Penetration of the iliac bone as a modified tunneling option for graft infection in the groin

A graft infection is one of the most fatal complications after surgical treatment for arteriosclerosis obliterans. Although both redo arterial revascularization for limb salvage and prevention of recurrent infection are necessary for the treatment of an infected prosthetic graft, surgical strategy is extremely troublesome and challenging. We successfully performed the extra-anatomic bypass by penetrating an iliac bone, in 3 cases. The anterior aspect of iliac crest was exposed through pararectal retroperitoneal incision. The hole in the iliac bone can be easily made by an electric scalpel. In performing redo arterial revascularization for the prosthetic vascular graft infection, reconstructing the extra-anatomic bypass by penetrating an iliac bone is one of the most advantageous treatments. This surgical strategy can help to select the flexible bypassed route, isolate the infected site, and completely eradicate its area of infection for wound healing.     

Retro-sartorius bypass in the treatment of graft infection after peripheral vascular surgery

Extra-anatomic bypass is preferred for revascularization after removal of infected vascular grafts. The obturator canal technique has been used to bypass an infected field in the groin, although this method has not always been definitive because of several drawbacks. We present a unique method of extra-anatomic revascularization for use in such a situation. An autogenous graft is placed just below the sartorius muscle in the thigh and penetrates the iliacus muscle near the lateral end of the inguinal ligament. Limb loss and recurrent infection are prevented postoperatively. This retro-sartorius bypass technique may be a useful alternative to obturator bypass grafting in selected patients.     

Recurrent aortic graft infection following descending thoracic aorta to femoral artery bypass. A case report and review

This paper presents a patient who developed a recurrent aortic graft infection after a descending thoracic aorta to femoral artery bypass. The patient had previously undergone successful management of an infected aortobifemoral bypass by removal of the graft and revascularization of the lower extremities with axillofemoral bypasses. A general discussion of the management of infected aortic grafts is presented and a discussion of the management of this particular patient is presented in detail.     

Disseminated histoplasmosis with embolic endovascular complications: a case report

A 57-year-old man had subacute embolic ischemia of his right foot and subsequent acute embolic ischemia of his left foot after angiography. Thrombus removed at the time of the left femoral thromboembolectomy grew Histoplasma capsulatum confirming the diagnosis of disseminated histoplasmosis. Surgical revascularization of the right leg and parenteral amphotericin B was followed by chronic ketoconazole therapy for 16 months. The patient has remained asymptomatic at 30 months after operation. Effective treatment of endovascular infection with ischemic complications of Histoplasmosis requires surgical revascularization and intensive chemotherapeutic intervention. Histoplasmosis is a ubiquitous infection in endemic areas that often has an asymptomatic subclinical course. Involvement of the cardiovascular system is rarely reported. Previous case reports have described infected cardiac valves and aortic aneurysms. This report describes the uncommon presentation of disseminated Histoplasma capsulatum infection as a peripheral embolic event and the successful management with revascularization combined with systemic amphotericin B followed by ketoconazole therapy.     

Femorofemoral bypass with an infrascrotal perineal approach for the patient with an infected groin wound

A technique is presented for revascularization of patients having a groin wound infection, which minimizes the risk of recurrent graft infection. A femorofemoral bypass with a subcutaneous perineal tunnel is constructed farther from the infected groin wound than the standard subcutaneous suprapubic tunnel. The route of the graft appears to result in neither excessive tension on the graft when the leg is abducted nor kinking of the graft when the leg is adducted. Long-term follow-up will be needed to compare the patency of this route with the standard suprapubic tunnel in patients with an infected groin wound who require a femorofemoral bypass graft.     

An ex-situ arterial reconstruction for the treatment of an infected suprarenal abdominal aortic aneurysm involving visceral vessels

A 66-year-old man, who had complaints of back pain, high fever, and constipation, with a suprarenal infected abdominal aortic aneurysm involving visceral vessels, was successfully treated by an ex situ arterial reconstruction. Blood culture revealed bacteroides melaninogenicus. After establishing a temporary bypass from right axillary to right external iliac artery, both renal arteries--superior mesenteric artery and common hepatic artery--were preliminary bypassed from external iliac arteries. Then aortic trunk reconstruction was performed with the body twisting left side to separate the graft from the infected field. The patient had good recovery and no evidence of recurrent infection 31 months after the operation.     

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.)     

