft. Pathology revealed giant cell granulomas, highly suggestive of tuberculosis.     

Delayed open conversion following endovascular aortoiliac aneurysm repair: partial (or complete) endograft preservation as a useful adjunct

OBJECTIVES: The purpose of this study was to review our experience with delayed open conversion (>30 days) following endovascular aortoiliac aneurysm repair (EVAR) and to introduce the concept and advantages of endograft retention in this setting. METHODS: From January 1992 to January 2003, a total of 386 EVARs using a variety of endografts were successfully deployed. Eleven (2.8%) patients required delayed conversion to open repair at an average of 30 months (range, 10-64). Data from all patients undergoing both EVAR and open conversion were prospectively collected. RESULTS: EVARs were performed using grafts made by Talent (4), Vanguard (2,) AneuRx (1), and Surgeon (4). Conversion to open repair (9 transabdominal, 1 retroperitoneal, 1 transabdominal plus thoracotomy) was performed for aneurysm rupture in 7 patients (4 type 1 endoleak, 2 type 2 endoleak, 1 aortoenteric fistula) and aneurysm enlargement in 4 patients (1 type 1 endoleak, 1 type 2 endoleak, 1 type 3 endoleak, 1 endotension). Patients with aneurysm rupture were treated on an emergent basis. Complete removal of the endograft with supraceliac cross-clamping was performed in two cases. One patient (rupture) did not survive the operation, and one patient (aortoenteric fistula) died 2 weeks postoperatively. In the remaining nine cases, the endograft was either completely (1) or partially (6) removed, or left in situ (2). Supraceliac balloon control (2), supraceliac clamping (1), suprarenal clamping (1), or infrarenal clamping (5) was used in these cases. All nine of these patients survived the operation. In one procedure in which the endograft was left intact (endotension), repair was accomplished by exposing the endograft and by placing a standard tube graft over it as a sleeve. In the second procedure in which the graft was left in situ (rupture), the graft was well incorporated, and bleeding lumbar arteries were oversewn and the sac was closed tightly over the endograft. In the remaining 7 cases, the endograft was transected and the proximal portion only (6) or the proximal and distal portions (1) were excised. All surviving patients continue to do well and remain without complications associated with the endograft remnant at a mean follow-up of 22 months (range, 3-56) from the time of open conversion and 46 months (range, 10-73) from the time of original EVAR. CONCLUSIONS: Open repair in the setting of a long-standing endograft offers several unique technical challenges but can be successfully accomplished in most patients. Preservation of all or part of the endograft is possible in many patients. This technique simplifies the operative approach and is preferred over complete endograft removal if possible.     

The significance and management of the leaking endograft.

Endoleak is the persistence of blood flow outside the lumen of an endograft, but within an aneurysm sac or adjacent vessel being treated by the graft. Diagnosis may be difficult, and treatment remains somewhat controversial. The purpose of this article is to discuss the clinical significance and appropriate management of endoleaks within the context of our current understanding of this phenomenon. The diagnosis of an endoleak can be made by conventional angiography, duplex ultrasound, intravascular ultrasound (IVUS), and computed tomography (CT) angiography. All of these modalities are effective, although CT angiography may be the most sensitive. Endoleaks can be categorized into 5 classes: (1) perigraft flow around the proximal end of the endograft; (2) perigraft flow around the distal end of the endograft; (3) flow through a defect in the body of the endograft; (4) flow between segments of a multicomponent endovascular graft; and (5) flow between arterial branches within an aneurysm sac. The first 4 classes have been shown to represent a clinical situation in which systemic arterial pressure is transmitted to an inadequately excluded aneurysm sac, placing the sac at risk of rupture. In contrast, branch-flow leaks do not appear to carry an increased risk of rupture, provided there is no increase in aneurysm sac diameter. However, an increase in the diameter of an aneurysm sac after endograft implantation may be a sign of occult endoleak, even if not visualized by current imaging techniques. Thus, we believe that collateral branch leaks with no associated aneurysm sac expansion may be observed with regular follow-up by CT angiography. All other endoleaks should be treated with adjunctive endovascular maneuvers or explanation of the endograft with standard open repair-in short, routine follow-up imaging on endografts to detect the presence of late endoleaks or aneurysm sac expansion.     

Aortic graft infection: update on management and treatment options

Replacement of the abdominal aorta, whether by autogenous or prosthetic conduit, has been an a priori requisite in the vascular surgeon's armamentarium since its technical feasibility was described in the early 1950s. The Achilles' heel of this operation, in spite of the progress made over the last half century, is still, however, aortic graft infection. Though survival and limb salvage rates have improved over time-commensurate with advances in surgical technique, critical care, and antimicrobial agents-the prevention and treatment of aortic graft infection remains a formidable challenge to the vascular surgeon. The authors herein review the current literature on this topic with an emphasis on the surgical management options available and suggest an individualized operative strategy based on patient as well as microbial factors to attain the best possible outcome.     

Carotid blowout with infection: management with endovascular and open vascular approaches--a case report

The management of patients with head and neck cancer can be complicated by massive carotid artery hemorrhage, often requiring ligation owing to the emergent conditions and scarring from previous surgery and radiation. A case of emergent endovascular management of carotid artery hemorrhage in a patient treated for pharyngeal carcinoma is described. Hemorrhage was controlled, but on follow-up the patient developed a carotid-cutaneous fistula with exposure of the coils. Further management required the use of autogenous vein to replace the involved vessels. This case demonstrates that endovascular control of carotid hemorrhage can be successful, but close follow-up is necessary to identify potential subsequent complications.     

Video-thoracoscopic and open surgical management of thoracic empyema

PURPOSE: To evaluate the outcomes of video-thoracoscopic and open surgical management of patients with thoracic empyema. METHODS: We studied 122 patients retrospectively who underwent surgery for thoracic empyema in our hospital between January, 1999 and January, 2005. Patients' medical records, surgical procedures, and outcomes were reviewed. The study identified 97 affected men and 25 affected women with a mean age of 54 years (range 16-78 years). The empyema was parapneumonic in 95 patients (78%). RESULTS: Forty-four patients who had stage II empyema underwent video-assisted thoracic surgery (VATS). The procedure was converted to thoracotomy in 13 patients (29.5%); the morbidity and mortality rates of VATS were 13% and 0, respectively. Seventy-eight patients had stage III empyema and, along with those 13 who were converted, underwent thoracotomy for decortication. The associated morbidity rate was 12%, and the mortality rate was 6.6%. Thoracotomy was considered successful in 90 of 91 patients (99%); one patient needed a reoperative thoracotomy for an organ space/surgical site infection with pus in the pleural cavity. CONCLUSIONS: Many treatment modalities are available for thoracic empyema, depending on the results of appropriate clinical and laboratory investigations. In fibrinopurulent empyema, VATS debridement is safe and effective, with minimal morbidity and no deaths. Lung decortication via thoracotomy is the only option for organized empyema and is associated with a substantial mortality rate.