Surgical treatment of methicillin-resistant Staphylococcus aureus infection following infrainguinal arterial reconstruction.

A 64-year-old man was referred to our hospital with Methicillin-resistant Staphylococcus aureus (MRSA) infection following infrainguinal arterial reconstruction. As repeated MRSA sepsis occurred, we decided to remove the infected graft with distal revascularization via circuitous graft tunneling to avoid serious infections and allow limb salvage. An iliofemoro bypass was performed via an extra-anatomical bypass, from just below the iliac crest into the musculus quadriceps femoris using an 8 mm-ringed polyester gelatin polypropylene tube graft, with complete debridement of a groin infection. Postoperative 3-dimentional CT angiography revealed that the prostheses was patent and the patient had an uneventful postoperative course. We concluded that this extra-anatomical bypass was a safe procedure and an excellent option for patients with an infected vascular prosthetic graft in the groin after previous revascularization, like in our case with no available autogeneous vein grafts.     

Infected cystic adenomatoid malformation in an adult

Congenital cystic adenomatoid malformation of the lung is rare in adults. We present a 51-year-old man with recurrent lower respiratory tract infections and intermittent febrile episodes for more than 10 years. Multiple cavitary lesions with fluid accumulation were seen in the right lower lobe of the lung on radiography and computed tomography of the chest. Wedge resection of the right lower lobe of the lung was performed through a mini-thoracotomy using video-assisted thoracoscopy. Multiple infected cysts were found in a 10 × 8 × 6 cm area of lung. The histologic diagnosis was infected type I congenital cystic adenomatoid malformation. The patient remains well 1 year after the operation.     

Multilevel diabetic foot revascularization in COVID 19 patient: Case report

IntroductionCoronavirus 2019 (COVID-19) has been associated with endothelial dysfunction. This hypercoagulable state coming from the endothelial injury pones COVID-19 patients to a higher risk for thrombosis. COVID 19 diabetic patients are more exposed to peripheral vascular disease progression. Multilevel peripheral arterial disease is the main cause of critical limb ischemia. Vascular interventions are required to increase distal blood flow and reduce the risk of amputation.Presentation of caseWe report a case of complex revascularization in a diabetic patient with aggressive right foot lesions evolution after COVID-19 infection. The patient presenting a Peripheral arterial ischemic involving the infrarenal aorta, iliac, femoral. The simultaneous intervention consisted of an endovascular aortic stent-graft placement and angioplasty of femoral artery.DiscussionDiabetes is a risk factor of severity and deaths in patients infected with pulmonary viruses. In our experience, COVID 19 virus can accelerate the ulcers generation and progression in diabetic patient. Hybrid interventions can be performed simultaneously or staged with benefit given by the complementary role of endovascular and surgical treatments. In the reported case, a complex simultaneous treatment in a patient presenting Multilevel peripheral arterial disease in association to COVID 19 infection was feasible in the same operation.ConclusionHybrid procedures are safe with high degree of efficacy in terms of revascularization, reduced morbidity and shorter intensive care. In our experience, the use of a hybrid procedure is technically feasible and allowed the treatment of complicated diabetic COVID-19 patient with a good outcome.     

Treatment of infected hip arthroplasty with antibiotic-impregnated calcium hydroxyapatite

We reviewed the treatment of infected hip arthroplasty with antibiotic-impregnated calcium hydroxyapatite (CHA) ceramic blocks. Seven consecutive patients consisting of 2 men and 5 women with an average age of 65 years were followed up for an average of 5.0 years. All patients received resection arthroplasty and thorough debridement, followed by implantation of antibiotic-impregnated CHA ceramic. Two-stage revision was performed in all patients. There was no evidence of a recurrent infection in 6 patients. The remaining one patient underwent an additional debridement 2 years after the second stage. This patient was free of infection at the time of the latest follow-up. Antibiotic-impregnated CHA ceramic is thus considered to be an excellent drug delivery system for the infected hip arthroplasty.     

Persistent infection associated with residual cement after resection arthroplasty of the hip

BACKGROUND: The danger of residual bone cement after resection of infected prosthetic components is controversial. PATIENTS AND METHODS: We analyzed 10 patients with infected total hip prosthesis who had been treated previously with resection arthroplasty and antibiotics and who had persistent infection with residual cement. In 9 patients, surgical debridement with resection of all the PMMA was performed, and adequate intravenous antibiotics were administered. 1 patient refused surgical treatment, but accepted antibiotics. RESULTS: At an average of 4 (1-18) years of follow-up, 8 patients had no signs or symptoms of recurrent infection. 1 severely immunodeficient patient died 2 years after the removal of residual cement, for reasons other than his hip. The patient who refused surgical treatment continues to have an active sinus 4 years after first consultation. INTERPRETATION: Residual cement may be responsible for chronic infection. At resection arthroplasty, as part of the treatment of an infected hip arthroplasty, all devitalized or foreign material must be removed.     

Our experiences for off-pump coronary artery bypass grafting to the circumflex system

BACKGROUND: Complete revascularization has been difficult in off-pump coronary artery bypass grafting (OPCAB). Hemodynamic deterioration often prevents access to the circumflex territory. This study presents instrumentation for accessing the circumflex territory, and our clinical experience. METHODS: From August 1999 through December 2002, 140 patients underwent OPCAB via sternotomy in our institution. The 114 requiring reconstruction of the circumflex artery are the subjects of this study. There were no exclusion criteria. A series of techniques and instruments were developed to provide access to the circumflex area while hemodynamic stability was preserved, including the left pericardial traction technique, compression of the right pericardium, a right sternal retractor, and a type of shunt tube. RESULTS: Patients received an average of 3.2 grafts (range, 2 to 6). Complete revascularization was achieved in 95% of the cases. Complications included respiratory insufficiency (0.8%), renal dysfunction (7%), and sternal wound infection (0.8%). Blood transfusions were required in 10 patients (8%). No patient suffered perioperative myocardial infarction or stroke. No operation was converted to cardiopulmonary bypass. There was no operative death. Predischarge angiography demonstrated a 99% patency rate. CONCLUSIONS: With our techniques and instruments, off-pump coronary revascularizaion of the circumflex area may be performed safely to achieve complete revascularization. Early clinical results are excellent, but long-term longitudinal follow-up is required to assess the future effectiveness of OPCAB procedure with our techniques.     

Ilizarov treatment of tibial nonunions results in 16 cases

Treatment with the Ilizarov technique was performed in 16 patients with complex tibial nonunions. Two years post treatment the functional stage and patient satisfaction were recorded. There were 4 hypertrophic, 3 atrophic and 9 infected nonunions. Eleven patients had segmental bone loss. Fifteen nonunions united, and limb length discrepancy was reduced within 1.5 cm of the contralateral leg. Average time in the frame was 182 days. Fifteen of the 16 patients were satisfied with the treatment. One patient demanded an amputation after 3 months of treatment, despite good signs of healing. There were no refractures or recurrent infections. In conclusion the Ilizarov technique for complex nonunions has a high rate of success in achieving union and eradicating infection, bone loss and malalignment. The treatment is demanding both to the surgeon and to the patient, but we strongly recommend the Ilizarov treatment for tibial nonunion, especially in cases with chronic infection and severe bone loss.     

Selection of surgical methods for infected infrarenal abdominal aortic aneurysms

BACKGROUND: There is no standard treatment for patients with infected abdominal aortic aneurysm (AAA). To determine the basis for selection of a surgical method, we reviewed our experiences with all patients who underwent surgery for infected infrarenal AAA. METHODS: Between 1993 and 2000, 6 patients with infected infrarenal AAA underwent surgery. Extra-anatomic bypass grafting was performed in 2 of 3 patients with infection extending into the retroperitoneum. In situ grafting was performed in 3 patients with localized infection and in 1 patient with extended infection. RESULTS: Severe peritonitis occurred in 2 patients with extended infection in the early postoperative phase. One patient, who had undergone in situ grafting, died of sepsis. The other patient, who had undergone extra-anatomic bypass grafting, was treated by continuous irrigation with an electrolyzed strong acid aqueous solution (ESAAS). He recovered gradually and was discharged. After a follow-up period with a mean of 40 months (range: 17-102 months), all 5 patients who survived surgery are alive and asymptomatic. CONCLUSIONS: It was suggested that the method used for revascularization should be selected based on the degree of diffusion of infection. For a patient with extended infection, postoperative continuous irrigation with ESAAS appears to be effective in eradicating retroperitoneal infection.     

Tuberculous aortitis with associated necrosis and perforation: treatment and options

Tuberculous aortitis is a rare entity and its association with necrosis and perforation is even more unusual. Our pulmonary medicine service originally evaluated an elderly woman with a right pleural effusion and upper lobe infiltrate thought to be tuberculosis. An abdominal CT scan performed at that time showed extensive periaortic adenopathy. Isoniazid and rifampin were started, but both were stopped by the patient after less than 6 months of therapy. The patient later had night sweats, a left pleural effusion, and a tender abdominal mass thought to be a symptomatic aneurysm. At operation, the aorta was necrotic and had an inflammatory mass and perforation on the left side. Infrarenal aortic ligation and resection were performed to control infection. A previously placed axillofemoral graft obviated the need for concomitant revascularization. The patient was treated postoperatively with isoniazid and rifampin until hyperbilirubinemia developed, which necessitated alternate therapy with ethambutol and streptomycin. The patient died one month after operation of a presumed pulmonary embolus.     

Infected midurethral tape presenting as an ischiorectal abscess

This is the first reported case of an ischiorectal abscess after a midurethral intravaginal slingplasty (IVS). The patient presented with recurrent ischiorectal abscess which was initially thought to be an unusual presentation of a fistula in ano. Subsequent examination under anaesthesia, however, revealed a fistulous tract extending from the right postero-lateral perianal opening to the vagina where the tape was noted to be eroded and infected. The abscess healed only after removal of the source of infection i.e. the IVS tape. In this report, we also discuss the two main types of meshes used as midurethral slings, the ways in which they differ and the arguments for and against using them.     

Surgical treatment of infected aneurysms and pseudoaneurysms of the thoracic and abdominal aorta

BACKGROUND: To review the outcome of infected aneurysms and pseudoaneurysms of the thoracic and abdominal aorta treated in a major teaching hospital. METHODS: Between December 1994 and January 2003, 13 infected aortic aneurysms and pseudoaneurysms (5 thoracic, 4 paravisceral, 4 infrarenal) in 10 consecutive patients were treated surgically. Aortic debridement with in situ reconstruction is our standard practice. Endovascular repair was offered to suitable patients with thoracic aortic involvement. RESULTS: There were six men and four women with a mean age of 63 years. The commonest pathogen was Salmonella species, accounting for 50% of the cases. Aortic debridement with in situ revascularization was performed for six patients with visceral reconstruction in four of them. One patient with aortic bifurcation involvement and gross purulent infection had ligation and debridement followed by right axillobifemoral bypass. Four infected thoracic aortic pseudoaneurysms in three other patients underwent endovascular repair. There was no hospital death, limb loss, renal failure, or intestinal ischemia. There were two late deaths from sepsis and pneumonia at 3 months and 77 months after operation. Eight patients were alive after a mean follow-up of 36 months and no late graft infection was evident. CONCLUSIONS: Surgical treatment for infected aortic aneurysms with in situ reconstruction is associated with favorable outcome and good long-term result. Endovascular repair has a potential role.     

Tuberculous pseudoaneurysm of the femoral artery complicated by cutaneous tuberculosis of the foot: a case report

An infected pseudoaneurysm of the right common femoral artery in a 69-year-old patient receiving methotrexate therapy was confirmed to have been caused by Mycobacterium tuberculosis. After surgical excision of the aneurysm and revascularization using femoral vein, cutaneous manifestations of M tuberculosis infection in the foot complicated the course. We hypothesized that methotrexate may have triggered the reactivation of dormant tuberculosis in this patient. Because extrapulmonary tuberculous pseudoaneurysms are clinically similar to other types of infected pseudoaneurysm, M tuberculosis infection should always be suspected during the initial diagnosis. We propose that mycobacterial cultures should be routine when initial cultures and Gram stain are negative.     

Chronischer zentraler Gefäßprotheseninfekt

A 67-year-old male patient presented with recurrent fever and septic emboli due to an aorto-duodenal fistula after previous aortobiiliac bypass grafting with suspected graft infection. Imaging by ultrasound, computed tomography scan (CT) and magnetic resonance imaging (MRI) could not confirm graft infection. A scan using 2-deoxy-2-fluoro-[18F]-d-glucose positron emission tomography CT (18F-FDG-PET/CT) revealed a pathological uptake. The bifurcated graft was removed und revascularization was performed by axillobifemoral bypass grafting. The clinical role of CT scanning with 18F-FDG-PET/CT is discussed including a review of the recent literature.